Self-reported attention and responses to cigarette package labels at the end of a two-week randomized trial of cigarette package labeling configurations.

INTRODUCTION: Cigarette package inserts that describe quitting benefits and tips may promote cessation; however, research is needed to understand better their effects, including potentially enhancing the effects of pictorial health warning labels (PHWLs). METHODS: A randomized trial with a 2×2 factorial design was conducted with adult smokers (n=356) assigned to either small text-only health warning labels (HWLs; control); inserts with cessation messages, and the small text-only HWLs (inserts-only); large PHWLs (PHWLs-only); both inserts and PHWLs (inserts + PHWLs). Participants received a 14-day supply of their preferred cigarettes with packs labeled to reflect their group. Upon finishing the trial, participants reported their past 14-day frequency of noticing, reading, thinking about smoking harms and cessation benefits, talking about labels, and forgoing cigarettes because of the labels. Ordered logistic models regressed these outcomes on labeling groups, and mediation analyses assessed whether attention (i.e. noticing, reading) to labels mediated effects of labeling exposure on other outcomes (i.e. thinking about harms/benefits, talking, forgoing). RESULTS: The inserts + PHWLs group reported higher frequencies than the control group for all outcomes. Compared to the control group, both the inserts-only and PHWLs-only groups reported higher frequency of noticing (AOR=3.53 and 2.46, respectively) and reading labels (AOR=2.89 and 1.71), thinking about smoking risks because of the labels (AOR=1.93 and 1.82), and talking about labels (AOR=2.30 and 2.70). Participants in the inserts-only group also reported more frequent thinking about quitting benefits (AOR=1.98). Attention mediated all labeling effects except for the contrast between PHWLs only and control. CONCLUSIONS: Compared to text-only HWLS, cigarette labeling that involves inserts, PHWLs, or both appears more effective at drawing attention to warnings, which mediated the effects on cessation-related psychosocial and behavioral outcomes.

Smoking Dependence, Time-Discounting, and Sustained Cessation Behavior: A Longitudinal Study of Predominantly Light Smokers.

INTRODUCTION: This study aimed to assess whether two established psychosocial predictors of smoking abstinence, nicotine dependence and time-discounting, also apply to a population of predominantly cigarette light smokers, which is the dominant pattern of smoking in countries like Mexico. Relatively infrequent smoking is increasingly prevalent, yet still harmful, making it important to understand the predictors of cessation in this population. AIMS AND METHODS: Mexican adult smokers recruited from an online consumer panel were surveyed every 4 months between November 2018 and July 2020. We considered respondents who reported a quit attempt in between surveys (n = 1288). Dependence was measured with a 10-item version of the Wisconsin Inventory of Smoking Dependence Motives (WISDM). Time-discounting was assessed with five branching questions about hypothetical reward scenarios. Logistic models regressed sustained quit attempts (≥30 days of abstinence) at time t + 1 on study variables at time t. RESULTS: We found strong interitem reliability (α = 0.92) and intraindividual consistency of our brief WISDM (ρ = 0.68), but moderate intraindividual consistency of the time-discounting measure (ρ = 0.48). Forty-eight percent of the sample reported sustained quit attempts, and 79% were non-daily or light daily smokers (≤5 cigarettes per day). Smokers with higher WISDM-10 had lower odds of sustained quitting and this result remained when controlling for smoking frequency and the Heaviness of Smoking Index (adjusted odds ratio [AOR] = 0.768). Time-discounting was unassociated with sustained quitting. CONCLUSIONS: Our findings suggest that a brief, 10-item multidimensional measure of dependence is useful for predicting sustained quitting in a context of relatively light smoking; time-discounting appears less relevant, although our results are not conclusive because of the low test-retest reliability of our measure. IMPLICATIONS: Given the increase in non-daily and light daily cigarette smoking in many countries, including in Mexico, and the health risks this still poses, it is important to understand the predictors of cessation among relatively light smokers. The WISDM-10 multidimensional measure seems to be a good instrument to assess dependence and predict successful quitting in this population, and possibly more appropriate than physical dependence measures. As such, it could help design and target more suitable cessation treatments for non-daily and daily light cigarette smokers. While this study did not find time-discounting to be a relevant predictor of smoking abstinence, future studies should explore other measures.

Combining Inserts With Warning Labels on Cigarette Packs to Promote Smoking Cessation: A 2-Week Randomized Trial.

