Negative but Not Positive Alcohol-Related Consequences Tend to Occur Above the Heavy Episodic Drinking Threshold: A Daily Study of Young Adult Heavy Drinkers.

AIMS: This study used event-level data to identify the threshold (i.e. number of standard alcoholic drinks) at which specific negative and positive alcohol-related consequences are likely to occur. METHODS: Ninety-six college students aged 18-20 reporting weekly heavy episodic drinking (HED) or at least one negative alcohol-related consequence in the past 2 weeks completed ecological momentary assessment over 28 days. Participants reported number of standard drinks consumed and negative (e.g. nausea) and positive (e.g. new friend) alcohol-related consequences on 492 drinking nights. The area under the receiver operating characteristic (AUROC) curve measured the ability of an increasing number of drinks consumed to discriminate between nights with versus without a given consequence. The Youden Index method was used to identify the optimal threshold of drinks for each consequence. Thresholds were examined for each consequence by participants' biological sex and heavy drinking status. RESULTS: Across subgroups, most consequences occurred on nights where participants reported higher consumption levels relative to nights where consequences did not occur. Thresholds for negative consequences ranged between four and nine drinks and thresholds for positive consequences were between three and six drinks. CONCLUSIONS: Many negative consequences are likely to occur following the traditional HED threshold of 4+/5+ drinks (females/males), with more severe consequences occurring at slightly higher thresholds. Positive consequences are likely to occur at lower thresholds. There may be an optimal number of drinks that maximize positive while minimizing negative consequences for heavy drinking college students.

Developing a theoretical marketing framework to analyse JUUL and compatible e-cigarette product promotion on Instagram.

BACKGROUND: E-cigarette promotion on social media coincided with the rapid growth of e-cigarette use among American youth, particularly with the increased JUUL pod vaporiser use. We examined commercial JUUL-related messages on Instagram to identify marketing appeals used to target users along the continuum of e-cigarette use; we mapped the appeals to existing theoretical marketing frameworks to better understand industry strategies. METHODS: Hashtag-based keyword rules were used to collect JUUL-related posts from the Instagram application programming interface, 1 March-13 November 2018. Posts were classified as commercial or non-commercial. A combination of machine learning methods, keyword algorithms and human coding were used to characterise message themes in commercial posts. RESULTS: Keyword filters captured 50 817 relevant posts and 41% were commercial. Among commercial posts, 91% contained recruitment/trial-based appeals (eg, combustible tobacco cessation; product sampling; giveaways) and 71% featured reinforcement/addiction-related appeals (eg, loyalty programmes). None of the commercial messages contained e-cigarette cessation-related appeals and less than 25% mentioned quitting combustible tobacco as a recruitment appeal. CONCLUSIONS: Instagram posts featuring e-cigarette related marketing can increase exposure to persuasive messages encouraging e-cigarette trial and use particularly among susceptible youth. Stronger regulations are needed to prevent exposure to social media marketing among young social media users.

Developing the Message Assessment Scale for Tobacco Prevention Campaigns: Cross-sectional Validation Study.

BACKGROUND: Mass media campaigns are effective for influencing a broad range of health behaviors. Prior to launching a campaign, developers often conduct ad testing to help identify the strengths and weaknesses of the message executions among the campaign's target audience. This process allows for changes to be made to ads, making them more relevant to or better received by the target audience before they are finalized. To assess the effectiveness of an ad's message and execution, campaign ads are often rated using a single item or multiple items on a scale, and scores are calculated. Endorsement of a 6-item perceived message effectiveness (PME) scale, defined as the practice of using a target audience's evaluative ratings to inform message selection, is one approach commonly used to select messages for antitobacco campaigns; however, the 6-item PME scale often does not produce enough specificity to make important decisions on ad optimization. In addition, the PME scale is typically used with adult populations for smoking cessation messages. OBJECTIVE: This study includes the development of the Message Assessment Scale, a new tobacco prevention message testing scale for youth and young adults. METHODS: Data were derived from numerous cross-sectional surveys designed to test the relevance and potential efficacy of antitobacco truth campaign ads. Participants aged 15-24 years (N=6108) responded to a set of 12 core attitudinal items, including relevance (both personal and cultural) as well as comprehension of the ad's main message. RESULTS: Analyses were completed in two phases. In phase I, mean scores were calculated for each of the 12 attitudinal items by ad type, with higher scores indicating more endorsement of the item. Next, all items were submitted to exploratory factor analysis. A four-factor model fit was revealed and verified with confirmatory factor analysis, resulting in the following constructs: personally relevant, culturally relevant, the strength of messaging, and negative attributes. In phase II, ads were categorized by performance (high/medium/low), and constructs identified in phase I were correlated with key campaign outcomes (ie, main fact agreement and likelihood to vape). Phase II confirmed that the four constructs identified in phase I were all significantly correlated with main fact agreement and vape intentions. CONCLUSIONS: Findings from this study advance the field by establishing an expanded set of validated items to comprehensively assess the potential effectiveness of advertising executions. This set of items expands the portfolio of ad testing measures for ads focused on tobacco use prevention. Findings can inform how best to optimize ad executions and message delivery for health behavior campaigns, particularly those focused on tobacco use prevention among youth and young adult populations.

