Development of the UNC Perceived Message Effectiveness Scale for Youth.

PURPOSE: Tobacco prevention media campaigns are an important tool to address youth tobacco use. We developed a theory-based perceived message effectiveness (PME) Scale to use when vetting messages for campaigns. METHODS: Participants were a national sample of N=623 US adolescents (ages 13-17 years) recruited from a national probability-based panel. In an online experiment, we randomised adolescents to view tobacco prevention ads. All participants viewed an ad on smoking or vaping from the US Food and Drug Administration's The Real Cost campaign and a control video, in a random order. After ad exposure, we assessed PME using nine candidate items and constructs for convergent and criterion validity analyses. We used confirmatory factor analysis and examined information curves to select the scale items. RESULTS: A brief PME scale with three items (α=0.95) worked equally well for demographically diverse adolescents with different patterns of tobacco use. The Real Cost ads generated higher PME scores than the control videos for both vaping and smoking (convergent validity; p<0.05). Higher PME scores were associated with greater attention, fear, cognitive elaboration and anticipated social interactions (convergent validity; r=0.31-0.66), as well as more negative attitudes toward and lower susceptibility to vaping and smoking (criterion validity; r=-0.14 to -0.37). A single-item PME measure performed similarly to the three-item version. CONCLUSIONS: The University of North Carolina PME Scale for Youth is a reliable and valid measure of the potential effectiveness of vaping and smoking prevention ads. Employing PME scales during message development and selection may help youth tobacco prevention campaigns deploy more effective ads.

Optimising messages and images for e-cigarette warnings.

BACKGROUND: The US Food and Drug Administration (FDA) requires electronic cigarettes (e-cigarettes) to have a single addiction warning, but many other health harms are associated with vaping and warnings grow stale over time. We aimed to develop new warning messages and images to discourage e-cigarette use. METHODS: Participants were 1629 US adults who vaped or smoked. We randomised each participant to evaluate 7 of 28 messages on newly developed warning themes (metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, addiction), and the current FDA-required warning (total of 8 messages). Then, participants evaluated images of hazards (eg, metal), internal harms (eg, organ damage) or people experiencing harms. RESULTS: Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<0.001), led to greater negative affect (all p<0.001) and led to more anticipated social interactions (all p<0.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<0.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<0.001), although unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<0.001). DISCUSSION: Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. Images of internal harm or people experiencing harms may be particularly effective at discouraging vaping.

Identifying Promising Themes for Adolescent Vaping Warnings: A National Experiment.

INTRODUCTION: Adolescent vaping remains a problem in the United States, yet little is known about what health warning themes most discourage vaping among adolescents. We sought to identify the most compelling themes for vaping warnings for US adolescents. METHODS: Participants were a national probability sample of 623 US adolescents aged 13-17 years, recruited in the summer of 2020. Adolescents were randomized to one of the five warning message themes about the potential health effects of vaping: 1. chemical harms, 2. lung harms, 3. Coronavirus Disease 2019 (COVID-19) harms, 4. nicotine addiction, or 5. control (messages about vape litter). The primary outcome was perceived message effectiveness (PME; 3-item scale). Secondary outcomes were negative affect (fear), attention, anticipated social interactions, and message novelty. RESULTS: Adolescents rated the chemical, lung, and COVID-19 harms warning messages higher on PME than nicotine addiction and control (all p < .05), while nicotine addiction was rated higher than control (p < .05). The chemical, lung, and COVID-19 harms warning themes also elicited greater negative affect than nicotine addiction and control (all p < .05). For all other secondary outcomes, the COVID-19 harms warning message theme was rated higher than nicotine addiction and control (all p < .05). CONCLUSION: Adolescents perceived warning message themes about lung, chemical and COVID-19 health effects of vaping as more effective than nicotine addiction. To discourage vaping, the FDA and others should communicate to youth about the health effects of vaping beyond nicotine addiction. IMPLICATIONS: Adolescents rated warning message themes about the lung, chemical, and COVID-19 health effects of vaping as more effective than nicotine addiction, while nicotine addiction was rated as more effective than control themes about vaping litter. To discourage vaping among adolescents, health messaging should expand message themes to communicate about a broader set of health effects of vaping beyond nicotine addiction.

Terms tobacco users employ to describe e-cigarette aerosol.

