Effects of a Social Media Intervention on Vaping Intentions: Randomized Dose-Response Experiment.

BACKGROUND: e-Cigarette use, especially by young adults, is at unacceptably high levels and represents a public health risk factor. Digital media are increasingly being used to deliver antivaping campaigns, but little is known about their effectiveness or the dose-response effects of content delivery. OBJECTIVE: The objectives of this study were to evaluate (1) the effectiveness of a 60-day antivaping social media intervention in changing vaping use intentions and beliefs related to the stimulus content and (2) the dose-response effects of varying levels of exposure to the intervention on vaping outcomes, including anti-industry beliefs, vaping intentions, and other attitudes and beliefs related to vaping. METHODS: Participants were adults aged 18 to 24 years in the United States. They were recruited into the study through Facebook (Meta Platforms) and Instagram (Meta Platforms), completed a baseline survey, and then randomized to 1 of the 5 conditions: 0 (control), 4, 8, 16, and 32 exposures over a 15-day period between each survey wave. Follow-up data were collected 30 and 60 days after randomization. We conducted stratified analyses of the full sample and in subsamples defined by the baseline vaping status (never, former, and current). Stimulus was delivered through Facebook and Instagram in four 15-second social media videos focused on anti-industry beliefs about vaping. The main outcome measures reported in this study were self-reported exposure to social media intervention content, attitudes and beliefs about vaping, and vaping intentions. We estimated a series of multivariate linear regressions in Stata 17 (StataCorp). To capture the dose-response effect, we assigned each study arm a numerical value corresponding to the number of advertisements (exposures) delivered to participants in each arm and used this number as our focal independent variable. In each model, the predictor was the treatment arm to which each participant was assigned. RESULTS: The baseline sample consisted of 1491 participants, and the final analysis sample consisted of 57.28% (854/1491) of the participants retained at the 60-day follow-up. We compared the retained participants with those lost to follow-up and found no statistically significant differences across demographic variables. We found a significant effect of the social media treatment on vaping intentions (ß=-0.138, 95% CI -0.266 to -0.010; P=.04) and anti-industry beliefs (ß=-0.122, 95% CI 0.008-0.237; P=.04) targeted by the intervention content among current vapers but not among the full sample or other strata. We found no significant effects of self-reported exposure to the stimulus. CONCLUSIONS: Social media interventions are a promising approach to preventing vaping among young adults. More research is needed on how to optimize the dosage of such interventions and the extent to which long-term exposure may affect vaping use over time. TRIAL REGISTRATION: ClinicalTrials.gov NCT04867668; https://clinicaltrials.gov/study/NCT04867668.

Cigar Use Progression Among New Cigar Initiators: A Two-Part Growth Curve Analysis Among a Youth and Young Adult Cohort.

INTRODUCTION: Youth and young adults (YYAs) are at high risk of cigar use. This study's objective was to examine progression and sociodemographic differences in current cigar use and frequency among new cigar initiators. AIMS AND METHODS: We conducted a two-part latent growth model among a nationally representative cohort of cigar initiators (aged 15-25) to examine 24-month trajectories of current cigar use and frequency (n = 1483). The cohort was recruited via address-based sampling with online data collection from 2014 to 2019 and surveyed approximately every 6 months. RESULTS: The unconditional odds of current cigar use (ie, past 30-day use) within 6 months of initiation was 0.72 (95% confidence interval: 0.63, 0.82), corresponding to a probability of 42%. The odds of current use among recent cigar initiates declined 6 months after initiation and was followed by a stabilization in use over time. Among continued users, frequency (# days used in past 30 days) increased linearly over time but remained low (3.47 days/months at 24 months). Younger individuals, non-Hispanic African Americans, those with lower subjective financial status, and current users of cigarettes, other tobacco products and/or marijuana were at highest risk within 6 months of initiation. Males, younger users, and current cigarette smokers had the highest risk for cigar progression over time. CONCLUSIONS: This study is the first to examine longitudinal cigar use patterns among YYA cigar initiators. Findings emphasize the need for research across the cigar use spectrum and the importance of interventions targeted by age, stage of use, cigarette, other tobacco, and marijuana use and key sociodemographics to interrupt use pathways. IMPLICATIONS: This study is the first to examine progression of cigar use among YYAs who have newly initiated cigars. Results show a high probability of current cigar use within 6 months of initiation followed by a rapid decline and stabilization over time. Frequency increases among those who continue using cigars. Males, younger users, and current cigarette smokers had the highest risk for cigar progression over time. Findings emphasize the need for targeting interventions by age, stage of use, cigarette, other tobacco, and marijuana use and key sociodemographics to interrupt use pathways.