BACKGROUND: Cigarette pack inserts with messages on cessation benefits and advice are a promising labeling policy that may help promote smoking cessation. PURPOSE: To assess insert effects, with and without accompanying pictorial health warning labels(HWLs), on hypothesized psychosocial and behavioral outcomes. METHODS: We conducted a 2 × 2 between-subject randomized trial (inserts with efficacy messages vs. no inserts; large pictorial HWLs vs. small text HWLs), with 367 adults who smoked at least 10 cigarettes a day. Participants received a 14-day supply of their preferred cigarettes with packs modified to reflect their experimental condition. Over 2 weeks, we surveyed participants approximately 4-5 times a day during their smoking sessions, querying feelings about smoking, level of worry about harms from smoking, self-efficacy to cut down on cigarettes, self-efficacy to quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported their perceived susceptibility to smoking harms and, for the last 24 hr, their frequency of thinking about smoking harms and cessation benefits, conversations about smoking cessation or harms, and foregoing or stubbing out cigarettes before they finished smoking. Mixed-effects ordinal and logistic models were estimated to evaluate differences between groups. RESULTS: Participants whose packs included inserts were more likely than those whose packs did not include inserts to report foregoing or stubbing out of cigarettes (OR = 2.39, 95% CI = 1.36, 4.20). Otherwise, no statistically significant associations were found between labeling conditions and outcomes. CONCLUSIONS: This study provides some evidence, albeit limited, that pack inserts with efficacy messages can promote behaviors that predict smoking cessation attempts.

Cigarette pack inserts (small leaflets inside packs) with messages about quitting benefits and tips to quit may promote smoking cessation. We randomly assigned 367 adult smokers to one of four groups: control group with small health warning labels (HWLs) on the side of packs; inserts with cessation messages and small HWLs; large picture HWLs showing health effects from smoking; inserts and large picture HWLs. Participants received a 14-day supply of their preferred cigarettes in packs that reflected their assigned group. Over 2 weeks, we surveyed participants 4­5 times a day during times when they smoked, asking their feelings about smoking and smoking-related harms, confidence to reduce cigarettes and quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported on the prior 24 hr: how often they thought about smoking harms and cessation benefits; conversations about smoking cessation or harms; and foregoing or stubbing out cigarettes before they finished smoking. People whose packs had inserts (with or without picture HWLs) were more likely than those whose packs did not include inserts (control group or picture HWLs only) to report foregoing or stubbing out of cigarettes. This study provides some evidence that inserts with cessation messages may promote smoking cessation.

A mixed-method study of perceptions of cigarette pack inserts among adult smokers from New York and South Carolina exposed as part of a randomized controlled trial.

While many countries require prominent pictorial health warning labels (PHWLs) on the outside of cigarette packs to communicate the harms of smoking, there is evidence that cigarette pack inserts that contain efficacy messages may enhance the effectiveness of PHWLs. The US Food and Drug Administration (FDA) has regulatory authority to communicate with smokers through inserts. While current labeling regulations do not require inclusion of inserts, the FDA could implement them in the future. This study assesses US smokers' perceptions of cigarette package inserts at the conclusion of a two-week randomized trial on cigarette labeling where half of participants were exposed to insert messages (two response-efficacy messages and two self-efficacy messages) in their packs. Participants (n = 359) completed a 30- to 60-min interview with both quantitative and qualitative assessments, including measures of recall and perceived message effectiveness (PME) for specific inserts. Correlates of recall and PME were estimated using mixed-effects regression models. Qualitative responses to PME items were analyzed using thematic analysis. Response-efficacy messages had higher PME and recall than self-efficacy messages. People had diverse responses to the inserts, including that they were positive, thought-provoking, and helpful. Reactions to and perceptions of the inserts indicate potential benefits of integrating efficacy messages into labeling policies.

Smoking Behaviors, Mental Health, and Risk Perceptions during the Beginning of the COVID-19 Pandemic among Mexican Adult Smokers.

