Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults.

BACKGROUND: The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings. METHODS: Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME). RESULTS: Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46). CONCLUSIONS: Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

Point-of-Sale Health Communication Campaigns for Cigarillos and Waterpipe Tobacco: Effects and Lessons Learned from Two Cluster Randomized Trials.

Many adolescents and young adults hold erroneous beliefs that cigarillos and waterpipe tobacco (WT) are safer than cigarettes, contributing to use. Communication campaigns can correct misperceptions and increase risk beliefs. We tested point-of-sale (POS) communication campaigns focused on chemical exposure for cigarillos and WT. We conducted two cluster randomized trials at 20 gas stations with convenience stores (10 stores for cigarillos, 10 for WT) in North Carolina between June and November 2017. Within each trial, stores were randomly assigned to either the intervention (campaign messages displayed) or a no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 adolescents and young adults (ages 16-25) per store, at baseline and follow-up. There were 978 participants (mean age = 20.9 years) in the cigarillo trial, and 998 participants (mean age = 21.0 years) in the WT trial. Rates of campaign exposure were low (26% for cigarillos; 24.3% for WT). The cigarillo campaign increased knowledge that ammonia is in cigarillo smoke (p < .01). There were also significant increases in knowledge about ammonia and cyanide in cigarillo smoke and arsenic in WT smoke (p < .05) in the sub-sample who reported exposure to the campaign. No differences were found in outcome expectancies, product attitudes, worry about chemical exposure, or behavioral intentions in either campaign. Garnering attention for communication campaigns in saturated POS environments, often dominated by tobacco advertising, is challenging. Our study demonstrates the feasibility of anti-tobacco campaigns at the POS and points to several lessons learned for future POS campaigns.

The Development and Testing of a Point-of-Sale E-Cigarette Health Communication Campaign.

Adolescents and young adults continue to use e-cigarettes, and communication campaigns are needed to decrease use among these populations. We developed and tested a point-of-sale communication campaign focused on e-cigarette chemical exposure. We developed messages based on formative research and tested them (versus text-only messages) in a nationally-representative online survey among adolescents and young adults (16-25) (Phase 1). Based on survey findings, we selected a message focused on nicotine and brain development for the point-of-sale trial (Phase 2). We then conducted a cluster-randomized trial at six gas stations with convenience stores, randomly assigned to the intervention (messages displayed) or no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 participants (ages 16-25) per store, at baseline and a four-week follow-up. Phase 1 included 1,636 participants in the online study. Intervention messages were rated as more attention grabbing than plain text messages (p < .05), though were rated similarly on other outcomes. Exposure to intervention messages resulted in larger changes from pre- to posttest for beliefs about addiction and relative harms versus cigarettes (p < .05). Phase 2 included 586 participants in the point-of-sale study. Real-world campaign exposure was low (31.8%), and no differences were found between conditions. E-cigarette prevention messages focused on nicotine's impact on brain development show promise. However, garnering attention for communication campaigns in saturated point-of-sale environments, often dominated by tobacco advertising, is challenging. Future efforts should utilize additional communication channels to directly target adolescents and young adults.

Cancer Risk Perceptions Among People Who Check Their Skin for Skin Cancer: Results from the 2017 U.S. Health Information National Trends Survey (HINTS).

When detected early, melanoma is highly treatable and rarely fatal. Self-skin checks can identify changes in moles that could be an indicator of melanoma. Cancer risk perceptions may influence the uptake of important preventive health behaviors such as self-skin checks. The purpose of this study is to examine cancer risk perception factors associated with those who have checked their skin for signs of skin cancer using the 2017 HINTS data. Retrospective cross-sectional analysis of a nationally representative sample of U.S. adults using the Health Information National Trends Survey (HINTS). Logistic regressions were performed to identify associations between having checked skin for signs of skin cancer, risk perceptions, and demographic variables. White women over the age of 45 with a college degree and annual incomes greater than $75,000 were more likely to check their skin for signs of skin cancer. More than a third reported they would rather not know if they had cancer and more than 60% had some level of worry about having cancer. Those with a personal or family history of cancer were more likely to check. HINTS is a cross-sectional survey which provides only a glimpse of behavioral predictors. Self-skin checks are simple and cost-effective to detect melanoma early and improve outcomes. Fear and worry about cancer were significant factors in the likelihood of checking skin for signs of skin cancer. Population-based strategies could be developed to reduce concerns about early detection.

