Differences in Presenting Health Warning Labels on Hookah Venue Menus Between Immersive Virtual Reality and Online Surveys.

BACKGROUND: Virtual reality (VR) platforms can simulate the real world, whereas online surveys are efficient settings for assessing and testing information. In this study, the effects of presenting health warning labels (HWLs) on hookah venue menus were compared between these two message-testing settings. METHODS: Separate studies were conducted in VR (n = 96) and online survey (n = 213) settings. Participants in both studies were randomly assigned to view menus with or without HWLs. This secondary data analysis compared outcomes between settings after propensity score weighting to account for differences in age, race, marital status, and education between studies. RESULTS: Significant between-study differences were noted for the effects of HWLs on people's perceptions of the absolute harm of hookah smoking (p = 0.0363), the relative harm of hookah compared to cigarettes (p < 0.001), the absolute addictiveness of hookah (p < 0.001), and the relative addictiveness of hookah compared to cigarettes (p = 0.0352). When outcome variables differed significantly between the HWL and control conditions in only one of the two studies, smaller p-values were identified for the online survey setting than for the VR setting. CONCLUSIONS: This study represents the first direct comparison of the effects of hookah HWLs between two message-testing settings. HWLs tested in the online survey setting were associated with larger shifts in attitudes and beliefs than those tested in the VR setting, suggesting that the effectiveness of hookah HWLs on attitudes and beliefs may be moderated by the message-testing platform. Additional real-world experiments remain necessary to determine whether either setting can accurately assess the effectiveness of HWLs.

A qualitative analysis of Ethiopian and Eritrean Americans' initiation and continuation of hookah smoking.

Hookah smoking is emerging as a popular social practice and health behavior risk among Ethiopian and Eritrean Americans. This qualitative study was the second phase of a sequential exploratory mixed methods study and examined factors that enable the initiation and facilitate the continuation of hookah smoking among Ethiopian and Eritrean Americans. Semi-structured interviews were conducted with twenty-five Ethiopian and Eritrean American hookah smokers residing in the Washington, DC Metropolitan Area of the United States. Interview questions were guided by the Theory of Planned Behavior and addressed: (1) initiation of hookah smoking, (2) past and current patterns of hookah smoking, and (3) behavioral, control and normative beliefs toward hookah smoking. Several themes were identified under the core constructs of 'factors influencing hookah smoking initiation' and 'factors influencing hookah smoking continuation' such as curiosity, lack of health knowledge, socio-cultural acceptance, accessibility, flavor, physical dependence, physiological effects and social connections. Based on these findings, it is recommended that future prevention activities (e.g. health messages) be embedded into a comprehensive tobacco prevention approach to address individual misperceptions of harm and addiction, community social norms and environmental access around hookah smoking, which contribute to both initiation and continuation in the Ethiopian and Eritrean American populations.

Visual Attention to Health Warning Labels on Waterpipe Venue Menus in Immersive Virtual Reality.

INTRODUCTION: This study examined how health warning labels (HWL) on a waterpipe venue menu captured and held the attention of consumers and influenced waterpipe tobacco smoking (WTS) attitudes, beliefs, and behaviors. AIMS AND METHODS: A randomized experiment (N = 96) of young adult waterpipe smokers was conducted in an immersive virtual reality laboratory. Participants viewed one of two virtual reality scenarios, a menu with an HWL and nicotine concentration or menu without an HWL and nicotine concentration. Eye-tracking metrics were collected, and participants completed posttest questionnaires on demographics, tobacco use history, and WTS attitudes, beliefs, and behaviors. T-tests were used to assess group differences, and a mediation analysis conducted to examine the relationship between the HWL and intention to quit WTS. RESULTS: Participants in the HWL group demonstrated greater visual attention to the warning and nicotine areas and less visual attention to the flavor and ingredients areas of the menu compared to the control group. The HWL group demonstrated greater negative attitudes toward WTS (p = .002), greater perceived risk of decreased lung function (p = .026), and greater intention to quit WTS (p = 0.003). The mediation model indicated the relationship between the HWL on a menu and intention to quit WTS was mediated by an increase in negative attitudes toward WTS. CONCLUSIONS: The HWLs on a menu captured and held the attention of consumers and increased negative attitudes, perceptions of health risk, and intention to quit WTS indicating potential benefit of including a warning label or nicotine concentration on menus to correct misperceptions of WTS. IMPLICATIONS: The study contributes to the broader literature on communicating the harms and risks of WTS. The findings suggest that HWL and nicotine concentration on waterpipe venue menus attract attention from consumers in environments comparable to the real world and the strategy warrants further exploration as a targeted policy intervention to educate the public and reduce the health burden of WTS.

