Despite high objective numeracy, lower numeric confidence relates to worse financial and medical outcomes.

People often laugh about being "no good at math." Unrecognized, however, is that about one-third of American adults are likely too innumerate to operate effectively in financial and health environments. Two numeric competencies conceivably matter-objective numeracy (ability to "run the numbers" correctly; like literacy but with numbers) and numeric self-efficacy (confidence that provides engagement and persistence in numeric tasks). We reasoned, however, that attaining objective numeracy's benefits should depend on numeric confidence. Specifically, among the more objectively numerate, having more numeric confidence (vs. less) should lead to better outcomes because they persist in numeric tasks and have the skills to support numeric success. Among the less objectively numerate, however, having more (vs. less) numeric confidence should hurt outcomes, as they also persist, but make unrecognized mistakes. Two studies were designed to test the generalizability of this hypothesized interaction. We report secondary analysis of financial outcomes in a diverse US dataset and primary analysis of disease activity among systemic lupus erythematosus patients. In both domains, best outcomes appeared to require numeric calculation skills and the persistence of numeric confidence. "Mismatched" individuals (high ability/low confidence or low ability/high confidence) experienced the worst outcomes. For example, among the most numerate patients, only 7% of the more numerically confident had predicted disease activity indicative of needing further treatment compared with 31% of high-numeracy/low-confidence patients and 44% of low-numeracy/high-confidence patients. Our work underscores that having 1 of these competencies (objective numeracy or numeric self-efficacy) does not guarantee superior outcomes.

Pictorial Warning Labels and Memory for Cigarette Health-risk Information Over Time.

BACKGROUND: Pictorial cigarette warning labels are thought to increase risk knowledge, but experimental research has not examined longer-term effects on memory for health risks named in text. PURPOSE: To investigate memory-consolidation predictions that high- versus low-emotion warnings would support better long-term memory for named cigarette health risks and to test a mediational model of warning-label effects through memory on risk perceptions and quit intentions. METHODS: A combined sample of U.S.-representative adult smokers, U.S.-representative teen smokers/vulnerable smokers, and Appalachian-representative adult smokers were randomly assigned to a warning-label condition (High-emotion pictorial, Low-emotion pictorial, Text-only) in which they were exposed four times to nine warning labels and reported emotional reactions and elaboration. Memory of warning-label risk information, smoking risk perceptions, and quit intentions were assessed immediately after exposures or 6 weeks later. RESULTS: Recall of warning-label text was low across the samples and supported memory-consolidation predictions. Specifically, immediate recall was highest for Low-emotion warnings that elicited the least emotion, but recall also declined the most over time in this condition, leaving its 6-week recall lowest; 6-week recall was similar for High-emotion and Text-only warnings. Greater recall was associated with higher risk perceptions and greater quit intentions and mediated part of warning-label effects on these important smoking outcomes. High-emotion warnings had additional non-memory-related effects on risk perceptions and quit intentions that were superior to text-only warnings. CONCLUSIONS: High- but not Low-emotion pictorial warning labels may support the Food and Drug Administration's primary goal to "effectively convey the negative health consequences of smoking." CLINICALTRIALS.GOV IDENTIFIER: NCT03375840.

Effects of Pictorial Warning Labels for Cigarettes and Quit-Efficacy on Emotional Responses, Smoking Satisfaction, and Cigarette Consumption.

Background: Experimental research on pictorial warning labels for cigarettes has primarily examined immediate intentions to quit. Purpose: Here, we present the results of a clinical trial testing the impact on smoking during and after a 28-day period of naturalistic exposure to pictorial versus text-only warnings. Methods: Daily cigarette smokers (N = 244) at two sites in the USA were randomly assigned to receive their regular brand of cigarettes for 4 weeks with one of three warnings: (a) text-only, (b) pictures and text as proposed by FDA, or (c) the warnings proposed by FDA with additional text that elaborated on the risks of smoking. Analyses examined the effects of pictorial versus text-only warnings and self-efficacy for quitting on cigarette consumption during and 1 month after the trial as mediated by emotional and cognitive responses as well as satisfaction with smoking. Results: Stronger emotional responses to pictorial than text-only warnings predicted reduced satisfaction with smoking during the trial and lower cigarette consumption at follow-up among the majority of smokers who continued to smoke. Consistent with the efficacy-desire model, those with moderate efficacy reported the greatest reduction in consumption at follow-up. However, a small proportion of smokers (7%) who reported 7-day abstinence at follow-up did not exhibit a significant relation with self-efficacy. Conclusions: Pictorial warning labels proposed by FDA create unfavorable emotional reactions to smoking that predict reduced cigarette use compared to text alone, with even smokers low in self-efficacy exhibiting some reduction. Predictions that low self-efficacy smokers will respond unfavorably to warnings were not supported.

Cigarette Graphic Warning Labels Are Not Created Equal: They Can Increase or Decrease Smokers' Quit Intentions Relative to Text-Only Warnings.