Trends in sexual orientation disparities in cigarette smoking: Intersections between race/ethnicity and sex.

Cigarette smoking is disproportionately high among sexual minority populations, but it is unclear whether these disparities exist among race/ethnicity subgroups. This study examined trends in sexual orientation disparities in cigarette smoking by race/ethnicity. Data are from the 2014-2019 Behavioral Risk Factor Surveillance System (N = 1,194,768). Trend analyses compared cigarette smoking by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic other) and sexual orientation (straight, lesbian or gay, bisexual, something else/don't know/refused). Multivariable analyses examined associations between sexual orientation and cigarette use for each race/ethnicity, controlling for other sociodemographic characteristics. Between 2014 and 2019, lesbian or gay, and bisexual populations consistently had higher smoking rates than straight populations, which held across race/ethnicity. Among non-Hispanic White adults, lesbians (OR = 1.51, 95% CI = 1.29, 1.76), bisexual females (OR = 1.56, 95% CI = 1.39, 1.75), gay (OR = 1.38, 95% CI = 1.22, 1.55), and bisexual males (OR = 1.22, 95% CI = 1.04, 1.43) had higher odds of smoking compared those self-identifying as straight. Among non-Hispanic Black adults, lesbians (OR = 1.90, 95% CI =1.33, 2.73) and bisexual females (OR = 1.85, 95% CI =1.42, 2.41) were more likely to currently smoke. Among Hispanic adults, those self-identifying as lesbian or gay (OR = 1.58, 95% CI = 1.19, 2.09) or bisexual (OR = 2.40, 95% CI = 1.88, 3.07) were more likely to currently smoke, though the associations were not significant in Hispanic males. Disparities in cigarette smoking by race/ethnicity and sexual orientation suggest that aggregating these groups mask important differences and limit efforts to target those most at risk.

The Impact of Varying Warning Color on E-Cigarette Advertisements: Results From an Online Experiment Among Young Adults.

INTRODUCTION: Advertisement warnings are often overlooked, which reduces the opportunity for risk communication. METHODS: We used Prolific to survey 1131 young adults (18-35) who currently used e-cigarettes or tobacco products. We randomized participants to one of four warning conditions: black text on white background (BW), white on black (WB), black on yellow (BY), and yellow on black (YB). We examined associations between condition and attention, recall, ad appeal, perceived message effectiveness (PME), and intentions to use e-cigarettes using chi-square and analysis of variance (ANOVA) where appropriate. We conducted logistic regressions by condition for attention and recall controlling for demographics and tobacco use. RESULTS: The warning was selected as the most attention-capturing area of the advertisement more often by those exposed to yellow warnings than white (59.9% vs. 46.8%), even after controlling for demographics and tobacco use (p < .05). Recall was greater among those exposed to yellow warnings than white (44.2% vs. 37.3%), which held in controlled models. There were no significant differences between yellow and white warnings for ad appeals, PME, or intentions to use. In subanalyses, WB warnings generated higher PME (10.1 vs. 9.5) and lower intentions to use e-cigarettes (3.0 vs. 3.3) than black on white (BW) (each p < .05). CONCLUSIONS: Yellow warning color increases attention and recall of the warning, but this increase in attention did not translate to differences in downstream effects. Among currently mandated warning variations, the white text on black background warning appears more effective than the BW. Future research should examine whether differences translate to behavior change. IMPLICATIONS: We tested color variations of the FDA-mandated nicotine text warning on e-cigarette advertisements. Yellow variations (yellow text on black background and BY) better-captured attention and increased warning recall compared to the mandated black and white warnings. Among the FDA-mandated BW and WB warnings, the WB variation appears more effective, generating higher perceived message effectiveness and lower intentions to use e-cigarettes. Given the difficulty in implementing pictorial warnings in the United States, color might represent an alternative to improve warning effectiveness. Findings may also be applicable to those designing tobacco-related health communications.

Developing Pictorial Cigarillo Warnings: Insights From Focus Groups.

