Do Flavour Descriptions Influence Subjective Ratings of Flavoured and Unflavoured E-Liquids among Non-Smoking and Non-Vaping UK Adolescents?

INTRODUCTION: Youth use of electronic cigarettes (e-cigarettes) is rising globally and is associated with health harms. Flavour descriptions on e-liquid packaging may contribute to the appeal of e-cigarettes among youth. This study compared subjective ratings of e-liquid packaging flavour descriptions among non-smoking and non-vaping UK adolescents. METHODS: This was an online observational study in a UK sample of non-smoking and non-vaping adolescents aged 11-17 years. The primary analyses compared flavoured versus unflavoured descriptions and the secondary analyses compared candy/sweet flavour versus fruit flavour descriptions. Outcomes were packaging appraisal, packaging receptivity, perceived harm, and perceived audience. RESULTS: The survey was completed by 120 participants (74% female). Packaging appraisal ratings were higher for e-liquids with flavoured descriptions than unflavoured descriptions (mean difference 5.9, 95% CI 4.2 to 7.6, p<.001). Similarly, packaging receptivity ratings were higher for e-liquids with flavoured descriptions than unflavoured descriptions (mean difference 4.2, 95% CI 2.8 to 5.6, p<.001). Participants also perceived e-liquids with flavoured (versus unflavoured) descriptions as less 'grown-up' (mean difference -5.2, 95% CI -7.3 to -3.1, p<.001). However, ratings of perceived harm were similar for flavoured and unflavoured descriptions (mean difference -1.0, 95% CI -2.6 to 0.5, p=.189). CONCLUSIONS: Although this study found differences in subjective ratings of e-liquids with flavoured and unflavoured descriptions, non-smoking and non-vaping UK adolescents generally had low appraisal and receptivity for e-liquids and they perceived them as being 'grown-up' and harmful. IMPLICATIONS: Youth use of electronic cigarettes (e-cigarettes) is increasing globally, leading to concerns about health harms. This study compared adolescents' ratings of e-liquids with flavoured versus unflavoured descriptions and e-liquids with candy/sweet flavour versus fruit flavour descriptions. This study adds to previous studies that have compared adolescents' ratings of e-liquids with tobacco flavour versus non-tobacco flavour descriptions. Although packaging appraisal and receptivity ratings were higher (more positive) for e-liquids with flavoured versus unflavoured descriptions, overall, adolescents who do not smoke or vape had low appraisal and receptivity for e-liquids, and they perceived them as being 'grown-up' and harmful.

The Effect of Conflicting Public Health Guidance on Smokers' and Vapers' E-cigarette Harm Perceptions.

BACKGROUND: E-cigarettes are increasingly being viewed, incorrectly, as more harmful than cigarettes. This may discourage smokers from switching to e-cigarettes. One potential explanation for these increasingly harmful attitudes is conflicting information presented in the media and online, and from public health bodies. AIMS AND METHODS: In this prospectively registered online study, we aimed to examine the impact of conflicting public health information on smokers' and vapers' e-cigarette harm perceptions. Daily UK smokers who do not vape (n = 334) and daily UK vapers (n = 368) were randomized to receive either: (1) a consistent harm reduction statement from two different public health bodies (Harm Reduction), (2) a consistent negative statement about e-cigarette harms from two different public health bodies (Negative), (3) a harm reduction statement from one public health body and a negative statement from another (Conflict), and (4) a statement of the risks of smoking followed by a harm reduction statement from one public health body and a negative statement from another (Smoking Risk + Conflict). Participants then answered questions regarding their perceptions of e-cigarette harm. RESULTS: The Negative condition had the highest e-cigarette harm perceptions, significantly higher than the Smoking Risk + Conflict condition (MD = 5.4, SE = 1.8, p < .016, d = 0.3 [CI 0.73 to 10.04]), which did not differ from the Conflict condition (MD = 1.5, SE = 1.8, p = .836, d = 0.1 [CI -3.14 to 6.17]). The Conflict condition differed from the Harm Reduction condition, where harm perceptions were lowest (MD = 5.4, SE = 1.8, p = .016, d = 0.3 [CI 0.74 to 10.07]). CONCLUSIONS: These findings are the first to demonstrate that, compared to harm reduction information, conflicting information increases e-cigarette harm perceptions amongst vapers, and smokers who do not vape. IMPLICATIONS: This research provides the first empirical evidence that conflicting information increases smokers' and vapers' e-cigarette harm perceptions, compared to harm reduction information. This may have a meaningful impact on public health as e-cigarette harm perceptions can influence subsequent smoking and vaping behavior. Conflicting information may dissuade smokers, who have the most to gain from accurate e-cigarette harm perceptions, from switching to e-cigarettes. These findings indicate that public health communications that are consensus-based can lower harm perceptions of e-cigarettes, and have the potential to reduce morbidity and mortality attributable to tobacco smoking.

