Design-development of an at-home modular brain-computer interface (BCI) platform in a case study of cervical spinal cord injury.

OBJECTIVE: The objective of this study was to develop a portable and modular brain-computer interface (BCI) software platform independent of input and output devices. We implemented this platform in a case study of a subject with cervical spinal cord injury (C5 ASIA A). BACKGROUND: BCIs can restore independence for individuals with paralysis by using brain signals to control prosthetics or trigger functional electrical stimulation. Though several studies have successfully implemented this technology in the laboratory and the home, portability, device configuration, and caregiver setup remain challenges that limit deployment to the home environment. Portability is essential for transitioning BCI from the laboratory to the home. METHODS: The BCI platform implementation consisted of an Activa PC + S generator with two subdural four-contact electrodes implanted over the dominant left hand-arm region of the sensorimotor cortex, a minicomputer fixed to the back of the subject's wheelchair, a custom mobile phone application, and a mechanical glove as the end effector. To quantify the performance for this at-home implementation of the BCI, we quantified system setup time at home, chronic (14-month) decoding accuracy, hardware and software profiling, and Bluetooth communication latency between the App and the minicomputer. We created a dataset of motor-imagery labeled signals to train a binary motor imagery classifier on a remote computer for online, at-home use. RESULTS: Average bluetooth data transmission delay between the minicomputer and mobile App was 23 ± 0.014 ms. The average setup time for the subject's caregiver was 5.6 ± 0.83 min. The average times to acquire and decode neural signals and to send those decoded signals to the end-effector were respectively 404.1 ms and 1.02 ms. The 14-month median accuracy of the trained motor imagery classifier was 87.5 ± 4.71% without retraining. CONCLUSIONS: The study presents the feasibility of an at-home BCI system that subjects can seamlessly operate using a friendly mobile user interface, which does not require daily calibration nor the presence of a technical person for at-home setup. The study also describes the portability of the BCI system and the ability to plug-and-play multiple end effectors, providing the end-user the flexibility to choose the end effector to accomplish specific motor tasks for daily needs. Trial registration ClinicalTrials.gov: NCT02564419. First posted on 9/30/2015.

Brain-Computer interface control of stepping from invasive electrocorticography upper-limb motor imagery in a patient with quadriplegia.

Introduction: Most spinal cord injuries (SCI) result in lower extremities paralysis, thus diminishing ambulation. Using brain-computer interfaces (BCI), patients may regain leg control using neural signals that actuate assistive devices. Here, we present a case of a subject with cervical SCI with an implanted electrocorticography (ECoG) device and determined whether the system is capable of motor-imagery-initiated walking in an assistive ambulator. Methods: A 24-year-old male subject with cervical SCI (C5 ASIA A) was implanted before the study with an ECoG sensing device over the sensorimotor hand region of the brain. The subject used motor-imagery (MI) to train decoders to classify sensorimotor rhythms. Fifteen sessions of closed-loop trials followed in which the subject ambulated for one hour on a robotic-assisted weight-supported treadmill one to three times per week. We evaluated the stability of the best-performing decoder over time to initiate walking on the treadmill by decoding upper-limb (UL) MI. Results: An online bagged trees classifier performed best with an accuracy of 84.15% averaged across 9 weeks. Decoder accuracy remained stable following throughout closed-loop data collection. Discussion: These results demonstrate that decoding UL MI is a feasible control signal for use in lower-limb motor control. Invasive BCI systems designed for upper-extremity motor control can be extended for controlling systems beyond upper extremity control alone. Importantly, the decoders used were able to use the invasive signal over several weeks to accurately classify MI from the invasive signal. More work is needed to determine the long-term consequence between UL MI and the resulting lower-limb control.

Implantable brain-computer interface for neuroprosthetic-enabled volitional hand grasp restoration in spinal cord injury.