E-cigarette device and liquid characteristics and E-cigarette dependence: A pilot study of pod-based and disposable E-cigarette users.

BACKGROUND: E-cigarette device and liquid characteristics, such as electrical power output and liquid nicotine concentration, determine the rate at which nicotine is emitted from the e-cigarette (i.e., nicotine flux), and thus are likely to influence user nicotine dependence. We hypothesize that nicotine flux would be associated with the E-cigarette Dependence Scale (EDS) among pod-based and disposable e-cigarette products. METHODS: Data were obtained from online panel participants between 18 and 65 years of age, who had indicated that they were either former or current e-cigarette users and resided within the United States (N = 1036). To be included in these analyses, participants had to provide information regarding device type (pod-based or disposable), power (watts), and nicotine concentration (mg/mL), from which we could determine nicotine flux (µg/s) (N = 666). To assess the relationship between nicotine flux and EDS, a series of multivariable linear regressions were conducted. Each model was separated by device type and adjusted for by age and past 30-day e-cigarette use. RESULTS: Greater nicotine flux was associated with higher EDS scores among pod-based e-cigarette users (beta = 0.19, SE = 0.09, p-value = 0.043), but not users of disposable e-cigarettes. Neither power nor nicotine concentration were associated with EDS scores among users of either e-cigarette device type. CONCLUSION: Results support the hypothesis that nicotine flux is positively associated with nicotine dependence in a sample of current users of pod-based and disposable e-cigarettes.

Evidence of the impact of a national anti-tobacco prevention campaign across demographic subgroups.

Mass media campaigns are an effective population-level intervention for preventing tobacco use. However, little evidence exists for whether these campaigns similarly influence demographic subgroups. This study examined the effects of the truth® campaign to reduce tobacco use among demographic subgroups. We used data from a national, continuous, cross-sectional tracking survey of 15-24-year-olds (n = 32 331). We used a measure of weekly aggregated campaign exposure to assess whether cigarette smoking intentions and current cigarette use varied by race/ethnicity, financial situation and population density subgroups, controlling for factors known to be associated with tobacco use. Examining estimates across subgroup categories in light of the overall model estimates revealed that the effects of week-level campaign exposure on cigarette smoking intentions and current cigarette use were similar across subgroups. Wald tests of equality across estimates in each subgroup suggested that the estimates did not differ from one another in any given instance. The truth campaign does not differ significantly in its capacity to prompt declines in tobacco use across a broad spectrum of US youth and young adults. Mass media tobacco prevention campaigns can be an effective and critical component of a comprehensive tobacco control program, particularly with respect to reducing tobacco-related disparities among demographic subgroups.

Identifying message themes to prevent e-cigarette use among youth and young adults.

In 2020, almost 20% of high school students reported current e-cigarette use. Mass media tobacco prevention campaigns are effective for preventing tobacco use among youth and young adults but selecting messages that will have maximum impact on the target audience is a significant challenge for campaign developers. This study describes the method for identification of potential messaging targets for a national anti-vape mass media campaign using criteria proposed by Hornik and Woolf in their health communication framework. A national sample of 15- to 24-year-olds (N = 1564) was recruited via an online panel in May 2020. Participants endorsed a series of vape-related attitudinal items. Items were considered potential message targets if they distinguished between the four vape use groups (current users, ever users, susceptible never-users, and non-susceptible never-users) and if less than 70% of respondents endorsed the anti-vape item response. The resulting items targeted five potential message themes, each forming a scale measured with three to four individual items. Message themes included social acceptability of vaping, anti-vape industry sentiment, independence from vaping, non-vaping identity, and perceived risk of harm. Findings were used to inform the development of truth® campaign messaging focused on reducing the prevalence of e-cigarette use among youth and young adults.

