Identifying effective vaccine champions: Findings from a national survey of primary care professionals.

BACKGROUND: Vaccine champions are common in primary care, but little is known about which champions are effective. METHODS: In 2022, we surveyed 2,144 US primary care professionals (PCPs) who reported working with vaccine champions. Respondents rated the champion with whom they worked most closely on their effectiveness at improving vaccination rates. RESULTS: About half (49 %) of PCPs perceived their closest champion as highly effective. PCPs perceived advanced practice providers and nursing staff as highly effective somewhat more often than physicians (52 % and 58 % vs 43 %, p <.001). Other correlates of perceived effectiveness included being a formally appointed versus informal champion, working extremely versus less closely with PCPs, and using a high (4-5) versus low (0-1) number of implementation strategies to improve vaccination rates (all p <.001). CONCLUSIONS: Results suggest vaccine champions may benefit from having formal roles and opportunities to work closely with colleagues to improve vaccination rates using multiple strategies.

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals.

BACKGROUND: Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care. METHODS: In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates." RESULTS: Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001). CONCLUSIONS: Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

Impact of visit characteristics on intention to recommend HPV vaccine: An experiment with US health care professionals.

OBJECTIVE: Presumptive recommendations that assume parents want to vaccinate can increase human papillomavirus (HPV) vaccine uptake. We sought to examine how visit characteristics affect health care professionals' (HCPs) intention to use this evidence-based recommendation style. METHODS: In 2022, we conducted an online experiment with 2527 HCPs who had a role in adolescent vaccination in the United States. Participants read 1 of 8 randomly assigned vignettes about a well-child visit. Using a 2 × 2 × 2 between-subjects factorial design, the vignettes varied the following visit characteristics: patient age (9 vs. 12-year-old), prior parental vaccine refusal (yes vs. no), and time pressure on the HCP (low vs. high). HCPs reported on their intention to use a presumptive HPV vaccine recommendation, as well as on related attitudes, subjective norms, and self-efficacy. Analyses used 3-way analysis of variance and parallel mediation. RESULTS: Participants were pediatricians (26%), family/general medicine physicians (22%), advanced practitioners (24%), and nursing staff (28%). Overall, about two-thirds of HCPs (64%) intended to use a presumptive recommendation. Intentions were higher for older children (b = 0.23) and parents without prior vaccine refusal (b = 0.39, both p < 0.001). Time pressure had no main effect or interactions. HCPs' attitudes and self-efficacy partially mediated effects of patient age and prior vaccine refusal (range of b = 0.04-0.28, all p < 0.05). CONCLUSION: To better support visits with younger children and parents who have refused vaccines, HCPs may need more training for making presumptive recommendations for HPV vaccine. Reinforcing positive attitudes and self-efficacy can help HCPs adopt this evidence-based recommendation style.

Optimising messages and images for e-cigarette warnings.

BACKGROUND: The US Food and Drug Administration (FDA) requires electronic cigarettes (e-cigarettes) to have a single addiction warning, but many other health harms are associated with vaping and warnings grow stale over time. We aimed to develop new warning messages and images to discourage e-cigarette use. METHODS: Participants were 1629 US adults who vaped or smoked. We randomised each participant to evaluate 7 of 28 messages on newly developed warning themes (metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, addiction), and the current FDA-required warning (total of 8 messages). Then, participants evaluated images of hazards (eg, metal), internal harms (eg, organ damage) or people experiencing harms. RESULTS: Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<0.001), led to greater negative affect (all p<0.001) and led to more anticipated social interactions (all p<0.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<0.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<0.001), although unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<0.001). DISCUSSION: Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. Images of internal harm or people experiencing harms may be particularly effective at discouraging vaping.

How pictorial warnings change parents' purchases of sugar-sweetened beverage for their children: mechanisms of impact.