Loss of hand function after cervical spinal cord injury severely impairs functional independence. We describe a method for restoring volitional control of hand grasp in one 21-year-old male subject with complete cervical quadriplegia (C5 American Spinal Injury Association Impairment Scale A) using a portable fully implanted brain-computer interface within the home environment. The brain-computer interface consists of subdural surface electrodes placed over the dominant-hand motor cortex and connects to a transmitter implanted subcutaneously below the clavicle, which allows continuous reading of the electrocorticographic activity. Movement-intent was used to trigger functional electrical stimulation of the dominant hand during an initial 29-weeks laboratory study and subsequently via a mechanical hand orthosis during in-home use. Movement-intent information could be decoded consistently throughout the 29-weeks in-laboratory study with a mean accuracy of 89.0% (range 78-93.3%). Improvements were observed in both the speed and accuracy of various upper extremity tasks, including lifting small objects and transferring objects to specific targets. At-home decoding accuracy during open-loop trials reached an accuracy of 91.3% (range 80-98.95%) and an accuracy of 88.3% (range 77.6-95.5%) during closed-loop trials. Importantly, the temporal stability of both the functional outcomes and decoder metrics were not explored in this study. A fully implanted brain-computer interface can be safely used to reliably decode movement-intent from motor cortex, allowing for accurate volitional control of hand grasp.

Association Between the Tips From Former Smokers Campaign and Smoking Cessation Among Adults, United States, 2012-2018.

In 2012, the Centers for Disease Control and Prevention (CDC) launched the national Tips From Former Smokers (Tips) campaign to encourage people who smoke to quit by showing real-life heath consequences of tobacco use and promoting evidence-based resources for quitting. To assess the campaign's impact on quit attempts and sustained-quit estimates (ie, quits lasting ≥6 mos), CDC analyzed data from a nationally representative longitudinal survey of US adults who smoke cigarettes, aged 18 years or older in 2012-2018. The Tips campaign was associated with an estimated 16.4 million quit attempts and 1,005,419 sustained quits. Continued implementation of cessation campaigns, including the Tips campaign, could accelerate progress toward reducing rates of smoking-related diseases and death.

Behavioral Alterations in Mice Carrying Homozygous HDAC4 A778T Missense Mutation Associated With Eating Disorder.

Eating disorders (EDs) are serious mental illnesses thought to arise from the complex gene-environment interactions. DNA methylation patterns in histone deacetylase 4 (HDAC4) locus have been associated with EDs and we have previously identified a missense mutation in the HDAC4 gene (HDAC4 A786T ) that increases the risk of developing an ED. In order to evaluate the biological consequences of this variant and establish a useful mouse model of EDs, here we performed behavioral characterization of mice homozygous for Hdac4 A778T (corresponding to human HDAC4 A786T ) that were further backcrossed onto C57BL/6 background. When fed high-fat diet, male, but not female, homozygous mice showed a trend toward decreased weight gain compared to their wild-type littermates. Behaviorally, male, but not female, homozygous mice spent less time in eating and exhibited reduced motivation to work for palatable food and light phase-specific decrease in locomotor activity. Additionally, homozygous Hdac4 A778T female, but not male, mice display social subordination when subjected to a tube dominance test. Collectively, these results reveal a complex sex- and circadian-dependent role of ED-associated Hdac4 A778T mutation in affecting mouse behaviors. Homozygous Hdac4 A778T mice could therefore be a useful animal model to gain insight into the neurobiological basis of EDs.

Evidence of the Impact of the Tips From Former Smokers Campaign: Results From the Behavioral Risk Factor Surveillance System.

The Tips From Former Smokers campaign (Tips) has demonstrated significant impact as a population-based intervention for smoking cessation in the United States. Since 2012, evaluations of Tips have relied on web-panel data to attribute the campaign to smoking cessation outcomes. We re-examined the relationship between market-level doses of the campaign and quit attempts by using Behavioral Risk Factor Surveillance System (BRFSS) data to triangulate prior findings. We found that Tips was associated with increased quit attempts among smokers, which validates prior evaluation research on the impact of Tips. These results suggest that continued investments in Tips may help sustain its impact on cessation-related outcomes.

Celastrol Reduces Obesity in MC4R Deficiency and Stimulates Sympathetic Nerve Activity Affecting Metabolic and Cardiovascular Functions.