INTRODUCTION: The Food and Drug Administration (FDA) selected six text-only warnings for cigarillos to be implemented on packaging and advertising. Pictorial warnings are more effective at discouraging cigarette use than text-only warnings, yet no research exists for cigarillos. We sought to understand what types of images might be most effectively paired with the cigarillo text warnings to inform broad principles for developing pictorial warnings, with a focus on young adults, who have the highest rate of cigarillo use. METHODS: We conducted five focus groups with a total of N = 30 young adult cigarillo users and susceptible nonusers (53% female, 50% White, and 33% Black). Participants were shown four to eight unique images for each of the six text statements and were asked about visual-verbal congruency, emotional and cognitive reactions, and perceived effectiveness of each image. Sessions were recorded and transcribed; two investigators independently coded transcripts for emergent themes. RESULTS: Participants reported images that were graphic or "gross" would best grab attention and discourage use of cigarillos. Participants preferred images that were a direct illustration of the information in the warning text, rather than abstract images that required more cognitive effort to understand. Participants also highlighted that including people in the images, especially youth and young adults making eye contact, helped them relate to the warnings, garner their attention, and positively influence their reactions. CONCLUSIONS: We identified several principles to inform the selection of images to pair with the FDA-required cigarillo text statements. These insights may also apply to pictorial warnings for other tobacco products. IMPLICATIONS: This focus group study identified principles for selecting images to develop pictorial warnings for the six FDA text-only cigarillo warnings. We found that young adult cigarillo users and susceptible nonusers preferred images that were graphic and gross, believable, congruent to the warning text, and included people. Images that match young adults' visual expectations of a disease and are emotion-provoking may be most effective in pictorial warnings and highlight challenges for developing pictorial warnings for health effects that do not have a visible health consequence.

Changes in knowledge, perceptions and use of JUUL among a cohort of young adults.

OBJECTIVE: E-cigarettes have gained popularity, most recently with pod-style devices, such as JUUL. We examined changes in JUUL awareness, use, perceptions, nicotine content knowledge, number of days a pod lasts and exposure to JUUL retail advertising over a 6-month period in a cohort of young adults. METHODS: In spring and fall 2018, 1836 young adults completed online surveys on tobacco use, including JUUL perceptions and use behaviours. Demographics, tobacco use and JUUL advertising exposure in spring 2018 were examined as predictors of current JUUL use in fall 2018. RESULTS: Ever and current JUUL use doubled in 6 months (5.9% vs 12.7%, p<0.001; 1.6% vs 3.4%, p<0.001). The number of days a JUUL pod lasts significantly changed (p=0.049). Although there was an increase in those reporting JUUL has as much or more nicotine than a pack of cigarettes, 58% are 'not sure' of JUUL's nicotine content. Exposure to JUUL's advertising significantly increased (31.8% to 46.4%; p<0.001). In multivariable models, those perceiving JUUL as or more harmful than cigarettes, and former and never cigarette smokers had significantly lower odds of current JUUL use at 6 months compared with their respective counterparts (p<0.0001). Those reporting exposure to JUUL's advertising had significantly increased odds of current JUUL use 6 months later (p<0.03). CONCLUSIONS: Findings demonstrate changes in knowledge of JUUL's nicotine content, perceptions and use over a short period of time, suggesting frequent measurement is necessary. Additionally, efforts are needed to regulate retail advertising and ensure consumer education about product risks as they are associated with current use.

Youth and Young Adult Convenience Store Behaviors: Findings From Intercept Surveys.

INTRODUCTION: To inform tobacco policy and prevention efforts, we examined youth and young adult behaviors at gas-station-convenience stores and whether these behaviors varied by demographics or tobacco use. AIMS AND METHODS: Between June and July 2017, we conducted 990 intercept surveys at convenience stores in North Carolina among 16- to 25-year olds who were susceptible to or used tobacco. We used logistic regression to examine whether demographics or tobacco use predicted pumping gas, entering the store, or purchasing tobacco, gas, food, lottery tickets, or other items inside the store. RESULTS: Most participants (85.3%) reported ever using tobacco. Most visited that store at least once per week (40.3%) or once within the past month (41.2%). Just over half (55.0%) reported pumping gas at the store. Of those who went or planned to go inside (68.8%), 43.2% purchased food, 39.2% purchased gas, 33.1% purchased tobacco, and 6.8% purchased lottery tickets. Those who were aged 21-25, visited the store two to three times a week, and went inside already were more likely to purchase tobacco (all p < .05). Past 30-day cigarette, cigar, smokeless, and other tobacco uses were positively associated with purchasing tobacco (all p < .05). CONCLUSIONS: Our sample of young people who were susceptible to or ever used tobacco regularly visited gas-station-convenience stores, and one-third purchased or planned to purchase tobacco during their visit. Convenience stores appear to be an important access point for young people. Practitioners and policy makers should consider a comprehensive set of strategies to reduce access among youth and young adults. IMPLICATIONS: We conducted 990 intercept surveys among youth and young adults at gas-station-convenience stores. Among our sample of those who had ever used tobacco or were susceptible to use, most visited the store frequently and one-third purchased tobacco, particularly those who used cigarettes and cigars. Tobacco companies heavily market in convenience stores, and our results show tobacco is a product often purchased by susceptible young adults. Practitioners and policy makers should consider prioritizing efforts at convenience stores to reduce product purchase and use.

