Effects of pictorial warning labels depicting lesser-known and well-known risks of smoking on viewing patterns, recall, and knowledge of smoking harms.

BACKGROUND: In 2019, the Food and Drug Administration introduced 11 pictorial warning labels (PWLs) for inclusion on cigarette packages, created in compliance with court recommendations and tailored to increase knowledge of smoking harms. Several highlighted lesser-known risks of smoking. No behavioral studies have yet evaluated how risk content in PWLs impacts viewing patterns, recall, and knowledge of smoking harms. METHODS: Seventy adults who reported smoking cigarettes daily (62.9% male, 57.1% African American, mean age = 50.3, mean cigarettes per day = 14.4) completed a single-session laboratory study. They were randomized to view a set of four PWLs depicting either lesser-known or well-known risks of smoking while having eye movements recorded, then completed post-exposure recall and knowledge measures. RESULTS: Participants exposed to PWLs depicting lesser-known smoking risks viewed the text of the warning sooner and for longer than the image (p's <0.05); those exposed to PWLs depicting well-known risks viewed the image longer than text (p <0.001). PWL condition did not affect recall of text or image (p's >0.1). Those viewing lesser-known (vs. well-known) risks had greater knowledge of smoking causing lesser-known risks of bladder cancer, blindness, bloody urine, cataracts, diabetes, and head and neck cancer (p's <0.001). CONCLUSIONS: Individuals viewing PWLs depicting lesser-known (vs. well-known) smoking risks visually engaged with the PWL text more than image, had similarly high recall of PWL content, and had greater knowledge of lesser-known risks of smoking. Findings suggest including lesser-known risk information on PWLs improves overall knowledge of smoking health risks.

Assessing Attention to Tobacco Warnings With a Heatmapping Task.

INTRODUCTION: Attention is a critical outcome to understanding the impacts of tobacco warning labels and is commonly measured using eye tracking. Self-report, online methods may be efficient, scalable alternatives to capture attention. This study assesses warning label attention on cigarette marketing using a heatmapping task. METHODS: Young adults (n=1,608) aged 18-30 years and registered on Mechanical Turk with a WorkerID verified in the U.S. were included. Data were collected in 2021-2022 and analyzed in 2022. Tobacco advertisement exposure included a 2 × 3 between-subjects factorial design for varying contexts and warnings. Attention was operationalized with self-reported frequency and timing of warning selection. Outcomes include credibility, willingness to use the advertised cigarettes, and intentions to use cigarettes and low-nicotine cigarettes. RESULTS: Early and more frequent attention to the warning was associated with higher credibility (frequent: ß=0.28, 95% CI=0.11, 0.44; early: ß=0.14, 95% CI=0.02, 0.25), lower willingness to use the advertised cigarettes (frequent: ß= -1.78, 95% CI= -2.24, -1.32; early: ß= -1.16, 95% CI= -1.49, -0.84), lower cigarette use intentions in the next week (frequent: ß= -0.44, 95% CI= -0.64, -0.25; early: ß= -0.21, 95% CI= -0.35, -0.08), and lower low-nicotine cigarette use intentions in the next week (frequent: ß= -0.47, 95% CI= -0.66, -0.28; early: ß= -0.25, 95% CI= -0.38, -0.12) than no attention at all. CONCLUSIONS: Greater attention as measured by a heatmapping task was observed for pictorial warnings and associated with lower intentions to use tobacco. Heatmapping selection patterns were a suitable proxy for attention in this online sample.

Construct validity of the Cigarette Ratings Scale and associations with tobacco use and product feature outcomes.