Educating Young Adults about Opioid Misuse: Evidence from a Mass Media Intervention.

The US opioid epidemic is a serious public health problem. Rates of opioid misuse and dependence are highest for young adults ages 18-25. Prevention strategies that reduce prescription opioid misuse while decreasing stigma around dependence and treatment are critical components of addressing the epidemic. The Truth About Opioids, a mass media public education campaign, was designed to prevent opioid misuse and dependence among young adults. This study examined the intervention's effectiveness to shift opioid-related knowledge, attitudes, and beliefs within targeted designated market areas (DMAs) over time. A sample of young adults (N = 1434) in DMAs with varying levels of media exposure was surveyed at baseline (June-September 2019) and post-intervention (July-August 2020). Logistic regression assessed associations between campaign awareness and campaign-targeted knowledge and attitudes, controlling for baseline variables. Those with any awareness had significantly higher odds of campaign-targeted opioid-related knowledge (versus no awareness) (low awareness OR = 1.52 (95% CI: 1.04, 2.24); high awareness OR = 2.47 (95% CI: 1.58, 3.87)). Those with campaign awareness were also more likely to report lower levels of opioid-related stigma and higher intentions to share information and talk to a friend about the epidemic. Mass media public education campaigns can help influence young adults' opioid-related knowledge and attitudes.

Association between e-cigarette use and future combustible cigarette use: Evidence from a prospective cohort of youth and young adults, 2017-2019.

INTRODUCTION: A surge in popularity of e-cigarettes prompts concern given the association between e-cigarettes and future cigarette use. However, much of the evidence for this association comes from early, less efficient, and lower nicotine e-cigarettes than are available and widely used now. The goal of this study was to examine the relationship between e-cigarette use in 2018 and subsequent smoking initiation and continued e-cigarette use. METHODS: Participants included members of a national longitudinal panel of youth and young adults aged 15-27 who, in 2017, reported never having used a nicotine containing product (n = 3360). Logistic regression analyses assessed associations between participants' self-reported ever e-cigarette use in 2018 and ever cigarette use, current cigarette use, and current e-cigarette use in 2019, after controlling for demographic and psychosocial variables. RESULTS: Compared with those who still had never used an e-cigarette, those who reported ever e-cigarette use in 2018 had significantly higher odds of ever cigarette use (aOR = 7.29, 95% CI [4.10, 12.97]), current cigarette use (aOR = 8.26, 95% CI [3.17, 21.53]), and current e-cigarette use (aOR = 9.70, 95% CI [6.41, 14.69]) one year later in 2019. CONCLUSIONS: These findings show that the pod mod style, high nicotine containing e-cigarettes subject young users to the same risks of transitioning to combustible cigarettes as their earlier, less efficient predecessors. Strong regulation of all nicotine products, including e-cigarettes, is needed to prevent the trajectory of e-cigarette to cigarette use among youth and young adults.

Going Smokeless: Promotional Features and Reach of US Smokeless Tobacco Direct-Mail Advertising (July 2017-August 2018).