BACKGROUND: The scientific term for the substance people inhale and exhale from a vaping device is 'aerosol', but whether the public uses this term is unclear. To inform tobacco control communication efforts, we sought to understand what tobacco users call e-cigarette aerosols. METHODS: Participants were a national convenience sample of 1628 US adults who used e-cigarettes, cigarettes or both (dual users). In an online survey, conducted in spring 2021, participants described what 'people inhale and exhale when they vape', using an open-ended and then a closed-ended response scale. Participants then evaluated warning statements, randomly assigned to contain the term 'aerosol' or 'vapor' (eg, 'E-cigarette aerosol/vapor contains nicotine, which can lead to seizures'). RESULTS: In open-ended responses, tobacco users most commonly provided the terms 'vapor' (31%) and 'smoke' (23%) but rarely 'aerosol' (<1%). In closed-ended responses, the most commonly endorsed terms were again 'vapor' (57%) and 'smoke' (22%) but again infrequently 'aerosol' (2%). In closed-ended responses, use of the term 'vapor' was more common than other terms among people who were older; white; gay, lesbian or bisexual; college educated; or vape users only (all p<0.05). In the experiment, warnings using the terms 'aerosol' and 'vapor' were equally effective (all p>0.05). CONCLUSIONS: The public rarely uses the term 'aerosol' to describe e-cigarette output, potentially complicating educational efforts that use the term. Future studies should explore public knowledge and understanding of the terms 'aerosol' and the more popular 'vapor' to better inform vaping risk communication.

Awareness of and reactions to the health harms of sugary drinks: An online study of U.S. parents.

Evidence about the health problems associated with sugary drink consumption is well-established. However, little is known about which sugary drink health harms are most effective at changing consumers' behavior. We aimed to identify which harms people were aware of and most discouraged them from wanting to buy sugary drinks. Participants were a national convenience sample of diverse parents (n = 1,058), oversampled for Latino parents (48%). Participants rated a list of sugary drink-related health harms occurring in children (7 harms) and in adults (15 harms). Outcomes were awareness of each harm and how much each harm discouraged parents from wanting to purchase sugary drinks. Most participants were aware that sugary drinks contribute to tooth decay in children (75%) and weight gain in both children (73%) and adults (69%). Few participants were aware that sugary drinks contribute to adult infertility (16%), arthritis (18%), and gout (18%). All health harms were rated highly in terms of discouraging parents from wanting to buy sugary drinks (range: 3.59-4.11 on a 1-5 scale), with obesity, pre-diabetes, and tooth decay eliciting the highest discouragement ratings. Harm-induced discouragement was higher for participants who were aware of more health harms (B = 0.05, p < 0.0001), identified as female (B = 0.15 compared to male, p = 0.02), or had an annual household income of $50,000 or more (B = 0.16 compared to less than $50,000, p = 0.03). These findings suggest health messages focused on a variety of health harms could raise awareness and discourage sugary drink purchases.

Using a Naturalistic Store Laboratory for Clinical Trials of Point-of-Sale Nutrition Policies and Interventions: A Feasibility and Validation Study.

Point-of-sale policies such as warnings and taxes are promising tools for improving the nutritional quality of food purchases. Research studies conducted in naturalistic store laboratories could improve the quality of evidence about point-of-sale interventions by allowing for realistic exposure in a controlled setting. This study aimed to assess whether purchasing behavior in a naturalistic store laboratory setting was similar to real-life purchasing behavior and to evaluate participants' perceptions of store realism and the acceptability of research study protocols in this setting. In a longitudinal observational study in 2019, Latinx parents in North Carolina (n = 61) attended five weekly visits at the UNC Mini Mart, a naturalistic store laboratory that resembled a small convenience store. At each visit, participants purchased a week's supply of beverages. Purchases of beverages in the Mini Mart were compared to participants' purchases from receipts submitted the week prior to the study. Analyses compared the percentage of participants buying sugary drinks and non-sugary drinks in the Mini Mart vs. in real stores using Chi-Square tests with Fisher's p. The percentage of parents who purchased sugary drinks in the Mini Mart (93%) was not significantly different from the percentage who purchased sugary drinks during the week before the study (74%, p = 0.28). The percentage purchasing non-sugary drinks was similar in the two settings (85% in the Mini Mart vs. 85% from receipts, p = 0.33). Nearly all participants reported that their Mini Mart purchases were similar to real-life purchases (96%); the Mini Mart felt like a real store (94%); they could find all the beverages they were looking for (92%); and they could imagine doing their real-life beverage shopping in the Mini Mart (92%). Moreover, retention was high, with 97% of participants attending the final study visit. These results indicate that naturalistic store laboratories are a promising method for increasing the ecological validity of trials to evaluate point-of-sale interventions.