The Measurement of Dose and Response for Smoking Behavior Change Interventions in the Digital Age: Systematic Review.

BACKGROUND: There is little consensus regarding effective digital health interventions for diverse populations, which is due in part to the difficulty of quantifying the impact of various media and content and the lack of consensus on evaluating dosage and outcomes. In particular, digital smoking behavior change intervention is an area where consistency of measurement has been a challenge because of emerging products and rapid policy changes. This study reviewed the contents and outcomes of digital smoking interventions and the consistency of reporting to inform future research. OBJECTIVE: This study aims to systematically review digital smoking behavior change interventions and evaluate the consistency in measuring and reporting intervention contents, channels, and dose and response outcomes. METHODS: PubMed, Embase, Scopus, PsycINFO, and PAIS databases were used to search the literature between January and May 2021. General and journal-based searches were combined. All records were imported into Covidence systematic review software (Veritas Health Innovation) and duplicates were removed. Titles and abstracts were screened by 4 trained reviewers to identify eligible full-text literature. The data synthesis scheme was designed based on the concept that exposure to digital interventions can be divided into intended doses that were planned by the intervention and enacted doses that were completed by participants. The intended dose comprised the frequency and length of the interventions, and the enacted dose was assessed as the engagement. Response measures were assessed for behaviors, intentions, and psychosocial outcomes. Measurements of the dose-response relationship were reviewed for all studies. RESULTS: A total of 2916 articles were identified through a database search. Of these 2916 articles, the title and abstract review yielded 324 (11.11%) articles for possible eligibility, and 19 (0.65%) articles on digital smoking behavior change interventions were ultimately included for data extraction and synthesis. The analysis revealed a lack of prevention studies (0/19, 0%) and dose-response studies (3/19, 16%). Of the 19 studies, 6 (32%) reported multiple behavioral measures, and 5 (23%) reported multiple psychosocial measures as outcomes. For dosage measures, 37% (7/19) of studies used frequency of exposure, and 21% (4/19) of studies mentioned the length of exposure. The assessment of clarity of reporting revealed that the duration of intervention and data collection tended to be reported vaguely in the literature. CONCLUSIONS: This review revealed a lack of studies assessing the effects of digital media interventions on smoking outcomes. Data synthesis showed that measurement and reporting were inconsistent across studies, illustrating current challenges in this field. Although most studies focused on reporting outcomes, the measurement of exposure, including intended and enacted doses, was unclear in a large proportion of studies. Clear and consistent reporting of both outcomes and exposures is needed to develop further evidence in intervention research on digital smoking behavior change.

Assessing the Health and Economic Impact of a Potential Menthol Cigarette Ban in New York City: a Modeling Study.