Mexico is one of the countries most affected by COVID-19. Studies have found that smoking behaviors have been impacted by the pandemic as well; however, results have varied across studies, and it remains unclear what is causing the changes. This study of an open cohort of smokers recruited from a consumer panel (n = 2753) examined changes in cigarettes per day (CPD), daily vs. non-daily smoking, recent quit attempts, perceived stress, depression, and perceived severity of COVID-19 at two points during the pandemic: March and July 2020. Differences in CPD between waves were estimated with Poisson regression using generalized estimating equations (GEE). Differences in perceived stress were estimated with linear regression using GEE, and differences in recent quit attempts, depression, and perceived severity of COVID-19 were estimated using separate logistic regression GEE models. Rates of depression were higher in July compared to March (AOR = 1.55, 95% C.I. 1.31-1.85), and the likelihood of recent quit attempt was lower in July compared to March (AOR = 0.85, 95% C.I. 0.75-0.98). There was no statistically significant change in CPD, daily smoking, or perceived stress. Perceived COVID-19 severity for oneself increased significantly (AOR: 1.24, 95% C.I. 1.02-1.52); however, the perceived COVID-19 severity for smokers remained constant. Our study suggests that as the COVID-19 pandemic expanded in Mexico, smoking frequency remained stable, and quit attempts decreased, even as adult smokers increasingly perceived infection with COVID-19 for themselves as severe. These results can aid in the development of health communication strategies to educate smokers about their risk for COVID-19, potentially capitalizing on concerns that stem from this syndemic of communicable and smoking-related non-communicable disease.

Evaluating Cigarette Pack Insert Messages with Tips to Quit.

Objectives: Canada is the only country that currently uses cigarette pack inserts to communicate health messages to smokers, including tips to quit. Messages about strategies for quitting smoking are also central to the US Food and Drug Administration's (FDA) Every Try Counts (ETC) campaign. This study assessed US smokers' responses to Canadian and ETC-based messages formatted for pack inserts. Methods: US adult smokers (N = 524) were recruited from an online consumer panel and rated 8 insert messages: 4 based on Canadian inserts and 4 based on ETC. Participants randomly viewed each message accompanied by an image of either a person or a symbolic representation of the topic. Participants rated the perceived effectiveness (PE) of each message. Paired t-tests were used to assess mean differences in PE across topics, image types, and quit intentions. Results: ETC messages were consistently rated as more effective than Canadian messages regardless of quit intentions. Image types did not significantly influence PE. Conclusions: Messages from ETC are perceived as more effective than messages used in Canada. The FDA has the authority to communicate with smokers through inserts and should consider adopting inserts to promote smoking cessation.

Estimating the price elasticity of demand for JUUL E-cigarettes among teens.

BACKGROUND: The widespread popularity of e-cigarettes, particularly JUUL, has led to an alarming increase in teen nicotine use, reversing a 40-year trend. One key question is how sensitive teens' demand for JUUL is to changes in price. METHODS: We estimate the price elasticity of demand using results from an experimental auction where teen nicotine users and nonusers bid on a JUUL kit. RESULTS: We find that a 10 % increase in price leads to as much as a 24 % reduction in JUUL demand among teens using nicotine, and as much as a 45 % reduction among teens not currently using nicotine. The teens in our study were more price sensitive than older adults who took part in a similar earlier study. CONCLUSIONS: From a public health standpoint, these are promising results. High e-cigarette taxes may dissuade relatively few older adult cigarette smokers from switching to e-cigarettes, but at the same time be highly effective at preventing teens from becoming e-cigarette users in the first place.

Cessation Conversations and Quit Attempts: Differences by Ethnicity and Language Preference.

Objectives: Conversations about pictorial cigarette health warning labels (HWLs) encourage quit attempts, and prior research suggests prevalence of these conversations varies by ethnicity. We assessed the frequency of conversations about text-only HWLs among Latino and non-Latino white smokers and the relationship between conversations and subsequent quit attempts. Methods: Latino and non-Latino white adult smokers in the United States (N = 4403) were surveyed every 4 months over 2 years. Surveys queried smoking behaviors, recent quit attempts, HWL responses, including HWL conversations, and socio-demographic variables. Negative binomial generalized estimating equation (GEE) models regressed the frequency of HWL conversations on study variables. Logistic GEE models regressed quit attempts at follow-up surveys on responses from the prior wave, including frequency of HWL conversations and their interaction with ethnicity. Results: Spanish preference Latinos reported the most HWL conversations (85%), followed by English preference Latinos (59%), and non-Latino Whites (35%). More frequent HWL conversations predicted subsequent quit attempts (AOR = 1.74, 95% CI = 1.32, 2.30), but ethnicity did not moderate this effect. Conclusions: Latinos appear to talk more frequently about HWLs than non-Latino Whites but are no more likely to quit as a result. Cessation campaigns should use messages that encourage conversations about quitting.