BACKGROUND: Pictorial health warnings on sugar-sweetened beverages (SSBs) are a promising policy for preventing diet-related disease in children. A recent study found that pictorial warnings reduced parents' purchases of SSBs for their children by 17%. However, the psychological mechanisms through which warnings affect parental behavior remain unknown. We aimed to identify the mechanisms that explain how pictorial warnings affect parents' SSB purchasing behavior for their children using secondary data from a randomized trial. METHODS: In 2020-2021, parents of children ages 2 to 12 years (n = 325) completed a shopping task in a convenience store laboratory in North Carolina, USA. Participants were randomly assigned to a pictorial warnings arm (SSBs displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (SSBs displayed a barcode label). Parents then bought a beverage for their child and took a survey measuring 11 potential psychological mediators, selected based on health behavior theories and a model explaining the impact of tobacco warnings. We conducted simple mediation analyses to identify which of the 11 mechanisms mediated the impact of exposure to pictorial warnings on purchasing any SSBs for their children. RESULTS: Two of the 11 constructs were statistically significant mediators. First, the impact of pictorial warnings on the likelihood of purchasing any SSB was mediated by parents' perceptions that SSBs were healthier for their child (mediated effect= -0.17; 95% CI = - 0.33, - 0.05). Second, parents' intentions to serve SSBs to their children also mediated the effect of warnings on likelihood of purchasing any SSB (mediated effect= -0.07, 95% CI=-0.21, - 0.003). CONCLUSIONS: Pictorial warnings reduced parents' purchases of SSBs for their children by making parents think SSBs are less healthful for their children and reducing their intentions to serve SSBs to their children. Communication approaches that target healthfulness perceptions and intentions to serve SSBs may motivate parents to buy fewer SSBs for their children.

Framing of national HPV vaccine recommendations and willingness to recommend at ages 9-10.

Proactive HPV vaccination at age 9 better prevents infection and improves vaccine series completion. Because national organizations recommend starting the vaccine at different ages, we sought to understand the impact of these recommendation frames. In 2022, we surveyed 2,527 US clinical staff (45% physicians) who provide HPV vaccine for children. We randomized respondents to one of three frames based on HPV vaccine recommendations of national organizations or a no-recommendation control, and assessed willingness to recommend HPV vaccine for children ages 9-10. Respondents also reported perceived benefits of HPV vaccination at ages 9 or 12. Recommending HPV vaccination "at ages 11-12" led to lower willingness to vaccinate at ages 9-10 than control (37% vs. 54%, p < .05). Recommending vaccination "at ages 9-12" led to similar willingness as control. However, "starting at age 9" led to higher willingness than control (63% vs. 54%, p < .05). Results were similar across respondents' training, specialty, or years in practice, or their clinic's rurality or healthcare system membership. More common benefits of recommending at age 9 than 12 were avoiding the topic of sex (24% vs. 10%, OR = 2.78, 95%CI: 2.23, 3.48) and completing the vaccine series before age 13 (56% vs. 47%, OR = 1.44, 95%CI: 1.23, 1.68). Less common benefits for age 9 were having parents ready to talk about HPV vaccine and agreeing to vaccination (both p < .05). An effective way to encourage proactive HPV vaccination is to say that it starts at age 9. Aligning national recommendations to start at age 9 can promote timely vaccination.

Effect of Cigarette Constituent Messages With Engagement Text on Intention to Quit Smoking Among Adults Who Smoke Cigarettes: A Randomized Clinical Trial.

Importance: The US Food and Drug Administration (FDA) is required to communicate the risks of tobacco constituents to the public. Few studies have addressed how FDA media campaigns can effectively communicate about cigarette smoke constituents. Objective: To examine whether messages about cigarette smoke constituents are effective in reducing smoking intentions and behaviors among adults who smoke. Design, Setting, and Participants: This randomized clinical trial enrolled participants who were aged between 18 and 65 years, were English speakers, were living in the United States, and who smoked at least 100 cigarettes during their lifetime and now smoked every day or some days. Participants received daily messages via email for 15 days. Participants were randomized to 1 of 2 message conditions or a control group and reported their previous-day smoking behaviors daily. Follow-up surveys were conducted on days 16 and 32. Data were collected from June 2017 to April 2018 and analyzed from April to September 2018. Interventions: The 3 groups were (1) constituent plus engagement messages (eg, "Cigarette smoke contains arsenic. This causes heart damage.") that included the FDA as the source and engagement text (eg, "Within 3 months of quitting, your heart and lungs work better. Ready to be tobacco free? You can quit. For free nicotine replacement, call 1-800-QUIT-NOW"); (2) constituent-only messages that did not list the FDA as the source or include engagement text; and (3) a control condition with messages about littering cigarette butts. Main Outcomes and Measures: The primary outcome was the change in quit intentions (range, 1-4, with higher scores indicating stronger intentions) from pretest to day 16. Secondary outcome measures included daily smoking behaviors and quit attempts. Results: A total of 789 participants (mean [SD] age, 43.4 [12.9] years; 483 [61.2%] women; 578 [73.3%] White; 717 [90.9%] non-Hispanic) were included in the study. The mean (SD) quit intention score was 2.5 (0.9) at pretest. Mean (SE) change in quit intention score from pretest to day 16 was 0.19 (0.07) points higher in the constituent plus engagement condition than in the control condition (P = .005) and 0.23 (0.07) points higher in the constituent-only condition compared with the control condition (P = .001). Participant reports of cigarettes smoked, forgone, and butted out were similar across study conditions at baseline and did not differ significantly at days 16 and 32 across study conditions. Viewing more messages was associated with an estimated decrease of 0.15 (SE, 0.01) cigarettes smoked per day per message viewed overall across conditions. Conclusions and Relevance: To our knowledge, this is the first longitudinal test of cigarette constituent campaign messages in a national sample of adults who currently smoke. Messages about cigarette smoke constituents, with or without engagement text and source information, increased participants' intentions to quit, lending support to FDA efforts to educate consumers about such constituents. Trial Registration: ClinicalTrials.gov Identifier: NCT03339206.