BACKGROUND: Subjective ratings are inconsistently associated with behavioral outcomes such as tobacco use and there is no current standard. The Cigarette Ratings Scale is an ideal measure for further evaluation because it has been widely used in tobacco regulatory science and tobacco industry research. PURPOSE: This study investigated the construct validity of the Cigarette Ratings Scale and associations with tobacco use and product feature outcomes. METHODS: Using secondary analysis of baseline data from five research trials, we conducted an exploratory factor analysis in one sample and validated the factor solution in a second sample. We then examined the relationship of the averaged subscales with tobacco outcomes and cigarette product features among current adult cigarette smokers (N = 752) who smoked ≥ 5 cigarettes daily for ≥ 5 years. RESULTS: The results supported a three-factor solution: 1. Product harshness evaluation, 2. Smoking satisfaction, and 3. Positive sensory experience. Multivariable general linear models indicated that cigarettes per day was associated with a lower harshness rating b = -0.29 (95% CI: -0.51, -0.07) and higher positive sensory experience b = 0.32 (95% CI: 0.08, 0.56). FTND average dependence scores were associated with a more positive sensory experience b = 1.08 (95% CI: 0.28, 1.89). CO boost was associated with smoking satisfaction b = 0.77 (95% CI: 0.30, 1.26). CONCLUSIONS: The Cigarette Ratings Scale subscales were primarily associated with behavioral outcomes, biological exposure, and nicotine dependence. This can help addiction efforts to determine how subjective evaluations of tobacco products relate to use behaviors.

Shedding 'light' on cigarette pack design: colour differences in product perceptions, use and exposure following the US descriptor ban.

INTRODUCTION: Many countries removed misleading descriptors (eg, 'light,' 'mild') from cigarette packaging because they falsely conveyed messages of reduced risk. It is unclear if relabelled products currently promote misperceptions or differences in product use and toxicant exposure. We compared product perceptions, use and exposure between a US sample of Marlboro Gold (formerly 'light') and Red smokers. METHODS: 240 non-treatment-seeking adult daily Marlboro smokers (70% male, 71% White, mean cigarettes/day=16.4 (SD=8.3)) completed two laboratory sessions over a 5-day period. During sessions, participants smoked two cigarettes through a topography device to capture their puffing behaviour, provided precigarette and postcigarette carbon monoxide (CO) assessments, and completed risk perception and subjective rating questionnaires. Self-reported cigarettes per day were verified via daily filter collection; urine collected at the end of the period was assayed for nicotine metabolites. RESULTS: Gold (n=49) smokers were more likely than Red (n=191) to incorrectly believe their cigarettes had less nicotine and tar than regular cigarettes (ps<0.001), and rated them as weaker, less harsh, and mild tasting (ps<0.05). Differences between Red and Gold smokers in cigarettes per day and puffing behaviours trended towards significance (ps<0.1). Notably, there were no group differences on CO boost or total nicotine equivalents (ps>0.1). CONCLUSIONS: Misperceptions about nicotine and tar exist years after rebranding Marlboro Lights as Marlboro Gold. Biological results support that Gold smokers do not have lower toxicant exposure. The US should consider comprehensive packaging or product design regulations to properly inform smokers of product risks.Trial registeration number NCT02301351.

Cognitive and emotional responses to pictorial warning labels and their association with quitting measures after continued exposure.

OBJECTIVE: Previous research has highlighted the role of cognitive and affective mediators in facilitating the effectiveness of pictorial warning labels (PWLs). This study examines smokers' responses towards PWLs after 10 days of use and their associations with changes in quitting attitudes, beliefs, and intentions during this period. METHODS: Non-treatment-seeking, daily smokers completed a randomized, parallel design trial. Participants were randomized to either a PWL or control (i.e., text only or no warning label) group and received their preferred brand cigarettes affixed with their assigned label for 10 days. We assessed quitting attitudes, intentions, and beliefs at the onset and end of the study. At study end, smokers rated their PWL on a 5-point scale for 8 cognitive and emotional attributes: memorable, understandable, shocking, informative, offensive, boring, relevant, and interesting. RESULTS: Mean ratings of the PWLs were high for memorable, understandable, informative, relevant, and interesting (range = 3.4 to 4.0), moderate for shocking (2.9), and low for offensive (1.7), and boring (1.5). Among the PWLs, quitting-related attitudes, positive beliefs, and intentions increased over the study period (p < .001) and these changes were positively associated with most attributes except offensive and boring (p < .05). For the text-only label group, attitudes and intentions increased significantly but these changes were not associated with any attributes. CONCLUSION: Smokers generally have favorable evaluations of PWLs following repeated exposures. Further, these evaluations are associated with increased quitting attitudes and intentions, which may facilitate cessation attempts over longer periods of exposure.