Menthol in cigarettes increases nicotine dependence and decreases the chances of successful smoking cessation. In New York City (NYC), nearly half of current smokers usually smoke menthol cigarettes. Female and non-Latino Black individuals were more likely to smoke menthol-flavored cigarettes compared to males and other races and ethnicities. Although the US Food and Drug Administration recently announced that it will ban menthol cigarettes, it is unclear how the policy would affect population health and health disparities in NYC. To inform potential policymaking, we used a microsimulation model of cardiovascular disease (CVD) to project the long-term health and economic impact of a potential menthol ban in NYC. Our model projected that there could be 57,232 (95% CI: 51,967-62,497) myocardial infarction (MI) cases and 52,195 (95% CI: 47,446-56,945) stroke cases per 1 million adult smokers in NYC over a 20-year period without the menthol ban policy. With the menthol ban policy, 2,862 MI cases and 1,983 stroke cases per 1 million adults could be averted over a 20-year period. The model also projected that an average of $1,836 in healthcare costs per person, or $1.62 billion among all adult smokers, could be saved over a 20-year period due to the implementation of a menthol ban policy. Results from subgroup analyses showed that women, particularly Black women, would have more reductions in adverse CVD outcomes from the potential implementation of the menthol ban policy compared to males and other racial and ethnic subgroups, which implies that the policy could reduce sex and racial and ethnic CVD disparities. Findings from our study provide policymakers with evidence to support policies that limit access to menthol cigarettes and potentially address racial and ethnic disparities in smoking-related disease burden.

Patterns of E-cigarette Use and Subsequent Cigarette Smoking Cessation Over 2 Years (2013/2014-2015/2016) in the Population Assessment of Tobacco and Health Study.

INTRODUCTION: Understanding the population impact of e-cigarettes requires determining their effect on cigarette smoking cessation. METHODS: Using the US Population Assessment of Tobacco and Health cohort, we examined smoking cessation among adult current cigarette smokers at Wave 1 with follow-up data at Waves 2 and 3 (n = 9724). RESULTS: By Wave 3 (2015/2016), 17.3% of smokers had quit smoking. Smokers using e-cigarettes daily or who increased to daily use over the three waves were two to four times more likely to have quit in the short term (<1 year) and long term (1+ years) compared with never e-cigarette users (p < .001). E-cigarette use in the last quit attempt was associated with a higher likelihood of short-term (<1 year) quitting at Wave 3 (adjusted relative risk ratio: 1.33; 95% confidence interval: 1.04, 1.71) compared with smokers who did not use an e-cigarette in their last quit attempt. Noncurrent (no use in any wave) e-cigarette users and users who were unstable in use frequency were 33% and 47% less likely to quit in the short-term, respectively (p < .001). Flavored (vs nonflavored) and using a rechargeable (vs disposable) e-cigarette device was associated with an increased likelihood of both short- and long-term quitting. CONCLUSION: Smoking cessation was more likely among frequent e-cigarette users, users of e-cigarettes in last quit attempt, and users of flavored and rechargeable devices. Less frequent, unstable, past, or never e-cigarette users were less likely to quit smoking. Monitoring the relationship between patterns of e-cigarette and cigarette use is complex but critical for gauging the potential of e-cigarettes as a harm reduction tool. IMPLICATIONS: This study suggests that consistent and frequent e-cigarette use over time is associated with cigarette smoking cessation among adults in the United States. In addition, findings suggest that flavored e-cigarette use and use of rechargeable e-cigarette devices can facilitate smoking cessation. These results underscore the importance of carefully defining and characterizing e-cigarette exposure patterns, potential confounders, and use of e-cigarettes to quit smoking, as well as variations in length of the smoking cessation.

History and Current Trends in the Electronic Cigarette Retail Marketplace in the United States: 2010-2016.