E-cigarette availability, price promotions and marketing at the point-of sale in the contiguous United States (2014-2015): National estimates and multilevel correlates.

Electronic cigarette (e-cigarette) sales and use have increased rapidly, yet point-of-sale e-cigarette availability and marketing is understudied. We estimated changes in e-cigarette availability and marketing among tobacco retailers in the U.S., and associations with neighborhood characteristics. A national sample of tobacco retailers in the Contiguous U.S. was audited in 2014 and 2015 (n = 1,905 and n = 2,126, respectively) to observe e-cigarette availability and marketing (signs, ads, displays and promotions) and generate national prevalence estimates. Store, neighborhood and state level correlates of 2015 e-cigarette availability, price promotions and exterior advertising were analyzed using multilevel mixed-effects generalized linear models. E-cigarettes were sold at 72.0% of retailers in 2014 and at 79.2% in 2015. Price promotions increased from 11.9% to 20.2% of retailers. Among retailers that did not previously sell e-cigarettes in 2012, availability in 2015 was greater for retailers in neighborhoods with the highest proportion of Black residents (vs. lowest). E-cigarette price promotions were more prevalent in neighborhoods with more Hispanic residents, while exterior e-cigarette marketing was more prevalent in neighborhoods with more Black residents. State smoking prevalence was positively associated with e-cigarette availability, promotions and advertising. E-cigarette point-of-sale availability and marketing increased between 2014 and 2015 and expanded to neighborhoods with a higher proportion of Black residents between 2012 and 2015. Retailers located within states with high smoking prevalence appear to be targeted by e-cigarette marketing. As e-cigarettes become the target of more regulations, understanding changes in the e-cigarette retail environment is critical to inform potential policies regulating their sale and marketing.

Are state-level income-based disparities in adult smoking declining?

The United States (US) has identified income-based disparities in smoking as a critical public health issue, but the extent to which these disparities are changing over time within states is not well documented. This study examined recent trends in current cigarette smoking in each state and the District of Columbia by self-reported annual household income. Data came from the Behavioral Risk Factor Surveillance System, a state-representative survey of US adults. Sample sizes for each state and year ranged from 2914 to 36,955 participants. We fit logistic regression models to examine linear time trends in cigarette smoking status in each state between 2011 and 2017. In every state, the odds of smoking were 1.4 to 3.0 times greater in the lower-income group as compared to the higher-income group in 2017. Among 47 states, linear time trends in smoking did not significantly differ by income group, suggesting no change in income-based disparities. In three states (Florida, Maine, West Virginia) disparities widened, primarily because smoking prevalence only dropped among higher-income groups. Disparities declined in only one state. In New York, smoking prevalence declined more for lower-income groups compared to higher-income groups. Findings from this study suggest that little progress has been made toward reducing income-based differences in smoking and additional policy and tobacco control efforts may be required to meet national disparity reduction goals.

Neighborhood Disparities in the Availability, Advertising, Promotion, and Youth Appeal of Little Cigars and Cigarillos, United States, 2015.