Nucleation increases the visual appeal of lager but does not alter overall likeability or drinking rate.

BACKGROUND: Glassware can be an effective vehicle to recruit customers, revive brands, build profits and increase alcohol consumption by capitalising on the immediacy of glassware to the point of consumption. The design of glassware can also contribute to harm reduction by slowing and reducing consumption. Nucleated bases have been added to lager glasses in recent years which allow carbon dioxide (CO2) to be more rapidly released and ascend through the solution. The aim of these studies was to investigate the effect of nucleated glasses on the likeability and drinking rate of lager in alcohol drinkers. METHODS: In Study 1, participants (n = 116) were asked to taste two glasses of lager (280 millilitres (ml) each) in separate 5-min taste tests and fill out a likeability questionnaire after each glass in a within-subjects design with one factor of glass (nucleated, non-nucleated). The primary outcome was the likeability of lager and the secondary outcome was volume consumption during taste tests. In Study 2, participants (n = 160) were asked to consume a pint of lager (568 ml) and fill out a likeability questionnaire in a between-subjects design with one factor of glass (nucleated, non-nucleated). The primary outcome was time taken to consume a pint of lager and secondary outcomes were the likeability of lager, mood and alcohol craving. RESULTS: There was no clear evidence that likeability of lager differed between nucleated and non-nucleated glasses in either study. In Study 1, a paired-samples t test found strong evidence that lager in nucleated glasses was more visually appealing (single item from likeability measure) than lager in non-nucleated glasses (mean difference (MD) = 10.2, 95% confidence interval (CI) 6.1, 14.2, p < 0.001). In Study 2, a linear regression found no clear evidence that lager was consumed at different rates from nucleated and non-nucleated glasses (nucleated: 16.9 min, non-nucleated: 16.3 min, MD: 0.6 min, 95% CI - 1.5, 2.7, p = 0.57). CONCLUSIONS: Nucleated lager glasses do not appear to alter the likeability or consumption (volume consumed in Study 1 or drinking rate in Study 2) of lager, although they do seem to increase the visual appeal and refreshment of lager. This may increase the number of drinking episodes by making the drinking experience more enjoyable which may lead to increased alcohol related harm.

Standardised packs and larger health warnings: visual attention and perceptions among Colombian smokers and non-smokers.

AIMS: To measure how cigarette packaging (standardised packaging and branded packaging) and health warning size affect visual attention and pack preferences among Colombian smokers and non-smokers. DESIGN: To explore visual attention, we used an eye-tracking experiment where non-smokers, weekly smokers and daily smokers were shown cigarette packs varying in warning size (30%-pictorial on top of the text, 30%-pictorial and text side-by-side, 50%, 70%) and packaging (standardised packaging, branded packaging). We used a discrete choice experiment (DCE) to examine the impact of warning size, packaging and brand name on preferences to try, taste perceptions and perceptions of harm. SETTING: Eye-tracking laboratory, Universidad Nacional de Colombia, Bogotá, Colombia. PARTICIPANTS: Participants (n = 175) were 18 to 40 years old. MEASUREMENTS: For the eye-tracking experiment, our primary outcome measure was the number of fixations toward the health warning compared with the branding. For the DCE, outcome measures were preferences to try, taste perceptions and harm perceptions. FINDINGS: We observed greater visual attention to warning labels on standardised versus branded packages (F[3,167] = 22.87, P < 0.001) and when warnings were larger (F[9,161] = 147.17, P < 0.001); as warning size increased, the difference in visual attention to warnings between standardised and branded packaging decreased (F[9,161] = 4.44, P < 0.001). Non-smokers visually attended toward the warnings more than smokers, but as warning size increased these differences decreased (F[6,334] = 2.92, P = 0.009). For the DCE, conditional trials showed that increasing the warning size from 30% to 70% reduced preferences to try (odds ratio [OR] = 0.48, 95% CI = [0.42,0.54], P < 0.001), taste perceptions (OR = 0.61, 95% CI = [0.54,0.68], P < 0.001); and increased harm perceptions (OR = 0.78, 95% CI = [0.76,0.80], P < 0.001). Compared with branded packaging, standardised packaging reduced our DCE outcome measures with ORs ranging from OR = 0.25 (95% CI = [0.17,0.38], P < 0.001) to OR = 0.79 (95% CI = [0.67,0.93], P < 0.001) across two brands. These effects were more pronounced among non-smokers, males and younger participants. Unconditional trials showed similar results. CONCLUSIONS: Standardised cigarette packaging and larger health warnings appear to decrease positive pack perceptions and have the potential to reduce the demand for cigarette products in Colombia.