Responses to reduced nicotine cigarette marketing features: a systematic review.

OBJECTIVE: To systematically review the literature regarding responses to commercial and public health marketing features for reduced nicotine cigarettes (RNCs) to anticipate potential industry and regulatory actions should an RNC product standard be issued. DATA SOURCES: We searched PubMed for English-language articles using several keywords for reduced nicotine products, cigarettes and marketing features published through 2020. STUDY SELECTION: Of 4092 records, 26 studies were retained for review that met criteria focusing on responses to RNC marketing features. DATA EXTRACTION: Search terms created by the research team were used for review and included independent extraction and coding by two reviewers. Coding was categorised using study design terminology, commercial and public health features in tobacco regulatory science, and their association with individual responses outlined by several message processing outcomes. DATA SYNTHESIS: Most studies focused on current cigarette smokers and were cross-sectional. Reactions to RNCs and attitudes and beliefs were the most common outcomes measured. For commercial features, articles generally studied RNC advertisements, products and/or descriptors. For public health features, articles studied counter-messaging (eg, warning labels) or general descriptors about nicotine or a reduced nicotine product standard. Commercial features were generally associated with favourable responses. Public health features offset favourable responses across most outcomes, though their efficacy was mixed. Contrasts in results by smoking status are discussed. CONCLUSIONS: Commercial marketing of RNCs is appealing and may need stronger regulations or communication campaigns to accurately convey risks. Opportunities exist for future research within tobacco regulatory science.

Comparing video observation to electronic topography device as a method for measuring cigarette puffing behavior.

BACKGROUND: Smoking topography, or puffing behavior, is an important measure of how consumers may use tobacco products. However, numerous issues may prevent collection of this data via in-person, electronic topography device (e.g., CReSS). This study compared cigarette topography measures collected by video observation and electronic device. METHODS: Laboratory smoking sessions were video recorded and scored for 96 cigarettes collected from 34 daily, adult non-treatment-seeking smokers (73.5 % male, 82.4 % White). Participants smoked three of their preferred brand cigarettes using an electronic topography device, providing carbon monoxide (CO) samples before and after each cigarette. Analyses compared measures from both assessment methods and examined associations with device-obtained total puff volume and CO boost. RESULTS: Agreement analyses indicated robust similarity between methods for measures of puff count and total interpuff interval (Intraclass Correlation Coefficient [ICC]'s > 0.96,p's < 0.001; Bland-Altman [B-A] plotted differences within a priori limit of clinical significance) but diverged on total duration (ICC's > .93, p's < .001, yet B-A plots outside a priori limits). Regardless of assessment method, total duration and puff count (but not total interpuff interval) predicted total puff volume (p's < .001). None predicted CO boost (p's = .07-.90)." CONCLUSIONS: Although some topography outcomes (e.g., total puff volume) cannot be assessed via video observation, video-observed measures of puff count, total duration, and total interpuff interval are generally interchangeable with their topography device-obtained counterparts. Thus, video observation is likely a sufficient substitute method for assessing cigarette topography when using an electronic device is not possible.

Temporal Effects of Message Congruency on Attention to and Recall of Pictorial Health Warning Labels on Cigarette Packages.

OBJECTIVES: Recent research has shown that message congruency is beneficial to recall of pictorial health warning label (PWL) content after initial exposure. Despite less attention to the text warning, smokers exposed to congruent PWLs were more likely to recall the text and the message. This study aimed to replicate these findings and to examine whether congruency also affects recall after multiple exposures over time. METHODS: A total of 320 daily smokers (39.7% female; cigarettes/day: M = 15.31, SD = 7.15) were randomized to one congruent or incongruent PWL and attended 4 laboratory sessions over 10 days. During each session, eye movements were recorded while viewing the PWL and open-ended recall of label content was assessed after exposure. RESULTS: Smokers who were exposed to a congruent PWL were more likely to recall the text (p = .01) and the message (p = .02) and less likely to recall the image (p = .003) of the PWL after initial exposure. By day 4, incongruent PWLs were recalled equally well as congruent PWLs. Independent of condition, image recall was initially high and remained high whereas text and message recall was relatively low initially but increased over time. It was not until day 7 that about 80% of text and message recall was observed. CONCLUSIONS: Even when exposed to the same PWL over time, smokers require multiple exposures to recall the text and the message of a PWL. More research on the effects of congruency in the natural environment, where smokers are exposed to multiple PWLs, is needed. IMPLICATIONS: The findings of this study, and of previous work showing that message congruency in PWLs is beneficial to initial recall of PWL content, could potentially help to address legal challenges regarding the implementation of PWLs in the United States. Factually correct text warnings have been uncontested on US cigarettes packages since 1966. Congruent PWLs simply provide a means to visually support the same information as the existing text using a medium that better garners attention to the health information. Investigating and understanding longer-term effects of congruency are important and can empirically inform future warning label development, both in the United States via the Family Smoking Prevention and Tobacco Control Act, and via other governing bodies.