Optimizing Warnings on E-Cigarette Advertisements.

INTRODUCTION: We examined the effect of visual optimizations on warning text recall. METHODS: We used Amazon's Mechanical Turk to recruit 1854 young adult (18-34 years) electronic cigarette (e-cigarette) users or susceptible nonusers. We conducted a between-subjects 3 × 2 × 2 experiment to examine the influence of color (black text on white background [BW] vs. black on yellow [BY] vs. yellow on black [YB]), shape (rectangle vs. novel), and signal word (presence vs. absence of the word "warning"). We randomized participants to view one of 12 warnings on a fictional e-cigarette advertisement. We coded open-ended recall responses into three categories: (1) recalled nothing, (2) recalled something, (3) recalled the concept. We examined main effects on warning text recall using multinomial regression. We examined differences in attention, perceived message effectiveness, and appeal. RESULTS: Those exposed to BW or BY warnings were more likely than those exposed to YB to recall something (AOR = 1.6, AOR = 1.5, respectively) or the concept (OR = 1.4, BW). Those exposed to novel shape (44.7% novel vs. 37.9% rectangle; p = .003) or color (44.5% BY vs. 41.9% YB vs. 37.5% BW; p = .04) warnings were more likely to report attention to the warning. In aided recall, those exposed to the signal word were more likely than those not exposed to select the correct response (64.0% vs. 31.3%; p < .0001). We did not find differences for message effectiveness or appeal. CONCLUSIONS: Visual optimizations such as color may influence warning text recall and should be considered for new warnings. Research should continue exploring variations for advertisement warnings to maximize attention to warning text. IMPLICATIONS: This study examines the impact of visual optimizations on recall of the US Food and Drug Administration-mandated e-cigarette advertisement warning text. We found that color might influence warning text recall, but we did not find effects for shape or signal word. It is possible the newly mandated e-cigarette advertisement warnings, which are required to occupy at least 20% of the advertisement, are currently novel enough to attract attention. Future research should examine optimizations following implementation of the new advertisement warnings.

Pinterest Homemade Sunscreens: A Recipe for Sunburn.

Social media, specifically Pinterest with more than 175 million users, has changed the way people seek and share health information. Recent consumer interest in natural products has led to an increase of shared recipes for homemade products including sunscreen. Homemade sunscreen products are risky because they are not regulated or tested for efficacy like commercial sunscreens. With rising skin cancer rates, the use of effective broadband sunscreen is critical to reduce incidence of skin cancer. This study used directed content analysis to examine how homemade sunscreens were portrayed on Pinterest. Using the search terms, homemade sunscreen and natural sunscreen, researchers sampled every fifth pin to collect 189 relevant pins. A codebook was developed, pilot tested, and used to code pins. Two researchers coded pins and interrater reliability was established at 90%. Of the 189 pins, the majority of pins (95.2%) positively portrayed the effectiveness of homemade sunscreens and 68.3% recommended recipes for homemade sunscreens that offered insufficient UV radiation protection. Sun Protection Factor (SPF) claims were made in 33.3% of pins with a range of SPF 2 to SPF 50. In this sample of pins, 41.8% of pins had been saved by other users ranging from one to more than 21,000 times. Social media is a powerful source of health information. However, this study revealed widespread interest and acceptance of insufficient sun protection information. Pinterest and the interest in homemade recipes for sunscreen present an opportunity for public health professionals to proactively engage on social media. Abbreviations: US: United States; SPF: sun protection factor; USFDA: United states food and drug administration; UV: ultraviolet.