Leptin resistance is a hallmark of obesity with unclear etiology. Celastrol, a compound found in the roots of the Tripterygium wilfordii and known to reduce endoplasmic reticulum (ER) stress, has recently emerged as a promising candidate to treat obesity by improving leptin sensitivity. However, the underlying neural mechanisms by which celastrol reduces obesity remain unclear. Using three different mouse models of obesity-diet-induced obesity (DIO), leptin receptor (LepR)-null, and melanocortin 4 receptor (MC4R)-null mice-in this study, we show that systemic celastrol administration substantially reduces food intake and body weight in MC4R-null comparable to DIO, proving the MC4R-independent antiobesity effect of celastrol. Body weight reduction was due to decreases in both fat and lean mass, and modest but significant body weight reduction was also observed in nonobese wild-type and LepR-null mice. Unexpectedly, celastrol upregulated proinflammatory cytokines without affecting genes involved in ER stress. Importantly, celastrol steadily increased sympathetic nerve activity to the brown fat and kidney with concordant increases of resting metabolic rate and arterial pressure. Our results suggest a previously unappreciated mechanism of action of celastrol in the regulation of energy homeostasis and highlight the need for careful consideration of its development as a safe antiobesity medication.

The 2016 Tips From Former Smokers® Campaign: Associations With Quit Intentions and Quit Attempts Among Smokers With and Without Mental Health Conditions.

INTRODUCTION: People living with mental health conditions (MH+) are more likely to smoke cigarettes than people without mental health conditions (MH-) and to experience tobacco-related disparities. The Tips From Former Smokers® (Tips®) campaign is a proven population-level strategy for motivating smokers to quit. In 2016, Tips included ads featuring Rebecca, a former smoker with depression. We evaluated self-reported frequency of exposure to the Rebecca and other Tips ads in association with quit intentions and quit attempts among MH+ and MH- smokers. METHODS: Intentions to quit and past 6-month quit attempts lasting at least 24 hours were reported from a two-wave longitudinal online survey conducted before and after the 2016 Tips campaign with a nationally representative sample of US adult cigarette smokers with (MH+, N = 777) and without (MH-, N = 1806) lifetime mental health conditions. RESULTS: In 2016, among MH+ respondents, greater exposure to the Rebecca ads was significantly associated with increased odds of intending to quit in the next 30 days (adjusted odds ratio [AOR] = 1.40, p < .05) and with reporting a quit attempt in the past 6 months (AOR = 1.25, p < .05). Among MH- respondents, greater exposure to the other Tips ads was associated with increased odds of making a quit attempt (AOR = 1.19, p < .05). CONCLUSIONS: Exposure to the Rebecca ads was associated with a greater likelihood of intentions to quit and quit attempts among MH+ smokers; whereas, exposure to the other (non-mental-health-related) Tips ads was associated with a greater likelihood of quit attempts among MH- smokers. IMPLICATIONS: National media campaigns are an important population-level strategy for reaching specific population groups who are experiencing tobacco-related disparities. The findings support the inclusion of ads featuring people living with mental health conditions in national tobacco education media campaigns, such as Tips.

Control of redundant pointing movements involving the wrist and forearm.

The musculoskeletal system can move in more ways than are strictly necessary, allowing many tasks to be accomplished with a variety of limb configurations. Why some configurations are preferred has been a focus of motor control research, but most studies have focused on shoulder-elbow or whole arm movements. This study focuses on movements involving forearm pronation-supination (PS), wrist flexion-extension (FE), and wrist radial-ulnar deviation (RUD) and elucidates how these three degrees of freedom (DOF) combine to perform the common task of pointing, which only requires two DOF. Although pointing is more sensitive to FE and RUD than to PS and could be easily accomplished with FE and RUD alone, subjects tend to involve a small amount of PS. However, why we choose this behavior has been unknown and is the focus of this paper. With the use of a second-order model with lumped parameters, we tested a number of plausible control strategies involving minimization of work, potential energy, torque, and path length. None of these control schemes robustly predicted the observed behavior. However, an alternative control scheme, hypothesized to control the DOF that were most important to the task (FE and RUD) and ignore the less important DOF (PS), matched the observed behavior well. In particular, the behavior observed in PS appears to be a mechanical side effect caused by unopposed interaction torques. We conclude that moderately sized pointing movements involving the wrist and forearm are controlled by ignoring forearm rotation even though this strategy does not robustly minimize work, potential energy, torque, or path length. NEW & NOTEWORTHY Many activities require us to point our hands in a given direction using wrist and forearm rotations. Although there are infinitely many ways to do this, we tend to follow a stereotyped pattern. Why we choose this pattern has been unknown and is the focus of this paper. After testing a variety of hypotheses, we conclude that the pattern results from a simplifying strategy in which we focus on wrist rotations and ignore forearm rotation.