INTRODUCTION: Between 2012 and 2016, sales of cigars increased by 29% in the United States. In small local studies, greater little cigar and cigarillo (LCC) availability and marketing has been documented in neighborhoods with a greater proportion of Hispanic or Latino and black residents, and near schools. This national study of cigarette retailers assesses whether LCC availability and marketing at the point of sale is associated with neighborhood racial, ethnic, income, and percent youth demographics. METHODS: In 2015, we collected LCC availability and marketing data through retailer audits of a nationally representative sample of 2128 cigarette retailers. Using 2011-2015 American Community Survey census tract estimates, we modeled associations of neighborhood demographics (in quartiles) with availability of LCC-flavored products, and presence of exterior advertisements, youth marketing, and promotions. RESULTS: Nearly 90% of retailers sold LCCs, 83.0% sold flavored LCCs, and 30.9% had youth marketing. Controlling for retailer type and other neighborhood characteristics, neighborhoods with the highest proportion of black residents had significantly higher odds of flavored LCC availability (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.52, 3.30); exterior advertisements (AOR = 2.84, 95% CI = 1.94, 4.16); price promotions (AOR = 1.62; 95% CI = 1.07-2.45), and youth appeal (AOR = 1.49, 95% CI 1.08-2.08) compared to the lowest. Disparities in flavored LCC availability, exterior advertising, and youth appeal were also present for lower income neighborhoods. CONCLUSION: Neighborhoods with a greater proportion of black or lower income residents have greater flavored LCCs availability and LCC marketing. Without stronger LCC regulation, residents of these neighborhoods may be at a greater risk of LCC use. IMPLICATIONS: LCCs are harmful combustible tobacco products that are less regulated than cigarettes (eg, lower taxation, cheaper outlay due to small package sizes, availability of flavors), which makes them an affordable and appealing product to youth. This study documents greater availability, advertising, and marketing of LCCs in neighborhoods with a higher proportion of black or lower-income residents, potentially putting these populations at a greater risk of using or switching to these products in the face of increasing cigarette regulations. These findings underscore the need for local, state, and federal LCC regulatory action.

An Eye Tracking Study of Anti-Smoking Messages on Toxic Chemicals in Cigarettes.

The US Food and Drug Administration is tasked with communicating information to the public about the harmful chemicals in cigarette smoke. Our study used eye tracking method to test the effectiveness of messages about the harmful chemicals in cigarettes smoke among adult smokers. A sample size of 211 current cigarette smokers viewed four communication messages that included: Health effects of a chemical in cigarette smoke and an image depicting the health effect. The messages focused on arsenic, formaldehyde, uranium, and general health. Eye tracking recorded the length of time participants viewed the text and the image. After each message, the participants were asked about the messages' effectiveness in changing attitudes towards smoking. We analyzed the data using multilevel modeling, and of the 211 smokers, 59.7% were female, 36.5% were Black, and 21.3% had a high school degree or less. Compared to the general message, the messages about formaldehyde and uranium were more discouraging to smoking (p < 0.05). Messages about formaldehyde were more believable and made participants want to quit more than the general messages. Increasing message dose was significantly associated with discouraging participants from smoking and made participants want to quit (p < 0.05). Our findings suggest that anti-smoking messages, containing chemical information, can successfully increase negative attitudes toward smoking cigarettes and potentially encourage quitting.

Receipt of direct tobacco mail/email coupons and coupon redemption: Demographic and socioeconomic disparities among adult smokers in the United States.

A key marketing strategy used by tobacco companies to lower tobacco product prices is the distribution of tobacco coupons via direct marketing channels such as mail or email. We analyzed data on adult smokers from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (n = 10,994) to examine the prevalence and correlates of coupon receipt via both channels, and associations with cigarette coupon redemption. Overall, 22% and 32% of smokers received tobacco coupons via email and mail, respectively, and 22% redeemed cigarette coupons. White, 25-44 year old, female, sexual minority, and more nicotine dependent smokers were more likely to receive coupons via both channels and to redeem coupons, as were smokers with mid-levels education (GED to associate degree) and those unable to pay important bills (OR email receipt = 1.37, 95% CI 1.22-1.54; OR mail receipt = 1.38, 95% CI 1.24-1.55; and OR coupon redemption = 1.44, 95% CI 1.26-1.64). Smokers who received coupons via mail only or via both channels, had three times (OR = 2.97, 95% CI 2.31-3.83) and five times (OR = 4.56, 95% CI 3.61-5.76) higher odds to redeem cigarette coupons compared to those who received them via email only. Major demographic and socioeconomic disparities exist in receipt and redemption of direct email\mail tobacco coupons among US smokers. Cigarette coupons received via direct mail are more likely to be redeemed than coupons received via email. Restrictions on tobacco coupon redemption, implemented jointly with increasing access to affordable cessation resources, may incentivize smokers vulnerable to tobacco marketing tactics to quit.