Tackling Smoker Misperceptions About E-cigarettes Using Expert Videos.

BACKGROUND: The pervasive misperception that e-cigarettes are equally or more harmful than combustible cigarettes is a barrier to current smokers switching to e-cigarettes. To tackle misperceptions, public health bodies are using informational videos, although their efficacy is unknown. METHODS: In our online study, current UK smokers who do not vape (n = 382) were randomized to view either: (1) a Cancer Research UK (CRUK) text-only video; (2) a video featuring leading e-cigarette experts (expert); or (3) a no video control condition, and then completed questions regarding e-cigarette harm perceptions. RESULTS: Compared to the control condition, participants in the CRUK condition, and especially those in the expert condition had more accurate harm perceptions of e-cigarettes and had more accurate knowledge of e-cigarette constituents. In the expert condition, 67% of individuals reported they would try an e-cigarette in a future quit attempt, compared with 51% in the CRUK condition and 35% in the control condition. CONCLUSIONS: Our findings are encouraging in the face of mounting evidence that e-cigarette misperceptions are increasing. Whilst misperceptions are often characterized as resistant to correction, we find that carefully designed public health information videos have the potential to promote a more accurate, informed view of e-cigarettes, and encourage intended e-cigarette use among UK smokers. Importantly, we find this among current smokers who do not vape, a group often reported as having the highest levels of misperceptions and as having the most to gain from accurate e-cigarette perceptions. IMPLICATIONS: There is mounting evidence that e-cigarette misperceptions are increasing, particularly among smokers who do not vape, a group who have most to gain from accurate information about e-cigarettes. Misperceptions are often characterized as difficult to change and there is relatively little research on how to correct e-cigarette misperceptions. Our research in the UK shows that, compared to controls, e-cigarette misperceptions can be corrected among those smokers who are shown carefully constructed expert videos. This work has important implications for the development and dissemination of these important messages.

Avoidance of tobacco health warnings? An eye-tracking approach.