Impact of the Tips From Former Smokers Campaign on Population-Level Smoking Cessation, 2012-2015.

This study provides estimates of the long-term cumulative impact of the Centers for Disease Control and Prevention's national tobacco education campaign, Tips From Former Smokers (Tips), on population-level smoking cessation. We used recently published estimates of the association between increased Tips campaign media doses and quit attempts to calculate campaign-attributable population sustained (6-month) quits during 2012-2015. Tips led to approximately 522,000 sustained quits during 2012-2015. These findings indicate that the Tips campaign's comprehensive approach to combining evidence-based messages with the promotion of cessation resources was successful in achieving substantial long-term cigarette cessation at the population level over multiple years.

Association Between Media Doses of the Tips From Former Smokers Campaign and Cessation Behaviors and Intentions to Quit Among Cigarette Smokers, 2012-2015.

BACKGROUND: Since 2012, the Centers for Disease Control and Prevention (CDC) has implemented Tips From Former Smokers ( Tips), the first federally funded tobacco education campaign in the United States. To date, there are no evaluations of its long-term impact. AIMS: To assess the impact of varied doses of the Tips campaign from 2012 through 2015 on cessation-related behaviors and intentions among U.S. smokers. METHOD: We used a national probability-based online survey of cigarette smokers ( n = 22,189) and recent quitters ( n = 776) to examine associations between doses of Tips advertising, measured by gross rating points (GRPs), and intentions to quit smoking in the next 30 days and quit attempts within the past 3 months. A curvilinear (i.e., square root) functional form of GRPs was used to capture patterns of diminishing effects at higher GRP levels. RESULTS: An increase of 1,000 quarterly Tips GRPs at the media market level was associated with increased odds of making a quit attempt in the past 3 months (adjusted odds ratio = 1.23, p < .001) and increased odds of intending to quit in the next 30 days (adjusted odds ratio = 1.17, p = .030). DISCUSSION: Results suggest that CDC-recommended media buys of 800 to 1,000 GRPs per quarter are sufficient to generate statistically significant increases in the likelihood of quit attempts in the past quarter. CONCLUSIONS: The Tips campaign has had a substantial impact on cessation behaviors among U.S. adult smokers over time. These data support the continued use of graphic and/or emotional media campaigns that encourage smokers to quit to further reduce tobacco use in the United States.

Evaluation of a federally funded mass media campaign and smoking cessation in pregnant women: a population-based study in three states.

OBJECTIVES: In 2012, theCenters for Disease Control and Prevention initiated a national anti-smoking campaign, Tips from Former Smokers (Tips). As a result of the campaign, quit attempts among smokers increased in the general population by 3.7 percentage points. In the current study, we assessed the effects of Tips on smoking cessation in pregnant women. METHODS: We used 2009-2013 certificates of live births in three US states: Indiana, Kentucky and Ohio. Smoking cessation by the third trimester of pregnancy was examined among women who smoked in the 3 months prepregnancy. Campaign exposure was defined as overlap between the airing of Tips 2012 (March 19-June 10) and the prepregnancy and pregnancy periods. Women who delivered before Tips 2012 were not exposed. Adjusted logistic regression was used to determine whether exposure to Tips was independently associated with smoking cessation. RESULTS: Cessation rates were stable during 2009-2011 but increased at the time Tips 2012 aired and remained elevated. Overall, 32.9% of unexposed and 34.7% of exposed smokers quit by the third trimester (p<0.001). Exposure to Tips 2012 was associated with increased cessation (adjusted OR: 1.07, 95% CI 1.05 to 1.10). CONCLUSIONS: Exposure to a national anti-smoking campaign for a general audience was associated with smoking cessation in pregnant women.