INTRODUCTION: The US market for electronic nicotine delivery systems (ENDS) has grown rapidly in the last decade. There is limited published evidence examining changes in the ENDS marketplace prior to the US Food and Drug Administration's (FDA) deeming rule in 2016. This study describes US ENDS retail market trends from 2010 to 2016. METHODS: National data were obtained from Nielsen retail scanners for five product types: (1) disposables, (2) rechargeables, (3) cartridge replacements, (4) e-liquid bottle refills, and (5) specialty vapor products. We examined dollar sales, volume, price, brand, and flavor. RESULTS: Adjusted national sales increased from $11.6 million in 2010 to $751.2 million in 2016. The annual rate of sales growth rapidly increased before slowing through 2015. The rate of growth spiked in 2016. Market share for menthol products and other assorted flavors increased from 20% in 2010 to 52.1% by 2016. NJOY's early market dominance shifted as tobacco industry brands entered the market and eventually captured 87.8% of share by 2016. Rechargeables and accompanying products comprised an increased proportion of total volume sold over time while disposable volume declined. Specialty vapor products appeared at retail in 2015. CONCLUSIONS: Findings show strong early growth in the ENDS retail market followed by considerable slowing over time, despite a slight uptick in 2016. Trends reflect shifts to flavored products, newer generation "open-system" devices, lower prices, and tobacco industry brands. This study provides a baseline against which to compare the impact of FDA's 2016 deeming rule and future actions on the ENDS marketplace. IMPLICATIONS: This study uses market scanner data from US retail outlets to describe trends in the ENDS retail market from 2010 to 2016, providing a baseline against which to compare the impact of FDA's 2016 deeming rule and future actions on the ENDS marketplace. Understanding historical market trends is valuable in assessing how future regulatory efforts and advances in ENDS technology may impact industry response and consumer uptake and use.

Impact of e-cigarette and cigarette prices on youth and young adult e-cigarette and cigarette behaviour: evidence from a national longitudinal cohort.

INTRODUCTION: Understanding the impact of prices for tobacco and nicotine products is critical for creating policies to prevent use among young people. This study examines the impact of electronic cigarette (e-cigarette) and cigarette prices on current e-cigarette and cigarette use among youth and young adults. METHODS: Data were from a national probability-based sample aged 15-21 collected in 2014 and followed every 6 months for 2.5 years through 2016. We conducted separate conditional likelihood logistic regression models with past 30-day e-cigarette use and past 30-day cigarette use outcomes on the sample of individuals who participated in at least two survey waves (n=11 578) with linked Nielsen market-level price data for rechargeable e-cigarettes and cigarettes. Models controlled for time-varying variables at the individual and state policy levels, and fixed effects at the individual, wave and market levels. RESULTS: Higher cigarette prices were associated with increased past 30-day e-cigarette use, indicating e-cigarettes may serve as a substitute for cigarettes. We did not find a statistically significant relationship between rechargeable e-cigarette prices and past 30-day e-cigarette use; neither did we find a significant relationship between rechargeable e-cigarette prices and past 30-day cigarette smoking. CONCLUSION: This is the first study to examine e-cigarette and cigarette prices on e-cigarette and cigarette behaviour longitudinally among young people. Findings suggest the need for better measuring the costs associated with e-cigarette use among this population, as well as a careful assessment of price and tax policies that takes into account cross-product impact to sufficiently discourage e-cigarette and cigarette use among young people.

Patterns of E-Cigarette Use Among Youth and Young Adults: Review of the Impact of E-Cigarettes on Cigarette Smoking.

There is concern that e-cigarette use among youth and young adults (YAs) may lead to future cigarette or other combustible tobacco product use. A synthesis of the literature on this topic is needed because existing longitudinal studies are limited in number and not consistent in their conclusions. We conducted a search in PubMed through December 31, 2017 for peer-reviewed studies related to e-cigarette patterns of use. Of 588 relevant studies, 26 had a youth or YA sample, were longitudinal in design, and assessed e-cigarette use at baseline and cigarette smoking at follow-up. Most studies followed a sample over time and compared cigarette smoking at follow-up between baseline e-cigarette users and nonusers. Other studies examined the difference at follow-up in cigarette smoking status among smokers according to e-cigarette use at baseline. Results suggest that, among never smokers, e-cigarette use is associated with the future (6 months to 2.5 years) cigarette trial; however, firm conclusions cannot be drawn because of limitations including small sample size, measurement of experimental use (ie, ever use, past 30-day use) rather than established use, and inadequate controls for potentially confounding variables. Conclusions also cannot be drawn from studies examining the impact of e-cigarette use among smokers due to the limited number of studies and additional limitations. A comprehensive understanding of this literature is needed to inform policy makers and consumers for evidence-based decision-making and to guide future research on e-cigarette use among youth and young adults. IMPLICATIONS: The present article provides a review of the impact of e-cigarette use on subsequent cigarette smoking among youth and YAs. Studies presented here suggest that e-cigarette use among nonsmokers is associated with subsequent cigarette smoking, but study designs are subject to numerous limitations. Future research should focus on addressing the characteristics that put youth and YAs at the risk of using either product and how appeal and accessibility of these products are related to product use in order to inform future policy-making.