INTRODUCTION: Although cigarette use in the United States has declined over time, smokeless tobacco (SLT) use has remained steady. Direct-mail advertising and coupon redemption have been linked to increased tobacco use, and efforts to promote SLT through direct-mail advertising may contribute to sustained SLT use. We examined reach of SLT direct-mail advertisements by recipient demographics and promotional features, including coupons. METHODS: Direct-mail data (n = 418) were acquired from Comperemedia (Mintel) and coded for product type (traditional [eg, chewing tobacco], pouched [eg, moist snuff, snus], or both [traditional SLT and any pouched SLT products]); promotions (eg, coupons); flavors; and themes (eg, masculinity). Using Mintel's volume estimates for number of pieces sent, we calculated the proportion of mail volume sent by recipient demographics (age, income, region) and advertising features across product type. RESULTS: Between July 2017 and August 2018, tobacco companies sent an estimated 249 million pieces of SLT direct-mail to US households; approximately half (49.6%) featured pouched SLT products. Across product types, over 75% of mail volume was sent to 31- to 60-year-old adults and 30-40% was sent to low-income households. The majority (>70%) of pouched SLT product mail contained coupons and flavor promotions. Outdoor and blue-collar-lifestyle themes were prominent in advertisements for all product types, along with less common adventure- and fun-related appeals. CONCLUSIONS: Coupons, flavors, and a combination of blue-collar and fun/adventure message themes were used to promote traditional and pouched SLT products through direct-mail, particularly to low-income households. Results support limits on direct-mail coupon distribution and continued surveillance of marketing appeals. IMPLICATIONS: There is a long history of research into tobacco advertising practices, largely focusing on cigarettes. This study highlights specific direct-mail marketing tactics used by the tobacco industry, including coupons to promote SLT products across the United States. Given the limited success in reducing SLT use and the association between direct-mail promotions and tobacco use, these study results provide support for policies to restrict use of coupons in direct-to-consumer tobacco marketing and indicate the need for continued surveillance of direct-mail advertisements as the SLT market continues to evolve.

E-cigarette Tobacco Retail Licensing Laws: Variance Across US States as of January 1, 2020.

Objectives. To describe how US states and the District of Columbia regulate e-cigarette sales by examining e-cigarette-specific tobacco retail licensing (TRL) laws.Methods. We coded 25 state-level e-cigarette TRL laws (effective as of January 1, 2020) for provisions we labeled as either "core" (e.g., presence of license terms, fees, and penalties) or "descriptive" (e.g., license fee amount and term length).Results. Overall, 23 laws clearly defined a license term, 23 laws required a license fee, and 19 laws identified penalties for violations that included both license suspension and revocation. Fees widely ranged ($5-$1000 annually), and 8 laws did not explicitly direct fees toward TRL administration or enforcement. No law required that retailers comply with all local, state, and federal tobacco or e-cigarette laws.Conclusions. Most laws contained core TRL provisions. Several laws, however, had minimal license fees and did not direct fees toward administration or enforcement. As youth e-cigarette use increases, more states should consider establishing e-cigarette TRL laws or incorporating provisions into existing TRL laws.

#toolittletoolate: JUUL-related content on Instagram before and after self-regulatory action.

INTRODUCTION: Digital e-cigarette marketing is largely unregulated and remains easily accessible to young people. The growing public concern around youth JUUL use and its viral presence on social media led the company to engage in several voluntary actions to remove and reduce JUUL-related content on Instagram in May 2018. The current study examined how JUUL-related Instagram content changed in the US following JUUL Labs' wave of voluntary actions in May 2018. METHODS: In 2019, we collected a total of 50,817 JUUL-relevant posts by 16,323 unique users on Instagram from March 1-May 15, 2018 (Phase 1) and May 16-November 11, 2018 (Phase II) using the application programming interface. We conducted a semantic network analysis to identify major topic clusters over time. RESULTS: Approximately 14,838 JUUL-related posts were made by 5,201 accounts in Phase I and 35,979 posts were made by 11,122 accounts in Phase II. Major content clusters remained unchanged over time-key topics were JUUL-related product characteristics and JUUL-communities; the general vape community; and cannabis-related behavior. Of note, cannabis-related content grew in Phase II, particularly use of the term CBD. CONCLUSIONS: Our results reflect the limits of voluntary industry actions to reduce or change vaping-related content on social media. Rather, strong federal restriction on commercial tobacco marketing is the optimal pathway to reduce initial product marketing exposure among youth. These limits would make the emergence and viral contagion of brand-related social media content less likely and reduce its influence on youth behavior.

Characterising JUUL-related posts on Instagram.