Cannabidiol (CBD): Perspectives from Pinterest.

BACKGROUND: Pinterest, a widely used social media platform, has shaped how people seek and share health information. Cannabidiol (CBD), a non-psychoactive component of cannabis is marketed as a treatment for many conditions and sales rose to more than 820 million in 2017. Yet CBD is mostly unregulated, legality is murky, and many of the health claims are not scientifically proven. Purpose: This content analysis examined how CBD products were portrayed on Pinterest. Methods: In 2018, using the search terms cannabidiol and CBD, researchers sampled every fifth pin to collect 226 relevant pins. A codebook was developed, pilot tested, and used to code pins. Results: The majority (91.6%) of pins positively portrayed CBD with many claiming a physical or mental benefit including anxiety, depression, pain, and inflammation relief. Most pins did not (98.2%) address potential side effects or recommend dosage. In this sample, user engagement was high with 85.2% of pins being saved and links to commercial sites selling CBD products, personal blogs, and social media accounts. Conclusions: Social media has become a powerful source of health information. This study revealed widespread acceptance of the use of CBD products with minimal information from reliable public health sources represented.

Are Waterpipe Café, Vape Shop, and Traditional Tobacco Retailer Locations Associated with Community Composition and Young Adult Tobacco Use in North Carolina and Virginia?

PURPOSE: We examined whether waterpipe café, vape shop, and traditional tobacco retailer (e.g. stores selling cigarettes, cigars, smokeless tobacco) locations were associated with census tract composition and tobacco use among young adults in North Carolina and Virginia. Methods: We identified waterpipe cafés, vape shops, and traditional tobacco retailers in North Carolina and Virginia and conducted multivariable analyses between community characteristics (gender, race, ethnicity, education, college enrollment, and poverty) and density per 1000 population. Using fall 2017 data from 1099 young adults residing in North Carolina and Virginia, we conducted logistic regression analyses to determine whether tobacco retailer density and proximity were associated with tobacco use. Results: Waterpipe café, vape shop, and traditional retailer density were higher in communities with more people who were Hispanic, college-educated, and college-enrolled (each p < .05). Waterpipe café and traditional retailer density were higher in communities with more people living below the poverty level (each p < .05). Waterpipe café density was higher in communities with more people who were male (p < .05), while traditional retailer density was lower (p < .05). Waterpipe café and vape shop proximity were associated with increased likelihood of waterpipe tobacco use in the past 6 months (each p < .05; unadjusted). Traditional retailer proximity and waterpipe café, vape shop, and traditional retailer density were not associated with tobacco use. Conclusions: Waterpipe cafés and vape shops are located in both impoverished and college-educated communities in North Carolina and Virginia, similar to where traditional tobacco retailers are located. Further research is needed to examine associations with tobacco use.

Reducing Nicotine Without Misleading the Public: Descriptions of Cigarette Nicotine Level and Accuracy of Perceptions About Nicotine Content, Addictiveness, and Risk.

SIGNIFICANCE: The public incorrectly believes very low nicotine content (VLNC) cigarettes are less carcinogenic than current cigarettes, a belief associated with lower motivation to quit under a VLNC standard. We examined how different descriptions of the nicotine level in VLNC cigarettes affect the accuracy of the public's perceptions about nicotine content, addictiveness, and cancer risk. METHODS: Participants were a national convenience sample of 1353 US adults (22% smokers). In an online experiment, we randomized participants to a VLNC description using (1) concise language; (2) a percentage; (3) an interpretation; (4) a percentage and interpretation; (5) a percentage and a pictograph; or (6) a percentage, interpretation, and pictograph; or to a control description using (7) FDA's "minimally or nonaddictive" phrasing. We assessed accuracy of perceived nicotine content, addictiveness, and cancer risk compared to current cigarettes. RESULTS: Compared to control, the percentage description resulted in more accurate perceptions about nicotine content (76% vs. 49% accuracy) and addictiveness (44% vs. 34%), but less accurate perceptions about cancer risk (56% vs. 68%; all ps < .05). Adding interpretation or pictographs to the percentage description did not increase accuracy. The concise language description reduced accuracy of perceived nicotine content and addictiveness but increased accuracy of cancer risk (all ps < .05). CONCLUSIONS: Stating that 95% of nicotine would be removed more accurately conveyed the nicotine content and addictiveness of VLNC cigarettes. However, descriptions that better conveyed nicotine content and addictiveness misled people about cancer risk. IMPLICATIONS: Implementation of a VLNC standard should include plans for a communication campaign that conveys that VLNC cigarettes will be less addictive but equally toxic to smoke. Stating the percent reduction in nicotine is likely to more clearly communicate reduced addictiveness but may also exacerbate risk misperceptions. VLNC communication requires further study to ensure the public accurately understands a VLNC standard.