Visual Attention Patterns Differ by Pictorial Health Warning Label Features.

OBJECTIVES: In this study, we sought to determine how smokers allocate their attention when viewing the 9 cigarette pictorial warning labels (PWLs) proposed by the Food and Drug Administration (FDA), and identify PWL attributes associated with increased attention. METHODS: Using eye-tracking data from an exploratory within-subject study, we examined smokers' attention (latency, latency duration, and dwell time) to areas of interest (image vs textual warning) for each PWL among 95 daily, non-treatment-seeking smokers (62.1% male, 48.4% white, mean [SD] age = 32.98 [10.14], mean [SD] cigarettes/day = 15.51 [8.43]). We also compared attention measures by PWL message congruency, textual warning location, and participant rankings of effectiveness. RESULTS: Attention measures differed significantly among PWLs (p s < .001) and by features and self-reported effectiveness rankings (p s < .001 - .039). Congruent PWLs, those displaying text across the warning label, and those ranked most effective were associated with sustained attention to image, whereas incongruent PWLs, those displaying left text, and those ranked least effective, were associated with faster and sustained attention to text. CONCLUSIONS: Smokers allocated their attention differently across PWLs. Formats and participant effectiveness rankings of PWLs were associated with visual attention patterns, suggesting the importance of these features to the design of potential future PWLs.

Nicotine Replacement, Topography, and Smoking Phenotypes of E-cigarettes.

OBJECTIVES: Little is known about the degree of nicotine replacement across first-generation e-cigarette brands, how e-cigarettes are used, and if there is variation across brands in relevant smoking phenotypes. The objective of this project was to collect data that are critical to better understanding, use, and exposure when using e-cigarettes, which may then inform clinical trials and tobacco regulatory policy. METHODS: Twenty-eight cigarette smokers were randomized to use one of 5 popular brands of e-cigarettes for a 10-day study. Day 1 (own cigarette brand) data established baseline levels for cotinine, carbon monoxide (CO), topography, cigarette liking, withdrawal, and craving. Participants returned on Days 5 and 10 to reassess these measures while exclusively using e-cigarettes. RESULTS: Compared to cigarette smoking, e-cigarettes provided significantly lower nicotine levels (25%-50%), reduced CO exposure, and lower ratings of liking (p < .05). Topography significantly differed between cigarette and e-cigarette sessions (p < .05). All brands significantly reduced withdrawal and craving (p < .05). There were no significant brand differences in outcome measures associated with exposure or use. CONCLUSIONS: E-cigarettes are not liked as much as cigarettes, provide significantly lower nicotine replacement, reduce CO exposure, and mitigate withdrawal and craving. The patterns of use significantly differ compared to cigarette smoking.

Using eye-tracking to examine how embedding risk corrective statements improves cigarette risk beliefs: Implications for tobacco regulatory policy.