BACKGROUND: JUUL, a high-tech, popular vaping device, was the first major electronic cigarette (e-cigarette) brand to incorporate social media into its marketing strategy. There is growing concern around the increasing use of JUUL and other electronic nicotine delivery devices among youth, and their potential to addict a new generation to nicotine. The current study analysed the amount and characteristics of JUUL-related posts on Instagram, a social media platform used frequently among youth and young adults. METHODS: Hashtag-based keyword queries (n=50) were used to collect JUUL-related posts from the Instagram application programming interface, March 2018-May 2018. Using a combination of machine learning methods, keyword algorithms and human coding, posts were characterised as featuring content related to product promotion, nicotine and addiction, youth culture and lifestyle. RESULTS: Keyword queries captured 14 838 JUUL-relevant posts by 5201 unique users. Over one-third of posts were promotional (eg, linked to commercial website) and 11% contained nicotine and addiction-related information. Approximately half of posts featured content related to youth (55%) or lifestyle (57%). Youth-related content or lifestyle appeals were also notably present within promotional posts and nicotine and addiction-related posts, respectively. Nicotine and addiction-related posts featured memes, hashtags (eg, #nichead, #juulbuzz) and tag lines (eg, 'more flavor, more buzz'). CONCLUSIONS: Findings reveal a proliferation of JUUL-related content on Instagram, which focused on product promotion and nicotine and addiction that included youth culture and lifestyle appeals. Regulatory actions should focus on restricting promotional efforts for e-cigarette products, particularly on social media platforms where young people are a primary audience.

Associations between public e-cigarette use and tobacco-related social norms among youth.

IMPORTANCE: E-cigarette use in public places may renormalise tobacco use. OBJECTIVE: To measure associations between e-cigarette use in public places and social norms among youth. DESIGN: Cross-sectional survey. SETTING: School-based. PARTICIPANTS: 24 353 never tobacco users in US 6th-12th grades who completed the 2016-2017 National Youth Tobacco Surveys. EXPOSURE: Individuals were classified as exposed in public places within the past 30 days to: (1) neither e-cigarette secondhand aerosol (SHA) nor combustible tobacco secondhand smoke (SHS); (2) SHA only; (3) SHS only; and (4) both SHA and SHS. OUTCOMES: Outcomes were overestimation of peer e-cigarette use (a measure of descriptive norms), harm perception and susceptibility. Data were analysed using descriptive statistics and logistic regression (p<0.05). RESULTS: Overall prevalence of SHS and SHA exposure in public places was 46.6% and 18.3%, respectively. SHA exposure in public places was associated with increased odds of overestimating peer e-cigarette use (adjusted OR (AOR): 1.83; 95% CI 1.29 to 2.58) and decreased odds of perceiving e-cigarettes as harmful (AOR: 0.63; 95% CI 0.51 to 0.79), compared with those exposed to neither emission. SHA exposure in public places was also associated with increased susceptibility to using e-cigarettes (AOR: 2.26; 95% CI 1.82 to 2.81) and cigarettes (AOR: 1.51; 95% CI 1.20 to 1.90). E-cigarette harm perception was lower among students in jurisdictions with no comprehensive clean indoor air laws (AOR: 0.79; 95% CI 0.71 to 0.88) or cigarette-only laws (AOR: 0.88; 95% CI 0.78 to 0.99) than in those prohibiting both cigarette and e-cigarette use in public places. CONCLUSIONS: Prohibiting both e-cigarette and cigarette use in public places could benefit public health.

Support for E-cigarette and Tobacco Control Policies Among Parents of Adolescents.

INTRODUCTION: Parents are essential stakeholders for policy implementation. However, data on parents' support for e-cigarette- and tobacco-related policies is limited. This study examines parents' support for five e-cigarette- and tobacco-related policies targeted to prevent youth initiation and exposure to industry marketing practices. METHODS: Data were from a 2018 nationally representative sample of US parents of 11- to 18-year-old middle and high school students. Weighted adjusted logistic regression models examined correlates of support for policy outcomes, controlling for demographics. Analyses were performed among the full sample (n = 2743) and among current tobacco users (n = 355). RESULTS: The majority of parents, including current tobacco users, supported tobacco control efforts to protect adolescents. More than 90% of all parents supported restrictions on e-cigarette marketing to youth and 75% supported a ban on flavored e-cigarette sales. Additionally, more than 80% of all parents supported increasing the age of tobacco product sale to 21, limiting tobacco retailer density near schools, and keeping tobacco products out of view where youth shop. Presence of strict home tobacco rules or reporting a high priority to prevent child's e-cigarette use were significantly associated with higher odds of policy support. Results were similar among current tobacco users. CONCLUSIONS: Parents are an important group of tobacco control stakeholders and should be utilized to garner support for tobacco control policies in the context of the recent growth in youth tobacco and e-cigarette use. Parents' public support for tobacco control policies, particularly regulations on e-cigarette sales and marketing, can motivate advocates and policymakers to advance tobacco control policy agendas. IMPLICATIONS: Youth tobacco and e-cigarette use in the United States has increased in recent years. Parents are important stakeholders to inform policy agendas and advance efforts to restrict youth access and exposure to tobacco products. This study provides evidence that parents of adolescents are highly supportive of youth-centered tobacco control policies, particularly those that restrict access to youth-targeted e-cigarette marketing and the sale of youth-appealing flavored e-cigarettes. Utilizing policy support to mobilize parents may be an important advocacy strategy to advance tobacco control policy agendas and curb rising rates of youth e-cigarette and tobacco use.