INTRODUCTION: Cigarette graphic-warning labels elicit negative emotion. Research suggests negative emotion drives greater risk perceptions and quit intentions through multiple processes. The present research compares text-only warning effectiveness to that of graphic warnings eliciting more or less negative emotion. METHODS: Nationally representative online panels of 736 adult smokers and 469 teen smokers/vulnerable smokers were randomly assigned to view one of three warning types (text-only, text with low-emotion images, or text with high-emotion images) four times over 2 weeks. Participants recorded their emotional reaction to the warnings (measured as arousal), smoking risk perceptions, and quit intentions. Primary analyses used structural equation modeling. RESULTS: Participants in the high-emotion condition reported greater emotional reaction than text-only participants (bAdult = 0.21; bTeen = 0.27, p's < .004); those in the low-emotion condition reported lower emotional reaction than text-only participants (bAdult = -0.18; bTeen = -0.22, p's < .018). Stronger emotional reaction was associated with increased risk perceptions in both samples (bAdult = 0.66; bTeen = 0.85, p's < .001) and greater quit intentions among adults (bAdult = 1.00, p < .001). Compared to text-only warnings, low-emotion warnings were associated with reduced risk perceptions and quit intentions whereas high-emotion warnings were associated with increased risk perceptions and quit intentions. CONCLUSION: Warning labels with images that elicit more negative emotional reaction are associated with increased risk perceptions and quit intentions in adults and teens relative to text-only warnings. However, graphic warnings containing images which evoke little emotional reaction can backfire and reduce risk perceptions and quit intentions versus text-only warnings. IMPLICATIONS: This research is the first to directly manipulate two emotion levels in sets of nine cigarette graphic warning images and compare them with text-only warnings. Among adult and teen smokers, high-emotion graphic warnings were associated with increased risk perceptions and quit intentions versus text-only warnings. Low-emotion graphic warnings backfired and tended to reduce risk perceptions and quit intentions versus text-only warnings. Policy makers should be aware that merely placing images on cigarette packaging is insufficient to increase smokers' risk perceptions and quit intentions. Low-emotion graphic warnings will not necessarily produce desired population-level benefits relative to text-only or high-emotion warnings.

How Do Health Literacy, Numeric Competencies, and Patient Activation Relate to Transition Readiness in Adolescents and Young Adults With Rheumatic Diseases?

OBJECTIVE: To evaluate how demographics, health literacy, numeracy, and patient activation are related to transition readiness in adolescent and young adult (AYA) patients and to describe how parent/guardian (PG) performance on these metrics predicts AYA patients' transition readiness. METHODS: In this single center, cross-sectional study, consecutive English-speaking AYA patients ages 17-21 years and PGs were recruited from outpatient rheumatology clinics. Participants completed the following self-reported instruments: demographic questionnaire, Short Test of Fundamental Health Literacy, Objective Numeracy Scale, Subjective Numeracy Scale, Symbolic-number mapping, Patient Activation Measure, and Transition Readiness Assessment Questionnaire (TRAQ; AYA patients only). RESULTS: Ninety-one AYA patients participated in the study, of whom 64 of 91 (70%) had juvenile idiopathic arthritis, and 54 PGs. Mean ± SD TRAQ score was 4.0 ± 0.65, correlating with "I am starting to do this" stage of change. Most participants (98%) had adequate health literacy. Multivariable regression analysis showed that AYA patients of female sex, older age, and higher patient activation significantly predicted higher TRAQ scores (P < 0.05). No PG characteristics were linked to higher AYA patient TRAQ scores. CONCLUSIONS: Transition readiness in AYA patients as measured by TRAQ is associated with female sex, older age, and higher patient activation. Though sex and age are nonmodifiable, interventions to boost patient activation represent a promising opportunity to improve transition readiness and outcomes.

Cigarette graphic warning labels increase both risk perceptions and smoking myth endorsement.

OBJECTIVE: Cigarette graphic warning labels elicit negative emotion, which increases risk perceptions through multiple processes. We examined whether this emotion simultaneously affects motivated cognitions like smoking myth endorsement (e.g. 'exercise can undo the negative effects of smoking') and perceptions of cigarette danger versus other products. DESIGN: 736 adult and 469 teen smokers/vulnerable smokers viewed one of three warning label types (text-only, low emotion graphic or high emotion graphic) four times over two weeks. MAIN OUTCOME MEASURES: Emotional reactions to the warnings were reported during the first and fourth exposures. Participants reported how often they considered the warnings, smoking myth endorsement, risk perceptions and perceptions of cigarette danger relative to smokeless tobacco and electronic cigarettes. RESULTS: In structural equation models, emotional reactions influenced risk perceptions and smoking myth endorsement through two processes. Emotion acted as information about risk, directly increasing smoking risk perceptions and decreasing smoking myth endorsement. Emotion also acted as a spotlight, motivating consideration of the warning information. Warning consideration increased risk perceptions, but also increased smoking myth endorsement. Emotional reactions to warnings decreased perceptions of cigarette danger relative to other products. CONCLUSIONS: Emotional reactions to cigarette warnings increase smoking risk perceptions, but also smoking myth endorsement and misperceptions that cigarettes are less dangerous than potentially harm-reducing tobacco products.

Improving numeracy through values affirmation enhances decision and STEM outcomes.

Greater numeracy has been correlated with better health and financial outcomes in past studies, but causal effects in adults are unknown. In a 9-week longitudinal study, undergraduate students, all taking a psychology statistics course, were randomly assigned to a control condition or a values-affirmation manipulation intended to improve numeracy. By the final week in the course, the numeracy intervention (statistics-course enrollment combined with values affirmation) enhanced objective numeracy, subjective numeracy, and two decision-related outcomes (financial literacy and health-related behaviors). It also showed positive indirect-only effects on financial outcomes and a series of STEM-related outcomes (course grades, intentions to take more math-intensive courses, later math-intensive courses taken based on academic transcripts). All decision and STEM-related outcome effects were mediated by the changes in objective and/or subjective numeracy and demonstrated similar and robust enhancements. Improvements to abstract numeric reasoning can improve everyday outcomes.