Evidence of the Impact of the truth FinishIt Campaign.

Introduction: Over the past decade, public education mass media campaigns have been shown to be successful in changing tobacco-related attitudes, intentions, and behaviors among youth and young adults. In 2014, the national truth® campaign re-launched a new phase of the campaign targeted at a broad audience of youth and young adults, aged 15-21, to help end the tobacco epidemic. Methods: The study sample for this analysis is drawn from the Truth Longitudinal Cohort (TLC), a probability-based, nationally representative cohort designed to evaluate the relationship between awareness of truth media messages and changes in targeted attitudes, beliefs, and behaviors over time. The sample for this study was limited to those with data at baseline and three subsequent follow-up surveys (n = 7536). Results: Logistic regression models indicate that truth ad awareness is significantly associated with increases in targeted anti-tobacco attitudes as well as reduced intentions to smoke over time, holding constant baseline attitudes and intentions. Results also suggest a dose-response relationship in that higher levels of truth ad awareness were significantly associated with higher likelihood of reporting agreement across all five attitudinal constructs: anti-smoking imagery, anti-social smoking sentiment, anti-tobacco social movement, anti-tobacco industry sentiment, and independence. Conclusions: Longitudinal results indicate a significant dose-response relationship between awareness of the new phase of the truth campaign and campaign-targeted attitudes and intentions not to smoke among youth and young adults. Implications: Findings from this study confirm that a carefully designed anti-tobacco public education campaign aimed at youth and young adults is a key population-level intervention within the context of an expanding tobacco product landscape and a cluttered media environment. As tobacco use patterns shift and new products emerge, evidence-based public education campaigns can play a central role in helping the next generation to reject tobacco. Public education mass media campaigns are a key component to changing tobacco use attitudes and behavior, particularly among youth and young adults.

Examining perceptions about IQOS heated tobacco product: consumer studies in Japan and Switzerland.

OBJECTIVE: To examine consumer perceptions, attitudes and behaviours regarding the heated tobacco product, IQOS, as well as to document the product's marketing strategies to determine its potential for appealing to youth and young adults. METHOD: Truth Initiative, in collaboration with Flamingo, collected qualitative data via: (1) expert interviews, (2) semiotic analysis of IQOS packing and marketing materials, and (3) 12 focus groups with adults in Switzerland (ages 19-44 years; June 6-9, 2016) and Japan (ages 20-39 years; June 22-24, 2016) (n=68 for both groups). RESULTS: Expert interviews and IQOS packing and marketing analyses revealed the product is being marketed as a clean, chic and pure product, which resonated very well in Japan given the strong cultural values of order, cleanliness, quality and respect for others. Focus groups results indicated Japanese IQOS users used the product for socialising with non-smokers. Focus group participants in both Japan and Switzerland reported lower levels of satisfaction with the product relative to combustible cigarettes, although many found the product packaging to be appealing. While participants identified several benefits and barriers related to IQOS, few reported any potential health benefits of use compared with combustible tobacco products. CONCLUSION: IQOS was marketed as a sophisticated, high tech and aspirational product. Because youth and young adults are more interested in such product positioning, this approach raises some concern about youth appeal. This research shows cultural factors appeared to affect the appeal of this messaging, indicating that prevalence and uptake data will likely not be similar from country to country.

Recruiting and retaining youth and young adults: challenges and opportunities in survey research for tobacco control.