New product trial, use of edibles, and unexpected highs among marijuana and hashish users in Colorado.

OBJECTIVE: This study examines the relationships between trial of new marijuana or hashish products and unexpected highs, and use of edible products and unexpected highs. METHODS: We conducted an online survey of 634 adult, past-year marijuana users in Colorado. We used logistic regression models to examine the relationship between new product trial or edible use and unexpected highs. RESULTS: In the first year that recreational marijuana was legal in Colorado, 71.4% of respondents tried a new marijuana or hashish product, and 53.6% used an edible product. Trial of new products was associated with greater odds of experiencing an unexpected high after controlling for age, gender, education, mental health status, current marijuana or hashish use, and mean amount of marijuana or hashish consumed in the past month (OR=2.13, p<0.001). Individuals who reported having used edibles had greater odds of experiencing an unexpected high, after controlling for the same set of variables (OR=1.56, p<0.05). CONCLUSION: People who try new marijuana or hashish products, or use edible marijuana or hashish products, are at greater risk for an unexpected high. It is possible that some negative outcomes associated with marijuana use and unexpected highs may be averted through a better understanding of how to use product packaging to communicate with consumers.

Quit Methods Used by US Adult Cigarette Smokers, 2014-2016.

To quantify the prevalence of 10 quit methods commonly used by adult cigarette smokers, we used data from a nationally representative longitudinal (2014-2016) online survey of US adult cigarette smokers (n = 15,943). Overall, 74.7% of adult current cigarette smokers used multiple quit methods during their most recent quit attempt. Giving up cigarettes all at once (65.3%) and reducing the number of cigarettes smoked (62.0%) were the most prevalent methods. Substituting some cigarettes with e-cigarettes was used by a greater percentage of smokers than the nicotine patch, nicotine gum, or other cessation aids approved by the US Food and Drug Administration. Further research into the effectiveness of e-cigarettes as a cessation aid is warranted.

Perceived Effectiveness of Antismoking Ads and Association with Quit Attempts Among Smokers: Evidence from the Tips From Former Smokers Campaign.

BACKGROUND: Measures of perceived effectiveness (PE) of ads have been validated to predict changes in cognitive precursors of quit attempts, but a relationship between PE and actual quit attempts has not been shown in population-based studies. We analyzed smokers' PE ratings of ads from the national Tips From Former Smokers (Tips) campaign to (1) establish the validity of PE in predicting quit attempts in a large, nationally representative sample of smokers; (2) identify behavioral and demographic correlates of PE among respondents; and (3) examine whether PE is influenced by matching the race/ethnicity of ad participants with that of the ad viewer. METHODS: We used survey data from two waves (baseline and follow-up) of a longitudinal online cohort of adult U.S. cigarette smokers. Respondents were shown one or more of 14 Tips campaign ads and were asked to assess each ad in terms of PE. We used multivariate models to estimate the association between baseline PE and prospective quit attempts; cross-sectional associations between PE and various respondent characteristics, including race/ethnicity, desire to quit, and health conditions; and the association between race/ethnicity of respondents and Tips ad participants. RESULTS: Higher PE at baseline was associated with increased odds of a quit attempt at follow-up. Higher PE scores were associated with non-Hispanic black race, Hispanic ethnicity, higher desire to quit, presence of a chronic health condition, and presence of a mental health condition. There was no relationship between PE scores and matched race/ethnicity of the respondent and Tips ad participants. CONCLUSIONS: This is the first study to demonstrate an association between PE scores for antismoking ads and prospective quit attempts in a large, nationally representative sample of smokers. Our findings also provide strong evidence that racial/ethnic minority subpopulations, including non-Hispanic blacks and Hispanics, react more favorably to Tips campaign ads irrespective of race/ethnicity of the ad participant. This suggests that message characteristics (e.g., graphic visuals and emotional content) may play a more important role in PE than race/ethnicity of ad participants.

The Eating-Disorder Associated HDAC4A778T Mutation Alters Feeding Behaviors in Female Mice.

