The Unintentional Nonconformist: Habits Promote Resistance to Social influence.

This research tests a novel source of resistance to social influence-the automatic repetition of habit. In three experiments, participants with strong habits failed to align their behavior with others. Specifically, participants with strong habits to drink water in a dining hall or snack while working did not mimic others' drinking or eating, whereas those with weak habits conformed. Similarly, participants with strong habits did not shift expectations that they would act in line with descriptive norms, whereas those with weak habits reported more normative behavioral expectations. This habit resistance was not due to a failure to perceive influence: Both strong and weak habit participants' recalled others' behavior accurately, and it was readily accessible. Furthermore, strong habit participants shifted their normative beliefs but not behavior in line with descriptive norms. Thus, habits create behavioral resistance despite people's recognition and acceptance of social influence.

The effect of deadlines on cancer screening completion: a randomized controlled trial.

Cancer is the second leading cause of death in the United States. Although screening facilitates prevention and early detection and is one of the most effective approaches to reducing cancer mortality, participation is low-particularly among underserved populations. In a large, preregistered field experiment (n = 7711), we tested whether deadlines-both with and without monetary incentives tied to them-increase colorectal cancer (CRC) screening. We found that all screening invitations with an imposed deadline increased completion, ranging from 2.5% to 7.3% relative to control (ps < .004). Most importantly, individuals who received a short deadline with no incentive were as likely to complete screening (9.7%) as those whose invitation included a deadline coupled with either a small (9.1%) or large declining financial incentive (12.0%; ps = .57 and .04, respectively). These results suggest that merely imposing deadlines-especially short ones-can significantly increase CRC screening completion, and may also have implications for other forms of cancer screening.

Two social lives: How differences between online and offline interaction influence social outcomes.

For hundreds of thousands of years, humans only communicated in person, but in just the past fifty years they have started also communicating online. Today, people communicate more online than offline. What does this shift mean for human social life? We identify four structural differences between online (versus offline) interaction: (1) fewer nonverbal cues, (2) greater anonymity, (3) more opportunity to form new social ties and bolster weak ties, and (4) wider dissemination of information. Each of these differences underlies systematic psychological and behavioral consequences. Online and offline lives often intersect; we thus further review how online engagement can (1) disrupt or (2) enhance offline interaction. This work provides a useful framework for studying the influence of technology on social life (119/120).

Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial.

BACKGROUND: Financial incentives may improve health behaviors. We tested the impact of offering financial incentives for mailed fecal immunochemical test (FIT) completion annually for 3 years. METHODS: Patients, ages 50 to 64 years, not up-to-date with screening were randomized to receive either a mailed FIT outreach (n = 6,565), outreach plus $5 (n = 1,000), or $10 (n = 1,000) incentive for completion. Patients who completed the test were reinvited using the same incentive the following year, for 3 years. In year 4, patients who returned the kit in all preceding 3 years were reinvited without incentives. Primary outcome was FIT completion among patients offered any incentive versus outreach alone each year. Secondary outcomes were FIT completion for groups offered $5 versus outreach alone, $10 versus outreach alone, and $5 versus $10. RESULTS: Year 1 FIT completion was 36.9% with incentives versus 36.2% outreach alone (P = 0.59) and was not statistically different for $10 (34.6%; P = 0.31) or $5 (39.2%; P = 0.070) versus outreach alone. Year 2 completion was 61.6% with incentives versus 60.8% outreach alone (P = 0.75) and not statistically different for $10 or $5 versus outreach alone. Year 3 completion was 79.4% with incentives versus 74.8% outreach alone (P = 0.080), and was higher for $10 (82.4%) versus outreach alone (P = 0.033), but not for $5 versus outreach alone. Completion was similar across conditions in year 4 (no incentives). CONCLUSIONS: Offering small incentives did not increase FIT completion relative to standard outreach. IMPACT: This was the first longitudinal study testing the impact of repeated financial incentives, and their withdrawal, on FIT completion.

Patient-Reported Barriers to Completing a Diagnostic Colonoscopy Following Abnormal Fecal Immunochemical Test Among Uninsured Patients.