INTRODUCTION: Evaluation studies of population-based tobacco control interventions often rely on large-scale survey data from numerous respondents across many geographic areas to provide evidence of their effectiveness. Significant challenges for survey research have emerged with the evolving communications landscape, particularly for surveying hard-to-reach populations such as youth and young adults. This study combines the comprehensive coverage of an address-based sampling (ABS) frame with the timeliness of online data collection to develop a nationally representative longitudinal cohort of young people aged 15-21. METHODS: We constructed an ABS frame, partially supplemented with auxiliary data, to recruit this hard-to-reach sample. Branded and tested mail-based recruitment materials were designed to bring respondents online for screening, consent and surveying. Once enrolled, respondents completed online surveys every 6 months via computer, tablet or smartphone. Numerous strategies were utilized to enhance retention and representativeness RESULTS: Results detail sample performance, representativeness and retention rates as well as device utilization trends for survey completion among youth and young adult respondents. Panel development efforts resulted in a large, nationally representative sample with high retention rates. CONCLUSIONS: This study is among the first to employ this hybrid ABS-to-online methodology to recruit and retain youth and young adults in a probability-based online cohort panel. The approach is particularly valuable for conducting research among younger populations as it capitalizes on their increasing access to and comfort with digital communication. We discuss challenges and opportunities of panel recruitment and retention methods in an effort to provide valuable information for tobacco control researchers seeking to obtain representative, population-based samples of youth and young adults in the U.S. as well as across the globe.

Harnessing Youth and Young Adult Culture: Improving the Reach and Engagement of the truth® Campaign.

The national youth and young adult tobacco prevention mass media campaign, truth®, relaunched in 2014 with the goal of creating "the generation that ends smoking." The objective of this study was to assess whether the strategy of airing truth ads during popular, culturally relevant televised events was associated with higher ad and brand awareness and increases in social media engagement. Awareness of six truth advertisements that aired during popular television events and self-reported social media engagement were assessed via cross-sectional online surveys of youth and young adults aged 15-21 years. Social engagement was also measured using separate Twitter and YouTube metrics. Logistic regression models predicted self-reported social engagement and any ad awareness, and a negative binomial regression predicted the total social media engagement across digital platforms. The study found that viewing a popular televised event was associated with higher odds of ad awareness and social engagement. The results also indicate that levels of social media engagement for an event period are greater than for a nonevent period. The findings demonstrate that premiering advertisements during a popular, culturally relevant televised event is associated with higher awareness of truth ads and increased social engagement related to the campaign, controlling for variables that might also influence the response to campaign messages.

The Relationship Between Advertising-Induced Anger and Self-efficacy on Persuasive Outcomes: A Test of the Anger Activism Model Using the Truth Campaign.

Turner's Anger Activism Model (AAM) contends anger and efficacy interact in a unique way to determine message responses to campaign materials. This study tested the AAM using responses to 2 truth antismoking advertisements collected in August-October 2014 via an online, cross-sectional survey of 15- to 21-year-olds. Those aware of each of the truth advertisements (n = 319 for each) were organized into 4 anger/efficacy groups. Analysis of variance and regressions were conducted to understand group differences in message-related cognitions (persuasiveness, receptivity, conversation). Message cognitions were highest among the high anger/high efficacy group and lowest among the low anger/low efficacy group.

Validity of a Subjective Financial Situation Measure to Assess Socioeconomic Status in US Young Adults.