Neighbourhood disparities in the price of the cheapest cigarettes in the USA.

BACKGROUND: There is evidence that the cheapest cigarettes cost even less in neighbourhoods with higher proportions of youth, racial/ethnic minorities and low-income residents. This study examined the relationship between the price of the cheapest cigarette pack and neighbourhood demographics in a representative sample of tobacco retailers in the USA. METHODS: Data collectors recorded the price of the cheapest cigarette pack (regardless of brand) in 2069 retailers in 2015. Multilevel linear modelling examined the relationship between price and store neighbourhood (census tract) characteristics, specifically median household income and percentage of youth, Black, Asian/Pacific Islander and Hispanic residents. RESULTS: Average price for the cheapest pack was $5.17 (SD=1.73) and it was discounted in 19.7% of stores. The price was $0.04 less for each SD increase in the percentage of youth and $0.22 less in neighbourhoods with the lowest as compared with the highest median household incomes. Excluding excise taxes, the average price was $2.48 (SD=0.85), and associations with neighbourhood demographics were similar. CONCLUSION: The cheapest cigarettes cost significantly less in neighbourhoods with a greater percentage of youth and lower median household income. Non-tax mechanisms to increase price, such as minimum price laws and restrictions on discounts/coupons, may increase cheap cigarette prices.

Tobacco Marketing at SNAP- and WIC-Authorized Retail Food Stores in the United States.

Background. Lower-income families in the United States are at increased risk for food insecurity and have higher rates of tobacco use. Many retailers accepting government food assistance benefits also sell tobacco products, whose marketing promotes smoking initiation and undermines quit attempts. We examined the presence of tobacco marketing in authorized retailers in the Supplemental Nutrition Assistance Program (SNAP) and/or Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), compared with nonauthorized retailers. Method. A nationally representative sample of tobacco retailers in the contiguous United States (N = 2,054) were audited for tobacco marketing in 2015. Using generalized estimating equations, we examined the association between WIC and SNAP authorization and presence of tobacco marketing, adjusted for store type and neighborhood demographics. Results. Both WIC-authorized (odds ratio [OR] 1.7, 95% confidence interval [CI] [1.1, 2.4]) and SNAP-authorized retailers (OR 2.3, 95% CI [1.7, 3.1]) had greater odds of displaying interior tobacco price promotions, compared with stores that were not WIC/SNAP authorized. SNAP-authorized stores (compared with nonauthorized) had almost 3 times greater odds of displaying interior tobacco advertisements (OR 2.9, 95% CI [1.9, 4.5]), while WIC-authorized retailers had 80% lower odds of displaying exterior tobacco advertisements (OR 0.2, 95% CI [0.1, 0.3]). Conclusion. Millions of lower-income American families may be disproportionately exposed to tobacco marketing at food retailers. Federal, state, and local policies could create healthier retail environments by restricting the marketing and availability of tobacco products and increasing promotions and access to healthy food options.

One-item susceptibility measure predicts waterpipe and little cigar/cigarillo uptake in a national sample of adolescents and young adults in the United States.

INTRODUCTION: Adolescents and young adults in the United States (US) are increasingly using non-cigarette tobacco products such as waterpipe (WP) and little cigars/cigarillos (LCC). One way to predict which non-user adolescents and young adults are most likely to use these products is through measuring their susceptibility or openness to using the products. METHODS: We conducted a national phone survey (baseline) and an internet survey (follow-up) of adolescents and young adults (ages 13-25 years), who, at baseline, had never used WP (N=1002) or LCC (N=990). At baseline, we measured susceptibility using a single item, asking participants whether they would try WP or LCC if their best friend offered it to them, and subsequently measured uptake at follow-up. We conducted multivariate regression analyses to determine whether product-specific susceptibility was a significant predictor of uptake at follow-up. RESULTS: Participants who were susceptible and participants who had ever used another tobacco product had higher odds of using WP (AOR=3.5, AOR=4.2) and LCC (AOR=3.2, AOR=5.3) at follow-up than those who were not susceptible to those products, and had not ever used tobacco products respectively, controlling for sociodemographic factors. The one-item measure had adequate sensitivity (WP=51.4%, LCC=40.2%) and specificity (WP=84.9%, LCC=87.9%). CONCLUSIONS: Our national study of US adolescents and young adults shows that a one-item susceptibility measure at baseline was a significant predictor of WP and LCC uptake at follow-up, even after controlling for other predictors. Future research should assess the predictive validity of the one-item compared to the multi-item scale.