BACKGROUND: While eating disorders (EDs) are thought to result from a combination of environmental and psychological stressors superimposed on genetic vulnerability, the neurobiological basis of EDs remains incompletely understood. We recently reported that a rare missense mutation in the gene for the transcriptional repressor histone deacetylase 4 (HDAC4) is associated with the risk of developing an ED in humans. METHODS: To understand the biological consequences of this missense mutation, we created transgenic mice carrying this mutation by introducing the alanine to threonine mutation at position 778 of mouse Hdac4 (corresponding to position 786 of the human protein). Bioinformatic analysis to identify Hdac4-regulated genes was performed using available databases. RESULTS: Male mice heterozygous for HDAC4A778T did not show any metabolic or behavioral differences. In contrast, female mice heterozygous for HDAC4A778T display several ED-related feeding and behavioral deficits depending on housing condition. Individually housed HDAC4A778T female mice exhibit reduced effortful responding for high-fat diet and compulsive grooming, whereas group-housed female mice display increased weight gain on high-fat diet, reduced behavioral despair, and increased anxiety-like behaviors. Bioinformatic analysis identifies mitochondrial biogenesis including synthesis of glutamate/gamma-aminobutyric acid as a potential transcriptional target of HDAC4A778T activity relevant to the behavioral deficits identified in this new mouse model of disordered eating. CONCLUSIONS: The HDAC4A778T mouse line is a novel model of ED-related behaviors and identifies mitochondrial biogenesis as a potential molecular pathway contributing to behavioral deficits.

Increasing the dose of television advertising in a national antismoking media campaign: results from a randomised field trial.

BACKGROUND: While antismoking media campaigns have demonstrated effectiveness, less is known about the country-level effects of increased media dosing. The 2012 US Tips From Former Smokers (Tips) campaign generated approximately 1.6 million quit attempts overall; however, the specific dose-response from the campaign was only assessed by self-report. OBJECTIVE: Assess the impact of higher ad exposure during the 2013 Tips campaign on quit-related behaviours and intentions, campaign awareness, communication about campaign, and disease knowledge. METHODS: A 3-month national media buy was supplemented within 67 (of 190) randomly selected local media markets. Higher-dose markets received media buys 3 times that of standard-dose markets. We compared outcomes of interest using data collected via web-based surveys from nationally representative, address-based probability samples of 5733 cigarette smokers and 2843 non-smokers. RESULTS: In higher-dose markets, 87.2% of smokers and 83.9% of non-smokers recalled television campaign exposure versus 75.0% of smokers and 73.9% of non-smokers in standard-dose markets. Among smokers overall, the relative quit attempt rate was 11% higher in higher-dose markets (38.8% vs 34.9%; p<0.04). The higher-dose increase was larger in African-Americans (50.9% vs 31.8%; p<0.01). Smokers in higher-dose markets without a mental health condition, with a chronic health condition, or with only some college education made quit attempts at a higher rate than those in standard-dose markets. Non-smokers in higher-dose markets were more likely to talk with family or friends about smoking dangers (43.1% vs 35.7%; p<0.01) and had greater knowledge of smoking-related diseases. CONCLUSIONS: The US 2013 Tips antismoking media campaign compared standard and higher doses by randomisation of local media markets. Results demonstrate the effectiveness of a higher dose for engaging non-smokers and further increasing quit attempts among smokers, especially African-Americans.

Acute Axonal Degeneration Drives Development of Cognitive, Motor, and Visual Deficits after Blast-Mediated Traumatic Brain Injury in Mice.

Axonal degeneration is a prominent feature of many forms of neurodegeneration, and also an early event in blast-mediated traumatic brain injury (TBI), the signature injury of soldiers in Iraq and Afghanistan. It is not known, however, whether this axonal degeneration is what drives development of subsequent neurologic deficits after the injury. The Wallerian degeneration slow strain (WldS) of mice is resistant to some forms of axonal degeneration because of a triplicated fusion gene encoding the first 70 amino acids of Ufd2a, a ubiquitin-chain assembly factor, that is linked to the complete coding sequence of nicotinamide mononucleotide adenylyltransferase 1 (NMAT1). Here, we demonstrate that resistance of WldS mice to axonal degeneration after blast-mediated TBI is associated with preserved function in hippocampal-dependent spatial memory, cerebellar-dependent motor balance, and retinal and optic nerve-dependent visual function. Thus, early axonal degeneration is likely a critical driver of subsequent neurobehavioral complications of blast-mediated TBI. Future therapeutic strategies targeted specifically at mitigating axonal degeneration may provide a uniquely beneficial approach to treating patients suffering from the effects of blast-mediated TBI.