BACKGROUND: Tobacco companies have deliberately used explicit and implicit misleading information in marketing campaigns. The aim of the current study was to experimentally investigate whether the editing of explicit and implicit content of a print advertisement improves smokers' risk beliefs and smokers' knowledge of explicit and implicit information. METHODS: Using a 2(explicit/implicit)×2(accurate/misleading) between-subject design, 203 smokers were randomly assigned to one of four advertisement conditions. The manipulation of graphic content was examined as an implicit factor to convey product harm. The inclusion of a text corrective in the body of the ad was defined as the manipulated explicit factor. Participants' eye movements and risk beliefs/recall were measured during and after ad exposure, respectively. RESULTS: Results indicate that exposure to a text corrective decreases false beliefs about the product (p<.01) and improves correct recall of information provided by the corrective (p<.05). Accurate graphic content did not alter the harmfulness of the product. Independent of condition, smokers who focused longer on the warning label made fewer false inferences about the product (p=.01) and were more likely to correctly recall the warning information (p<.01). Nonetheless, most smokers largely ignored the text warning. CONCLUSIONS: Embedding a corrective statement in the body of the ad is an effective strategy to convey health information to consumers, which can be mandated under the Tobacco Control Act. Eye-tracking results objectively demonstrate that text-only warnings are not viewed by smokers, thus minimizing their effectiveness for conveying risk information.

A Randomized Controlled Trial of Progressively Reduced Nicotine Content Cigarettes on Smoking Behaviors, Biomarkers of Exposure, and Subjective Ratings.

BACKGROUND: The U.S. FDA has the authority to reduce cigarette nicotine content if found to benefit public health. Reduced nicotine content (RNC) cigarette use does not appear to increase harm exposure, but studies have not rigorously assessed smoking behavior or used a comprehensive panel of biomarkers. This study examined the effects of progressively decreasing RNC cigarettes on smoking behaviors, biomarkers of exposure, and subjective ratings. METHODS: One hundred and fifty-eight daily, non-treatment-seeking smokers participated in a 35-day randomized, unblinded, parallel study. After a 5-day baseline period, participants were randomly assigned to an experimental group (n = 80) that smoked progressively decreasing RNC cigarettes during three 10-day periods, or control group (n = 78) that smoked their own brand throughout the study. RESULTS: Daily cigarette consumption significantly increased for the intermediate RNCs (P's < 0.001) but approached baseline rate for the lowest RNC (P = 0.686); in contrast, puffing behavior significantly decreased at intermediate levels and increased for the lowest RNC (P's < 0.001). Cotinine and NNAL significantly decreased by RNC period (P's ≤ 0.001-0.02), whereas CO boost initially increased (P's = 0.001-0.005). 1-HOP did not change by period (P = 0.109). CONCLUSIONS: Smoking behaviors changed by RNC period via CPD and puffing behavior. Biomarkers of exposure generally decreased with nicotine content. IMPACT: Findings suggest that RNC use does not ubiquitously reduce smoking behaviors or biomarkers, yet the lowest RNC level tested may reduce harm exposure. This emphasizes the importance of using multiple behavioral and biologic measures to address the impact of RNC cigarette smoking. Cancer Epidemiol Biomarkers Prev; 25(7); 1125-33. ©2016 AACR.

Time dependency of craving and response inhibition during nicotine abstinence.

BACKGROUND: Nicotine withdrawal produces increased craving for cigarettes and deficits in response inhibition, and these withdrawal symptoms are predictive of relapse. Although it is well-established that these symptoms emerge early during abstinence, there is mixed evidence regarding whether they occur simultaneously. Given the importance of the early withdrawal period, this study examined craving and response inhibition at 24h and 72h abstinence. METHODS: Twenty-one non-treatment seeking adult smokers were evaluated at baseline, 24h, and 72h abstinence for craving (Questionnaire on Smoking Urges - Brief) and response inhibition (Stop Signal Task, Stroop Task, Continuous Performance Task). Generalized linear regression models were used for primary outcomes, and Pearson correlations for examining the association between craving and response inhibition. RESULTS: Factor 2 craving (anticipated relief of negative affect) increased from baseline to 24h abstinent (p=0.004), which subsided by 72h (p=0.08). Deficits in response inhibition measured by the Stop Signal Task were observed at 72h (p=0.046), but not 24h (p=0.318). No correlation was found between response inhibition and craving at any time point (p-values>0.19), except between the Stroop Task and factor 1 craving at baseline (p=0.025). CONCLUSIONS: Factor 2 craving peaked at 24h, whereas deficits in response inhibition did not emerge until 72h, indicating that need to target craving and cognitive function during early abstinence may not occur simultaneously. Further characterizing the time course of withdrawal symptoms may guide development of targeted treatments for smoking cessation.