Adolescents' Aided Recall of Targeted and Non-Targeted Tobacco Communication Campaigns in the United States.

We examined whether advertisements from two national tobacco control campaigns targeting adolescents (i.e., The Real Cost, Fresh Empire) and one campaign targeting adults (i.e., Tips from Former Smokers) were reaching adolescents. Data came from a national sample of adolescents aged 13 to 17 years (n = 975) surveyed by phone from August 2016 to May 2017. We assessed recall and attitudes toward five specific advertisements and three campaign slogans and examined differences by sub-groups. Almost all (95%) adolescents recalled seeing at least one campaign advertisement. Aided recall of The Real Cost and Tips from Former Smokers slogans was high (65.5% and 71.6%, respectively), while aided recall of Fresh Empire slogan was lower (15.3%) (χ² p-value: p < 0.001); however, Black adolescents had higher odds of recalling the Fresh Empire ad (aOR: 2.28, 95% CI: 1.39, 3.73) and slogan (aOR: 2.64, 95% CI: 1.06, 6.54) compared to White adolescents. Increased exposure to the advertisements (i.e., recalling more advertisements) was significantly associated with higher odds of reporting negative feelings toward tobacco products in 4/5 models (aORs from 1.34 to 1.61). Large-scale national campaigns can have wide reach among both targeted and non-targeted audiences with added benefits for cumulative cross-campaign exposure to advertisements.

Disparities in retail marketing for menthol cigarettes in the United States, 2015.

This study describes retail marketing for menthol cigarettes and its relationship with neighborhood demographics in a national sample of tobacco retailers in the United States. Mixed-effects models were used to examine three outcomes: menthol cigarette exterior advertising, menthol cigarette price promotions, and the pack price of menthol and non-menthol cigarettes. Thirty-eight percent of retailers displayed at least one menthol advertisement on the store exterior and 69% advertised price promotions. Retail advertising was more common in neighborhoods in the second (OR = 1.5 [1.1, 2.0]) and fourth (OR = 1.9 [1.3, 2.7]) quartiles of Black residents as compared to the lowest quartile. Menthol advertising was more prevalent in the third (OR = 1.4 [1.0, 1.9]) and lowest (OR = 1.6 [1.2, 2.2]) income quartiles as compared to the highest quartile. Price promotions for Newport were more common in neighborhoods with the highest quartile of Black residents (OR = 1.8 [1.2, 2.7]). Prices of Newport were cheaper in neighborhoods with the highest quartiles of youth, Black residents, and lower-income households. Policies that restrict the sales and marketing of menthol cigarettes are needed to address disparities.

The effect of cigarillo packaging elements on young adult perceptions of product flavor, taste, smell, and appeal.

INTRODUCTION: Product packaging has long been used by the tobacco industry to target consumers and manipulate product perceptions. This study examines the extent to which cigarillo packaging influences perceptions of product flavor, taste, smell, and appeal. METHODS: A web-based experiment was conducted among young adults. Participants viewed three randomly selected cigarillo packs, varying on pack flavor descriptor, color, type, branding, and warning-totaling 180 pack images. Mixed-effects models were used to estimate the effect of pack elements on product perceptions. RESULTS: A total of 2,664 current, ever, and never little cigar and cigarillo users participated. Cigarillo packs with a flavor descriptor were perceived as having a more favorable taste (ß = 0.21, p < .001) and smell (ß = 0.14, p < .001) compared to packs with no flavor descriptor. Compared to packs with no color, pink and purple packs were more likely to be perceived as containing a flavor (ß = 0.11, p < .001), and were rated more favorably on taste (ß = 0.17, p < .001), smell (ß = 0.15, p < .001), and appeal (ß = 0.16, p < .001). While warnings on packs decreased favorable perceptions of product taste (pictorial: ß = -0.07, p = .03) and smell (text-only: ß = -0.08, p = .01; pictorial: ß = -0.09, p = .007), warnings did not moderate the effects of flavor descriptor or color. CONCLUSIONS: To our knowledge, this study provides the first quantitative evidence that cigarillo packaging alters consumers' cognitive responses, and warnings on packs do not suffice to overcome the effects of product packaging. The findings support efforts at federal, state, and local levels to prohibit flavor descriptors and their associated product flavoring in non-cigarette products such as cigarillos, along with new data that supports restrictions on flavor cues and colors.