BACKGROUND: For colorectal cancer (CRC) screening to improve survival, patients with an abnormal fecal immunochemical test (FIT) must follow-up with a diagnostic colonoscopy. Adherence to follow-up is low and patient-level barriers for suboptimal adherence have yet to be explored. OBJECTIVE: To characterize barriers for non-completion of diagnostic colonoscopy after an abnormal FIT reported by under- and uninsured patients receiving care in a safety-net health system. DESIGN: A longitudinal, cohort study of CRC screening outreach to 8565 patients using mailed FIT kits. Patients with abnormal FIT results received telephonic navigation to arrange for a no-cost diagnostic colonoscopy. PATIENTS: Adults aged 50-64 years receiving care at a North Texas safety-net health system. APPROACH: Descriptive analyses characterized the patient sample and reasons for lack of follow-up after abnormal FIT over the 3-year outreach program. Thematic qualitative analyses characterized reasons for lack of follow-up with a colonoscopy after the abnormal FIT. KEY RESULTS: Of 689 patients with an abnormal FIT, 45% (n = 314) did not complete a follow-up colonoscopy. Among the 314 non-completers, 184 patients reported reasons for not completing a follow-up colonoscopy included health insurance-related challenges (38%), comorbid conditions (37%), social barriers such as transportation difficulties and lack of social support (29%), concerns about FIT/colonoscopy process (12%), competing life priorities (12%), adverse effects of bowel preparation (3%), and poor health literacy (3%). Among the 314 non-completers, 131 patients did not report a barrier, as 51% reported that that had completed a previous colonoscopy in the past 10 years, 10% refused with no reason, and 10% were never reached by phone. CONCLUSIONS: Future studies aimed at improving FIT screening and subsequent colonoscopy rates need to address the unique needs of patients for effective and sustainable screening programs. TRIAL REGISTRATION: NCT01946282.

Mailed Outreach Is Superior to Usual Care Alone for Colorectal Cancer Screening in the USA: A Systematic Review and Meta-analysis.

Mailed outreach promoting colorectal cancer (CRC) screening with a stool blood test kit may increase participation, but magnitude and consistency of benefit of this intervention strategy is uncertain. Our aim was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing mailed outreach offering stool tests to usual care, clinic-based screening offers on CRC screening uptake in the USA. We performed a systematic literature search of five databases for RCTs of mailed outreach from January 1980 through June 2017. Primary outcome was screening completion, summarized using random-effects meta-analysis as pooled differences in proportion completing the screening and relative risk of achieving screening compared to control. Subgroup analyses by test type offered-fecal immunochemical test (FIT) or guaiac fecal occult blood test (gFOBT), the presence of telephone reminders, and the presence of predominant underserved/minority population within study were performed. Quality of evidence was evaluated using the GRADE framework. Seven RCTs which enrolled 12,501 subjects were included (n = 5703 assigned mailed outreach and n = 6798 usual care). Mailed outreach resulted in a 28% absolute (95% CI 25-30%; I2 = 47%) and a 2.8-fold relative (RR 2.65, 95% CI 2.03-3.45; I2 = 92%) increase in screening completion compared to usual care, with a number needed to invite estimated to be 3.6. Similar outcomes were observed across subgroups. Overall body of evidence was at moderate quality. Mailed outreach offering a gFOBT or FIT is associated with a large and consistent increase in CRC screening completion and should be considered for more widespread implementation for improving screening rates nationwide.

Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial.

OBJECTIVES: Offering financial incentives to promote or "nudge" participation in cancer screening programs, particularly among vulnerable populations who traditionally have lower rates of screening, has been suggested as a strategy to enhance screening uptake. However, effectiveness of such practices has not been established. Our aim was to determine whether offering small financial incentives would increase colorectal cancer (CRC) screening completion in a low-income, uninsured population. METHODS: We conducted a randomized, comparative effectiveness trial among primary care patients, aged 50-64 years, not up-to-date with CRC screening served by a large, safety net health system in Fort Worth, Texas. Patients were randomly assigned to mailed fecal immunochemical test (FIT) outreach (n=6,565), outreach plus a $5 incentive (n=1,000), or outreach plus a $10 incentive (n=1,000). Outreach included reminder phone calls and navigation to promote diagnostic colonoscopy completion for patients with abnormal FIT. Primary outcome was FIT completion within 1 year, assessed using an intent-to-screen analysis. RESULTS: FIT completion was 36.9% with vs. 36.2% without any financial incentive (P=0.60) and was also not statistically different for the $10 incentive (34.6%, P=0.32 vs. no incentive) or $5 incentive (39.2%, P=0.07 vs. no incentive) groups. Results did not differ substantially when stratified by age, sex, race/ethnicity, or neighborhood poverty rate. Median time to FIT return also did not differ across groups. CONCLUSIONS: Financial incentives, in the amount of $5 or $10 offered in exchange for responding to mailed invitation to complete FIT, do not impact CRC screening completion.

Using Twitter Data to Gain Insights into E-cigarette Marketing and Locations of Use: An Infoveillance Study.