AIMS: Among three eye-tracking studies, we examined how cigarette pack features affected visual attention and self-reported avoidance of and reactance to warnings. DESIGN: Study 1: smoking status × warning immediacy (short-term versus long-term health consequences) × warning location (top versus bottom of pack). Study 2: smoking status × warning framing (gain-framed versus loss-framed) × warning format (text-only versus pictorial). Study 3: smoking status × warning severity (highly severe versus moderately severe consequences of smoking). SETTING: University of Bristol, UK, eye-tracking laboratory. PARTICIPANTS: Study 1: non-smokers (n = 25), weekly smokers (n = 25) and daily smokers (n = 25). Study 2: non-smokers (n = 37), smokers contemplating quitting (n = 37) and smokers not contemplating quitting (n = 43). Study 3: non-smokers (n = 27), weekly smokers (n = 26) and daily smokers (n = 26). MEASUREMENTS: For all studies: visual attention, measured as the ratio of the number of fixations to the warning versus the branding, self-reported predicted avoidance of and reactance to warnings and for study 3, effect of warning on quitting motivation. FINDINGS: Study 1: greater self-reported avoidance [mean difference (MD) = 1.14; 95% confidence interval (CI) = 0.94, 1.35, P < 0.001, ηp2  = 0.64] and visual attention (MD = 0.89, 95% CI = 0.09, 1.68, P = 0.03, ηp2  = 0.06) to long-term warnings, but not for reactance (MD = 0.14, 95% CI = -0.04, 0.32, P = 0.12, ηp2  = 0.03). Increased visual attention to warnings on the upper versus lower half of the pack (MD = 1.8; 95% CI = 0.33, 3.26, P = 0.02, ηp2  = 0.08). Study 2: higher self-reported avoidance of (MD = 0.70; 95% CI = 0.59,0.80, P < 0.001, ηp2  = 0.61) and reactance to (MD = 0.37; 95% CI = 0.27, 0.47, P < 0.001, ηp2  = 0.34) loss-framed warnings but little evidence of a difference for visual attention (MD = 0.52; 95% CI = -0.54, 1.58, P = 0.30, ηp2  = 0.01). Greater visual attention, avoidance and reactance to pictorial versus text-only warnings (all Ps < 0.001, ηp2  > 0.25). Study 3: greater self-reported avoidance of (MD = 0.37; 95% CI = 0.25, 0.48, P < 0.001, ηp2  = 0.33) and reactance to (MD = 0.14; 95% CI = 0.05, 0.23, P = 0.003, ηp2  = 0.11) highly severe warnings but findings were inconclusive as to whether there was a difference in visual attention (MD = -0.55; 95% CI = -1.5, 0.41, P = 0.24, ηp2  = 0.02). CONCLUSIONS: Subjective and objective (eye-tracking) measures of avoidance of health warnings on cigarette packs produce different results, suggesting these measure different constructs. Visual avoidance of warnings indicates low-level disengagement with warnings, while self-reported predicted avoidance reflects higher-level engagement with warnings.

Reactions to graphic and text health warnings for cigarettes, sugar-sweetened beverages, and alcohol: An online randomized experiment of US adults.

We aimed to examine reactions to graphic versus text-only warnings for cigarettes, SSBs, and alcohol. A convenience sample of US adults completed an online survey in 2018 (n = 1352 in the analytic sample). We randomly assigned participants to view a: 1) text-only warning without efficacy information (i.e., message intended to increase consumers' confidence in their ability to stop using the product), 2) text-only warning with efficacy information, 3) graphic warning without efficacy information, or 4) graphic warning with efficacy information. Participants viewed their assigned warning on cigarettes, SSBs, and alcohol, in a random order. Across product types, graphic warnings were perceived as more effective than text-only warnings (p < .001) and led to lower believability, greater reactance (i.e., resistance), more thinking about harms, and lower product appeal (all p < .05); policy support did not differ. Compared to SSB and alcohol warnings, cigarette warnings led to higher perceived message effectiveness, believability, fear, thinking about harms, policy support, and greater reductions in product appeal (all p < .05). The efficacy information did not influence any outcomes. Graphic warnings out-performed text-only warnings on key predictors of behavior despite causing more reactance.

Tobacco and electronic cigarette cues for smoking and vaping: an online experimental study.

OBJECTIVE: This study examined whether exposure to smoking and vaping cues the urge to smoke or vape. It extends previous studies on first-generation cigalikes (visually similar to cigarettes) and second-generation devices (visually similar to pens) by including third-generation tank system devices (larger bulky units). In an online experiment, participants were randomly assigned to view one of four videos, which included smoking, vaping (cigalike or tank system), or neutral cues. The primary outcome was urge to smoke. Secondary outcomes were urge to vape, desire to smoke and vape, and intention to quit or remain abstinent from smoking. RESULTS: UK adults varying in smoking (current or former) and vaping (user or non-user) status (n = 1120) completed the study: 184 (16%) failed study attention checks meaning 936 were included in the final analysis. Urges to smoke were similar across cue groups. Urges to vape were higher following exposure to vaping compared to neutral cues. There was no clear evidence of an interaction between cue group and smoking or vaping status. The lack of cueing effects on smoking urges is inconsistent with previous research, raising questions about the ability to assess craving in online settings.

Have e-cigarettes renormalised or displaced youth smoking? Results of a segmented regression analysis of repeated cross sectional survey data in England, Scotland and Wales.