Parents' Awareness and Perceptions of JUUL and Other E-Cigarettes.

INTRODUCTION: The purpose of this study is to examine awareness, attitudes, and related knowledge of e-cigarettes, and JUUL specifically, among parents of middle and high school students. METHODS: Data were collected in October-November 2018 from a nationally representative sample of U.S. parents of middle and high school students aged 11-18 years (n=2,885) to examine e-cigarette and JUUL awareness, concern about e-cigarette use, and school communication regarding e-cigarettes. Weighted frequencies and percentages are reported; Rao-Scott chi-square tests examined differences by school level. Data were analyzed in 2019. RESULTS: Although most parents (96.2%) had seen or heard of e-cigarettes, only 55.9% had seen or heard of JUUL, and only 44.2% accurately identified an image of JUUL as a vaping device. Many parents reported concern about adolescent e-cigarette use (60.6%), but fewer reported concern about their own child's use (32.9%). Most parents (73.5%) reported receiving no communication from their child's school about e-cigarettes or JUUL. CONCLUSIONS: There are notable gaps in parents' awareness of JUUL. School-to-parent communication efforts are necessary to build parents' knowledge of e-cigarettes like JUUL to prevent the growing youth uptake of these novel and addictive products.

Tobacco Abstinence Motives in Young Adult College Students: Scale Development and Validation.

Objectives: Our objective was to develop a scale to assess motives for abstaining from tobacco use among young adults. Methods: We analyzed 2016 survey data from 2094 US college students (ages 18-25) who reported no past-4-month tobacco use. We developed a 10-item scale and examined its reliability and validity, specifically in relationship to future use intentions; perceived addictiveness, health risks, and social acceptability of tobacco use; and tobacco product use at 4-month follow-up. Results: Factor analysis identified 2 factors: Social Concerns and Instrumental Concerns. Bivariate analyses regarding convergent and discriminant validity indicated that both subscales were associated with lower future tobacco use intentions; greater perceived addictiveness and harm to health; and lower likelihood of follow-up use across products (ps < .05). Social Concerns scores were associated with all psychosocial factors; Instrumental Concerns scores were not associated with perceived social acceptability or parental tobacco use. Multivariable logistic regression indicated that lower Social Concerns scores predicted any follow-up tobacco use (p = .027); lower Instrumental Concerns scores predicted follow-up e-cigarette use (p = .037). Additionally, Tobacco Abstinence Motives scores contributed significantly to each model. Conclusions: This scale demonstrated good psychometric properties and identi- fied social and instrumental concerns as potential intervention targets to promote young adult abstinence.

Cigarette Brand Preference and Pro-Tobacco Advertising Among Middle and High School Students - United States, 2012-2016.

Nearly all adult smokers first try cigarettes before age 18 years (1), and adolescents can show symptoms of nicotine dependence within days to weeks of the onset of occasional cigarette smoking (2). Having a usual cigarette brand among adolescent smokers could reflect exposure and receptivity to pro-tobacco advertising and tobacco product appeal (1). To identify usual cigarette brands smoked among U.S. middle and high school students who were current (past 30-day) cigarette smokers, CDC analyzed data from the 2012-2016 National Youth Tobacco Survey (NYTS). Marlboro, Newport, and Camel were the most commonly reported brands smoked during 2012-2016; in 2016, these three were the brands usually smoked for 73.1% and 78.7% of current cigarette smokers in middle and high school, respectively. These three brands also were the three most commonly identified as having a "favorite cigarette ad" in 2012. Efforts to reduce youth exposure to pro-tobacco advertising could help reduce youth smoking (1,3).