BACKGROUND: Marketing and use of electronic cigarettes (e-cigarettes) and other electronic nicotine delivery devices have increased exponentially in recent years fueled, in part, by marketing and word-of-mouth communications via social media platforms, such as Twitter. OBJECTIVE: This study examines Twitter posts about e-cigarettes between 2008 and 2013 to gain insights into (1) marketing trends for selling and promoting e-cigarettes and (2) locations where people use e-cigarettes. METHODS: We used keywords to gather tweets about e-cigarettes between July 1, 2008 and February 28, 2013. A randomly selected subset of tweets was manually coded as advertising (eg, marketing, advertising, sales, promotion) or nonadvertising (eg, individual users, consumers), and classification algorithms were trained to code the remaining data into these 2 categories. A combination of manual coding and natural language processing methods was used to indicate locations where people used e-cigarettes. Additional metadata were used to generate insights about users who tweeted most frequently about e-cigarettes. RESULTS: We identified approximately 1.7 million tweets about e-cigarettes between 2008 and 2013, with the majority of these tweets being advertising (93.43%, 1,559,508/1,669,123). Tweets about e-cigarettes increased more than tenfold between 2009 and 2010, suggesting a rapid increase in the popularity of e-cigarettes and marketing efforts. The Twitter handles tweeting most frequently about e-cigarettes were a mixture of e-cigarette brands, affiliate marketers, and resellers of e-cigarette products. Of the 471 e-cigarette tweets mentioning a specific place, most mentioned e-cigarette use in class (39.1%, 184/471) followed by home/room/bed (12.5%, 59/471), school (12.1%, 57/471), in public (8.7%, 41/471), the bathroom (5.7%, 27/471), and at work (4.5%, 21/471). CONCLUSIONS: Twitter is being used to promote e-cigarettes by different types of entities and the online marketplace is more diverse than offline product offerings and advertising strategies. E-cigarettes are also being used in public places, such as schools, underscoring the need for education and enforcement of policies banning e-cigarette use in public places. Twitter data can provide new insights on e-cigarettes to help inform future research, regulations, surveillance, and enforcement efforts.

The relationship between amount of soda consumed and intention to reduce soda consumption among adults exposed to the Choose Health LA 'Sugar Pack' health marketing campaign.

OBJECTIVE: To examine behavioural intention to reduce soda consumption after exposure to the Choose Health LA 'Sugar Pack' campaign in Los Angeles County, California, USA. DESIGN: A cross-sectional street-intercept survey was conducted to assess knowledge, attitudes, health behaviours and behavioural intentions after exposure to the 'Sugar Pack' campaign. A multivariable regression analysis was performed to examine the relationships between the amount of soda consumed and self-reported intention to reduce consumption of non-diet soda among adults who saw the campaign. SETTING: Three pre-selected Los Angeles County Metro bus shelters and/or rail stops with the highest number of 'Sugar Pack' campaign advertisement placements. SUBJECTS: Riders of the region's Metro buses and railways who were the intended audience of the campaign advertisements. RESULTS: The overall survey response rate was 56 % (resulting n 1041). Almost 60 % of respondents were exposed to the advertisements (619/1041). The multivariable logistic regression analysis suggested that the odds of reporting intention to reduce soda consumption among moderate consumers (1-6 sodas/week) were 1·95 times greater than among heavy consumers (≥1 soda/d), after controlling for clustering and covariates. Respondents with less than a high-school education and who perceived sugary beverage consumption as harmful also had higher odds; in contrast, respondents aged ≥65 years had lower odds. CONCLUSIONS: Results suggest that future campaigns should be tailored differently for moderate v. heavy consumers of soda. Similar tailoring strategies are likely needed for younger groups, for those with less educational attainment and for those who do not perceive consumption of soda as harmful.

Crowdsourcing data collection of the retail tobacco environment: case study comparing data from crowdsourced workers to trained data collectors.

OBJECTIVE: To assess whether crowdsourcing is a viable option for conducting surveillance of point of sale (POS) tobacco marketing practices. METHODS: We posted jobs to an online crowdsourcing platform to audit 194 Florida licensed tobacco retailers over a 3-week period. During the same period, trained data collectors conducted audits at the same retail locations. Data were collected on cigarette advertising, cigarette promotions and product availability (electronic cigarettes, snus and dissolvables). We compared data collected by crowdsourced workers and trained staff and computed frequencies, percent agreement and inter-rater reliability. Photographs of e-cigarettes and exterior cigarette advertisements submitted by crowdsourced workers were used to validate responses. RESULTS: Inter-rater reliability between crowdsourced and trained data collectors was moderate to high for coding exterior cigarette advertisements, product availability and some tobacco promotions, but poor to fair when coding presence of sales and interior cigarette advertisements. Photos submitted by crowdsourced workers confirmed e-cigarette availability that was missed by trained data collectors in three stores. CONCLUSIONS: Crowdsourcing may be a promising form of data collection for some POS tobacco measures. Future studies should examine the cost-effectiveness of crowdsourcing compared with traditional trained data collectors and assess which POS measures are most amenable to crowdsourcing.