OBJECTIVES: To examine whether during a period of limited e-cigarette regulation and rapid growth in their use, smoking began to become renormalised among young people. DESIGN: Interrupted time-series analysis of repeated cross-sectional time-series data. SETTING: Great Britain PARTICIPANTS: 248 324 young people aged approximately 13 and 15 years, from three national surveys during the years 1998-2015. INTERVENTION: Unregulated growth of e-cigarette use (following the year 2010, until 2015). OUTCOME MEASURES: Primary outcomes were prevalence of self-reported ever smoking and regular smoking. Secondary outcomes were attitudes towards smoking. Tertiary outcomes were ever use of cannabis and alcohol. RESULTS: In final models, no significant change was detected in the pre-existing trend for ever smoking (OR 1.01, CI 0.99 to 1.03). There was a marginally significant slowing in the rate of decline for regular smoking (OR 1.04, CI 1.00 to 1.08), accompanied by a larger slowing in the rate of decline of cannabis use (OR 1.21, CI 1.18 to 1.25) and alcohol use (OR 1.17, CI 1.14 to 1.19). In all models and subgroup analyses for smoking attitudes, an increased rate of decline was observed after 2010 (OR 0.88, CI 0.86 to 0.90). Models were robust to sensitivity analyses. CONCLUSIONS: There was a marginal slowing in the decline in regular smoking during the period following 2010, when e-cigarettes were emerging but relatively unregulated. However, these patterns were not unique to tobacco use and the decline in the acceptability of smoking behaviour among youth accelerated during this time. These analyses provide little evidence that renormalisation of youth smoking was occurring during a period of rapid growth and limited regulation of e-cigarettes from 2011 to 2015. TRIAL REGISTRATION NUMBER: Research registry number: researchregistry4336.

Causal Language in Health Warning Labels and US Adults' Perception: A Randomized Experiment.

Objectives. To examine US adults' reactions to health warnings with strong versus weak causal language.Methods. In 2018, we randomly assigned 1360 US adults to answer an online survey about health warnings for cigarettes, sugar-sweetened beverages, or alcohol. Participants rated 4 warning statements using different causal language variants ("causes," "contributes to," "can contribute to," and "may contribute to") displayed in random arrangement.Results. Most participants (76.3%) selected the warning that used "causes" as the 1 that most discouraged them from wanting to use the product. "Causes" was also selected most often (39.0% of participants) as the warning that participants most supported implementing. By contrast, most (66.1%) chose "may contribute to" as the warning that least discouraged them from wanting to use the product. We found few demographic differences in these patterns.Conclusions. Warnings with stronger causal language are perceived to be effective and are supported by the public.

Using Neuroscience to Inform Tobacco Control Policy.

INTRODUCTION: Techniques employed in the field of neuroscience, such as eye tracking, electroencephalography, and functional magnetic resonance imaging, have been important in informing our understanding of the cognitive mechanisms underlying tobacco smoking. These techniques are now increasingly being used to investigate the likely impact of tobacco control policies. AIMS AND METHODS: In this narrative review, we outline the value of these methodological approaches in answering policy-relevant tobacco control research questions, with a particular focus on their use in examining the impact of standardized cigarette packaging and health warnings. We also examine the limitations of these methodologies and provide examples of how they can be used to answer other policy-relevant questions. RESULTS: We argue that neuroscience techniques can provide more objective evidence of the impacts of policy measures, allow investigation where it is not possible to conduct behavioral manipulations, and facilitate a deeper understanding of the cognitive mechanisms underlying the impacts of tobacco control policies such as standardized packaging, health warnings, point-of-sale displays, and mass media campaigns. CONCLUSIONS: Rather than replacing more traditional methods of examining tobacco control measures, such as observational experiments, surveys, and questionnaires, neuroscience techniques can complement and extend these methods. IMPLICATIONS: Neuroscience techniques facilitate objective examination of the mechanisms underlying the impacts of tobacco control measures. These techniques can therefore complement and extend other methodologies typically used in this field, such as observational experiments, surveys, and questionnaires.

Informing drinkers: Can current UK alcohol labels be improved?