Optimizing Tailored Communications for Health Risk Assessment: A Randomized Factorial Experiment of the Effects of Expectancy Priming, Autonomy Support, and Exemplification.

BACKGROUND: Health risk assessments with tailored feedback plus health education have been shown to be effective for promoting health behavior change. However, there is limited evidence to guide the development and delivery of online automated tailored feedback. OBJECTIVE: The goal of this study was to optimize tailored feedback messages for an online health risk assessment to promote enhanced user engagement, self-efficacy, and behavioral intentions for engaging in healthy behaviors. We examined the effects of three theory-based message factors used in developing tailored feedback messages on levels of engagement, self-efficacy, and behavioral intentions. METHODS: We conducted a randomized factorial experiment to test three different components of tailored feedback messages: tailored expectancy priming, autonomy support, and use of an exemplar. Individuals (N=1945) were recruited via Amazon Mechanical Turk and randomly assigned to one of eight different experimental conditions within one of four behavioral assessment and feedback modules (tobacco use, physical activity [PA], eating habits, and weight). Participants reported self-efficacy and behavioral intentions pre- and postcompletion of an online health behavior assessment with tailored feedback. Engagement and message perceptions were assessed at follow-up. RESULTS: For the tobacco module, there was a significant main effect of the exemplar factor (P=.04); participants who received exemplar messages (mean 3.31, SE 0.060) rated their self-efficacy to quit tobacco higher than those who did not receive exemplar messages (mean 3.14, SE 0.057). There was a three-way interaction between the effect of message conditions on self-efficacy to quit tobacco (P=.02), such that messages with tailored priming and an exemplar had the greatest impact on self-efficacy to quit tobacco. Across PA, eating habits, and weight modules, there was a three-way interaction among conditions on self-efficacy (P=.048). The highest self-efficacy scores were reported among those who were in the standard priming condition and received both autonomy supportive and exemplar messages. In the PA module, autonomy supportive messages had a stronger effect on self-efficacy for PA in the standard priming condition. For PA, eating habits, and weight-related behaviors, the main effect of exemplar messages on behavioral intentions was in the hypothesized direction but did not reach statistical significance (P=.08). When comparing the main effects of different message conditions, there were no differences in engagement and message perceptions. CONCLUSIONS: Findings suggest that tailored feedback messages that use exemplars helped improve self-efficacy related to tobacco cessation, PA, eating habits, and weight control. Combining standard priming and autonomy supportive message components shows potential for optimizing tailored feedback for tobacco cessation and PA behaviors.

Do Smokers Recall Source or Quitline on Cigarette Constituent Messages?

OBJECTIVES: The Food and Drug Administration (FDA) is required under the Family Smoking Prevention and Tobacco Control Act to communicate the risks of tobacco use to the public. Little research exists about methods to communicate the constituents of tobacco in a media campaign. This research examines specific strategies to increase effectiveness of a media campaign for cigarette smoking adults about tobacco constituents by including engagement text about smoking cessation and FDA as the source of the campaign. METHODS: In an eye tracking study of 211 current cigarette smokers, participants randomly viewed 4 cigarette constituent messages that varied engagement text for quitting (benefits of quitting and quitline number, presence, absence) and by FDA source (presence, absence). After the eye tracking session, participants were asked about recall of the national quitline number and the source of message. RESULTS: Participants in conditions with engagement text were significantly more likely than those in the no engagement conditions to recall the national quitline number. Few participants saw or recalled the FDA source. CONCLUSIONS: Engagement text for smoking cessation on constituent communication campaign messages significantly increases recall of the quitline, an important resource for smokers.