Reasons for current E-cigarette use among U.S. adults.

E-cigarette use has increased rapidly among U.S. adults. However, reasons for use among adults are unclear. We assessed reasons for e-cigarette use among a national sample of U.S. adults. Data were collected via online surveys among U.S. adults aged 18 or older from April through June 2014. Descriptive and multivariate regression analyses were conducted to assess reasons for e-cigarette use among 2448 current e-cigarette users, by sociodemographic characteristics and product type. Assessed reasons included cessation/health, consideration of others, convenience, cost, curiosity, flavoring, and simulation of conventional cigarettes. Among current e-cigarette users, 93% were also current cigarette smokers. The most common reasons for e-cigarette use were cessation/health (84.5%), consideration of others (71.5%), and convenience (56.7%). The prevalence of citing convenience (adjusted prevalence ratio [aPR]=1.49) and curiosity (aPR=1.54) as reasons for e-cigarette use were greater among current cigarette smokers than nonsmokers (P<0.05). The prevalence of citing flavoring as a reason for use was greater among adults aged 18 to 24 (aPR=2.02) than 55 or older (P<0.05). Tank use was associated with greater prevalence of citing every assessed reason except convenience and curiosity. Cessation- and health-related factors are primary reasons cited for e-cigarette use among adults, and flavorings are more commonly cited by younger adults. Efforts are warranted to provide consumers with accurate information on the health effects of e-cigarettes and to ensure that flavoring and other unregulated features do not promote nicotine addiction, particularly among young adults.

Does Digital Video Advertising Increase Population-Level Reach of Multimedia Campaigns? Evidence From the 2013 Tips From Former Smokers Campaign.

BACKGROUND: Federal and state public health agencies in the United States are increasingly using digital advertising and social media to promote messages from broader multimedia campaigns. However, little evidence exists on population-level campaign awareness and relative cost efficiencies of digital advertising in the context of a comprehensive public health education campaign. OBJECTIVE: Our objective was to compare the impact of increased doses of digital video and television advertising from the 2013 Tips From Former Smokers (Tips) campaign on overall campaign awareness at the population level. We also compared the relative cost efficiencies across these media platforms. METHODS: We used data from a large national online survey of approximately 15,000 US smokers conducted in 2013 immediately after the conclusion of the 2013 Tips campaign. These data were used to compare the effects of variation in media dose of digital video and television advertising on population-level awareness of the Tips campaign. We implemented higher doses of digital video among selected media markets and randomly selected other markets to receive similar higher doses of television ads. Multivariate logistic regressions estimated the odds of overall campaign awareness via digital or television format as a function of higher-dose media in each market area. All statistical tests used the .05 threshold for statistical significance and the .10 level for marginal nonsignificance. We used adjusted advertising costs for the additional doses of digital and television advertising to compare the cost efficiencies of digital and television advertising on the basis of costs per percentage point of population awareness generated. RESULTS: Higher-dose digital video advertising was associated with 94% increased odds of awareness of any ad online relative to standard-dose markets (P<.001). Higher-dose digital advertising was associated with a marginally nonsignificant increase (46%) in overall campaign awareness regardless of media format (P=.09). Higher-dose television advertising was associated with 81% increased odds of overall ad awareness regardless of media format (P<.001). Increased doses of television advertising were also associated with significantly higher odds of awareness of any ad on television (P<.001) and online (P=.04). The adjusted cost of each additional percentage point of population-level reach generated by higher doses of advertising was approximately US $440,000 for digital advertising and US $1 million for television advertising. CONCLUSIONS: Television advertising generated relatively higher levels of overall campaign awareness. However, digital video was relatively more cost efficient for generating awareness. These results suggest that digital video may be used as a cost-efficient complement to traditional advertising modes (eg, television), but digital video should not replace television given the relatively smaller audience size of digital video viewers.