Waterpipe tobacco package warning exposure's impact on risk perceptions and use among young adults in the USA: a longitudinal analysis of the population assessment of tobacco and health study.

BACKGROUND: Although Food and Drug Administration (FDA)-mandated waterpipe tobacco warnings were not required until August 2018, some waterpipe tobacco packaging (WTP) sold in the USA, contained warnings prior to this date. We examined the prevalence of WTP warning exposure and whether exposure influenced risk perceptions or use among young adult (aged 18-24 years) current waterpipe users. METHODS: We used data from waves 1 (2013-2014) and 2 (2014-2015) of the Population Assessment of Tobacco and Health Study, a nationally representative longitudinal study of US adults and youth. We conducted logistic regression analyses to identify factors associated with wave 1 warning exposure, and whether wave 1 WTP warning exposure predicted wave 2 relative risk perceptions and waterpipe use. RESULTS: More than one-third of our sample (35.9%, 95% CI 33.5 to 38.4) reported past-month WTP warning exposure. Exposure was higher among males (adjusted OR (AOR)=1.34, 95% CI 1.04 to 1.72), those who usually do not share the waterpipe (AOR=3.10, 95% CI 1.45 to 6.60), those who purchased waterpipe tobacco (AOR=1.73, 95% CI 1.28 to 2.34), and those with a regular brand (AOR=1.84, 95% CI 1.26 to 2.68). Those exposed to WTP warnings at wave 1 were more likely than those not exposed to perceive waterpipe tobacco to be as or more harmful than cigarettes at wave 2 (AOR=1.35, 95% CI 1.02 to 1.78). There was no association between wave 1 WTP exposure and wave 2 waterpipe use. CONCLUSIONS: More than one-third of US young adult current waterpipe users reported WTP warning exposure prior to FDA-mandated warning implementation. Findings suggest the mandated warning may result in high exposure among users; it will be critical to assess exposure's impact on risk perceptions and behaviour after FDA-mandated warnings are implemented.

Health claims made in vape shops: an observational study and content analysis.

BACKGROUND: Prior to the final deeming rule, federal law in the USA prohibited electronic cigarettes (e-cigarettes) from being marketed as smoking cessation products; for other therapeutic purposes and in ways that conveyed Food and Drug Administration (FDA) approval/endorsement. After August 2016, additional federal prohibitions were added including false/misleading and unauthorised modified risk tobacco product (MRTP) claims. No systematic investigation of e-cigarette health claims has been conducted in the retail environment. We sought to document and characterise claims made in vape shops. METHODS: Between November 2015 and February 2016, before final deeming rule implementation, two trained data collectors conducted unannounced observational assessments of 46 vape shops in North Carolina. Data collectors used wearable imaging technology to document health claims about e-cigarettes. Photos were coded for five claim types: (1) cessation device; (2) drug effect/device; (3) FDA-approved/endorsed; (4) false/misleading and (5) MRTP. Photos were double coded; differences between coders were adjudicated and reviewed by an expert panel. RESULTS: At least one health claim was displayed in 41.3% (n=19) of retailers, ranging from 0 to 27 claims per retailer. All claim types were found. Cessation device claims were the most prevalent (62.2%, n=84), followed by MRTP (27.4%, n=37), drug effect/device (8.1%, n=11), false/misleading (1.5%, n=2), and FDA approved/endorsed (0.7%, n=1). Retail chains made the majority of claims compared with independent shops (88.9% vs 11.1%). CONCLUSIONS: Many vape shops displayed e-cigarette health claims, which are all now FDA prohibited. These claims could mislead consumers and influence behaviour. Findings highlight the need for retailer education, continued surveillance, enforcement specific to advertising and research on consumer perceptions of claims.