Using Electrophysiological Measures to Assess the Consumer Acceptability of Smokeless Tobacco Products.

INTRODUCTION: Adequate evaluation of novel tobacco products must include investigation of consumers' psychological response to such products. Traditionally, subjective scales of product liking have been used to assess consumer acceptability of tobacco products. However, subjective scales may miss cognitive changes that can only be captured by direct neurophysiological assessment. The present investigation explored the viability of using electroencephalography (EEG), in combination with traditional subjective measures, to assess consumer acceptability of five smokeless tobacco products. Given previous work linking product liking to arousal/attentional (executive function) enhancement, we focused on EEG measures of attention/arousal to objectively characterize cognitive changes associated with tobacco product use. METHODS: During five separate laboratory visits, smokeless tobacco users used Verve discs, Ariva dissolvables, Skoal snuff, Camel snus, or Nicorette lozenges. The N2 and P3b event-related potential components elicited by an oddball task were used to index attentional changes before/after product usage. Additionally, resting state alpha band EEG activity was analyzed before/after product usage to index cortical arousal. RESULTS: Although analyses of the subjective results provided limited inference, analyses of the electrophysiological measures, particularly the alpha suppression measure, revealed robust differences between products. Skoal elicited significantly enhanced alpha suppression compared to all four other products tested. Additionally, alpha suppression was found to correlate positively with subjective measures of satisfaction and psychological reward, but was unrelated to perceived aversion. CONCLUSIONS: The present results provide evidence that electrophysiological measures can yield important insights into consumer acceptability of novel tobacco products and are a valuable complement to subjective measures. IMPLICATIONS: This study is the first to employ a combination of electrophysiological measures and traditional subjective assays in order to assess the consumer acceptability of smokeless tobacco products. The results highlight the importance of adopting a multidimensional/multi-method approach to studying the consumer acceptability of tobacco products.

Health Information on Waterpipe Lounge Menus to Educate Young Adults: Pilot Study Findings.

BACKGROUND: For years, tobacco risk communication has largely focused on cigarette smoking. New strategies must be developed to adapt to emerging tobacco products, such as waterpipe tobacco smoking (WTS). AIMS: The purpose of this pilot study was to determine the preliminary effects of health information on waterpipe lounge menus on the perceptions of harm and risk from WTS and inform future efficacy interventions for health communication (i.e., educating populations on the risks, harms, and health consequences of WTS). METHOD: Participants aged 18 to 24 years (n = 213) who smoked waterpipe at least monthly were randomized to one of four waterpipe lounge menu groups using a two-by-two experimental design with "warning message" and "nicotine content" as factors. RESULTS: Those who viewed waterpipe lounge menus that included a warning message had greater perceived relative harm to health and perceived risk of decreased lung function from WTS. Those who viewed waterpipe lounge menus that included nicotine content had greater perceived risk of heart attack from WTS. DISCUSSION: Participants who were exposed to health warnings of WTS and information on the nicotine content of waterpipe tobacco increased on measures of perceived relative harm and risk of health consequences. CONCLUSION: The pilot test results indicate promise for providing health information on waterpipe lounge menus to educate young adults on the harms and risks of WTS.

Assessing the Knowledge, Attitudes, and Behaviors of Hookah Smoking among Ethiopian and Eritrean Americans.

The aims of this study were to estimate the prevalence of hookah smoking and describe its associated knowledge, attitudes, and behaviors among Ethiopian and Eritrean Americans. Approximately 400 participants completed an online survey on hookah tobacco use, perceptions of harm and social acceptability. Nearly 80% had tried hookah in their lifetime (ever users), and about 43% had smoked hookah in the past 30 days (current users). Hookah ever use was highest among people 24-29 years of age, but there were no significant differences by gender, education or employment. Ever users were less supportive of bans on hookah smoking in a bar or restaurant compared with never users, X2 (3, N = 396) = 57.56, p<.001. Additionally, ever users more often reported hookah smoking was less harmful than cigarette smoking compared with never users. Future research is needed to understand the predictors of hookah smoking in this subpopulation and inform interventions.