BACKGROUND: Alcohol labeling provides a relatively low-cost, population-level approach to providing information about alcohol's content and harms. METHOD: We conducted an online between-subjects experiment with two tasks to examine the impact of alcohol labels (n = 1884). In one task, participants were randomized to view one of four different unit labels (including labels currently used by the alcohol industry and novel labels which provide more information about how the number of units relates to recommended drinking guidelines). We assessed participants' accuracy of estimating weekly serving limits of alcohol. In a second task, participants were randomized to view one of eight health warnings (which varied according to message content, specificity, and framing). We assessed the motivation to quit after viewing the health warning. RESULTS: Accuracy of estimating weekly serving limits of alcohol was greater for participants who viewed novel unit labels compared to the industry standard labels. Motivation to drink less was higher amongst participants who had viewed both cancer and negatively framed messages, compared to mental health and positively framed messages. CONCLUSION: Existing unit labels used by the alcohol industry can be improved; the inclusion of unit information per serving and how these relate to low-risk drinking guidelines may be important for facilitating consumer understanding. Health warning labels should be included alongside units to provide consumers with information about the harms associated with alcohol and discourage riskier drinking behavior.

Severity and susceptibility: measuring the perceived effectiveness and believability of tobacco health warnings.

BACKGROUND: Pictorial tobacco health warning labels (HWLs) have been shown to be more effective than text-only HWLs in changing smoking attitudes and intentions. However, there is contradictory evidence regarding how the severity of the content of HWLs influences responses to them. METHODS: We examined the perceived believability and effectiveness of HWLs in an online study using a convenience sample of non-smokers (N = 437) and smokers (N = 436). HWLs were in one of three presentation formats: (text-only, a moderately severe image or highly severe image) and focussed on three disease outcomes (lung cancer, blindness or tooth and gum disease). Participants rated the effectiveness and believability of each HWL and also rated their perceived susceptibility to each disease. RESULTS: A 2 (smoking status) × 3 (presentation format) × 3 (disease outcome) ANOVA was run for both believability and effectiveness ratings. The most severe pictorial HWLs received the highest believability and effectiveness ratings and as expected, the text-only HWLs received the lowest. Lung cancer HWLs were rated most believable and effective, with the blindness HWLs receiving the lowest scores. A 2 (smoking status) × 3 (disease outcome) ANOVA was conducted on the ratings of perceived susceptibility to the three diseases. Smokers considered themselves to be more susceptible to all three diseases, and among smokers, perceived susceptibility to the diseases was positively correlated with effectiveness and believability ratings of the HWLs. CONCLUSION: Our findings support previous evidence that pictorial HWLs are rated as more effective and believable than text-only warnings, and provide some support for the use of severe or 'grotesque' HWLs on tobacco products. Our data also suggest that HWLs should aim to increase perceived susceptibility to disease, as this was positively related to perceived message effectiveness and believability.

Neural mechanisms underlying visual attention to health warnings on branded and plain cigarette packs.

AIMS: To (1) test if activation in brain regions related to reward (nucleus accumbens) and emotion (amygdala) differ when branded and plain packs of cigarettes are viewed, (2) test whether these activation patterns differ by smoking status and (3) examine whether activation patterns differ as a function of visual attention to health warning labels on cigarette packs. DESIGN: Cross-sectional observational study combining functional magnetic resonance imaging (fMRI) with eye-tracking. Non-smokers, weekly smokers and daily smokers performed a memory task on branded and plain cigarette packs with pictorial health warnings presented in an event-related design. SETTING: Clinical Research and Imaging Centre, University of Bristol, UK. PARTICIPANTS: Non-smokers, weekly smokers and daily smokers (n = 72) were tested. After exclusions, data from 19 non-smokers, 19 weekly smokers and 20 daily smokers were analysed. MEASUREMENTS: Brain activity was assessed in whole brain analyses and in pre-specified masked analyses in the amygdala and nucleus accumbens. On-line eye-tracking during scanning recorded visual attention to health warnings. FINDINGS: There was no evidence for a main effect of pack type or smoking status in either the nucleus accumbens or amygdala, and this was unchanged when taking account of visual attention to health warnings. However, there was evidence for an interaction, such that we observed increased activation in the right amygdala when viewing branded as compared with plain packs among weekly smokers (P = 0.003). When taking into account visual attention to health warnings, we observed higher levels of activation in the visual cortex in response to plain packaging compared with branded packaging of cigarettes (P = 0.020). CONCLUSIONS: Based on functional magnetic resonance imaging and eye-tracking data, health warnings appear to be more salient on 'plain' cigarette packs than branded packs.