Availability and Placement of Electronic Nicotine Delivery Systems at the Point-of-Sale.

Introduction: Electronic nicotine delivery systems (ENDS) are widely available and come in a variety of forms, including disposable cigalikes and refillable tank systems. However, little is known about their placement at the point-of-sale. We explored the placement of various ENDS types among tobacco retailers. Methods: Systematic assessments at the point-of-sale were completed by trained data collectors in 90 tobacco retailers, including grocery stores, convenience stores, and pharmacies in North Carolina, United States. Availability and placement of various ENDS types including cigalikes, e-hookahs, tank systems, and e-liquids was recorded. Results: Almost all retailers (97.8%) sold cigalikes; 41.4% sold devices labeled as e-hookahs; 54.4% sold tank systems; and 56.2% sold e-liquids. Fewer than half of stores placed ENDS exclusively behind the counter; significant differences in ENDS placement were found by store type. Grocery stores carried cigalikes, tank systems, and e-liquids and placed them exclusively behind the counter. Pharmacies only sold cigalikes; most placed them exclusively behind the counter (91.7%) with cessation aids and other tobacco products. Convenience stores carried all ENDS types and placed them with other tobacco products (55.1%) and candy (17.4%). Only about one-third of convenience stores placed ENDS exclusively behind the counter. Conclusions: This exploratory study shows ENDS availability and placement at the point-of-sale varies by retailer type. Pharmacies placed cigalikes with cessation aids behind the counter suggesting their ability to aid in smoking cessation. Most convenience stores placed ENDS in self-service locations, making them easily accessible to youth. Findings highlight the need for ENDS regulation at the point-of-sale. Implications: Our study highlights the need for regulatory efforts aimed at ENDS placement at the point-of-sale. While pharmacies and grocery stores offered fewer ENDS types and typically placed them in clerk-assisted locations, all ENDS types were found at convenience stores, some of which were placed in youth-friendly locations. Regulatory efforts to control ENDS placement and limit youth exposure should be examined, such as requiring products be placed in clerk-assisted locations and banning ENDS placement next to candy.

Cancer Risk Factor Knowledge Among Young Adults.

Cancer is the second leading cause of death in the USA. Incidence and mortality rates for cancer have risen steadily and cost the healthcare system over $264 billion annually. Cancer risk can be reduced by restricting alcohol consumption, avoiding tobacco, eating a balanced diet, limiting sun exposure, exercising, and seeking routine cancer screenings. The purpose of this study is to examine cancer risk factor knowledge among college students. Researchers surveyed undergraduate and graduate students (n = 758) at a mid-sized public university in the Southeast about their knowledge regarding cancer risk factors including smoking, alcohol consumption, diet, obesity, hypertension, and human papillomavirus (HPV). Participants were mostly able to identify the association between cancers and health risk behaviors that have received widespread media coverage, are somewhat intuitive, or are salient to their life stage such as drinking, tanning, and smoking. Nearly all participants correctly reported exposure to ultraviolet (UV) rays, and smoking increased risk of developing skin and lung cancer, respectively. Most students correctly identified an increased risk of liver cancer associated with alcohol use but missed head/neck and breast cancer. However, knowledge of less publicized relationships was insufficient. The findings offer encouragement to public health professionals that campaigns have increased awareness of cancer risk. However, there were many relationships that revealed a lack of knowledge, and future campaigns can target lesser-known cancer risk relationships to reduce the personal tragedy and societal burden of cancer.

Total body skin examination adherence among young adults with an increased risk for skin cancer.

Although ultraviolent radiation exposure and skin cancer rates are rising in the US, there is not a consistent national message calling for routine total body skin examinations (TBSE) by a healthcare provider. This pilot study examined TBSE rates among adults at an increased risk for skin cancer (history of sunburn, indoor tanning use, excessive UV exposure, poor sunscreen use). Overall skin cancer prevention behaviors were insufficient among respondents (n=953) and only a quarter of respondents considered at an increased risk for skin cancer reported a TBSE. White, older students with light skin who regularly use sunscreen were significantly more likely to report a TBSE. These findings highlight the need for a national study examining TBSE across the lifespan among high-risk individuals.