PURPOSE: Young adulthood is an important period for preventing the establishment of negative health behaviors that can influence trajectories to chronic disease and early death. Given the evolving nature of educational attainment and income variation during this developmental period, identifying indicators of socioeconomic status (SES) remains a challenge. This study examines measures of subjective and objective indicators of SES to predict health risk for young adults. METHODS: This study uses data from the Truth Initiative Young Adult Cohort Study from respondents aged 18 to 34 years who completed 3 consecutive surveys between June 2011 and August 2012 (n = 2182). Analyses were conducted to compare a measure of subjective financial situation (SFS) to commonly used SES measures for adults and adolescents. Age-stratified, multivariable logistic regression was used to model the relationship between 5 SES indicators (SFS, household income, respondent education, parental education, and subjective childhood financial situation) and dichotomized versions of 3 health status measures (body mass index, self-reported health status, and quality of life), controlling for gender, race/ethnicity, and region. RESULTS: Findings indicate that SFS is associated with other commonly used SES measures. Prospective associations with health outcomes revealed that SFS is a stronger predictor of health outcomes among young adults aged 18 to 24 years as compared with other SES measures. CONCLUSION: This study provides evidence that subjective financial situation may be more robust than traditional SES indicators in predicting health outcomes among young adults, particularly for 18- to 24-year-olds, and should be considered a viable candidate measure for assessing SES among this age group.

Direct-to-Consumer Marketing of Cigar Products in the United States.

INTRODUCTION: Although cigar use and sales have increased in the United States over the past decade, little is known about how these products are promoted. Direct-to-consumer (DTC) advertising is a common method used to promote tobacco products and may be a potential channel through which cigars are advertised. METHODS: Comperemedia (Mintel) was used to acquire opt-in direct mail and email advertising for the top 10 cigar brands in the United States between January 2013 and July 2014. The advertisement and corresponding data on brand, advertising spend, and mail volume were downloaded and summarized. Promotions such as coupons, giveaways, and sweepstakes were also examined. RESULTS: A total of 92 unique advertisements met the search criteria and included two brands: Black & Mild (n = 77) and Swisher Sweets (n = 15). Expenditures on direct mail advertising during this period totaled $12 809 630. Black & Mild encompassed 80% of total direct mail volume and 78% of direct mail advertising expenditures. Almost all advertisements contained at least one promotion (88%) and included a URL to the product website (85%). CONCLUSIONS: The results suggest that Black & Mild and Swisher Sweets are the primary cigar brands using DTC advertising. Promotional offers were nearly ubiquitous among the advertisements, which may appeal to price-sensitive populations. Future studies should continue to examine cigar advertising via direct mail and email, in addition to other channels, such as the point-of-sale. IMPLICATIONS: Although cigar use and sales have increased in the United States over the past decade, there is limited data on cigar advertising. This article provides a snapshot of expenditures, volume, and promotional content of DTC cigar advertising in the United States between January 2013 and July 2014.

Tobacco Retail Outlet Density and Young Adult Tobacco Initiation.

BACKGROUND: A growing body of evidence indicates that the density of tobacco retail outlets around the home residence may influence tobacco use among youth and adults. The purpose of this study was to examine the impact of neighborhood tobacco retail outlet density on young adult initiation of different tobacco product types. METHODS: Cross-sectional data from a 2013 nationally representative sample of young adults aged 18-34 was examined in relation to a 2012 geocoded listing of all outlets likely to sell tobacco in the United States. Separate multivariable logistic regression analyses examined associations between neighborhood outlet density and past 6 months first use of cigarettes, non-cigarette combustible products, and noncombustible products among adults aged 18-24 and 25-34. RESULTS: Outlet density was significantly associated with recent initiation of cigarettes and other combustibles, but this impact varied for younger and older groups. Increased density was significantly associated with a higher likelihood of initiating cigarette use among adults aged 25-34 (OR = 3.75, 95% CI = 1.18, 11.90), and of initiating non-cigarette combustible use among 18-24 year olds (OR = 3.16, 95% CI = 1.03, 9.74). There was no impact of outlet density on recent noncombustible product initiation among either group. CONCLUSION: This study is the first to examine the impact of tobacco outlet density on young adult initiation of cigarettes and other tobacco products. Findings demonstrate that residential neighborhood outlet density is associated with recent initiation of combustible products and this effect varies by product type and age. The tobacco outlet environment may be a critical factor in promoting young adult tobacco use initiation.

American Spirit Pack Descriptors and Perceptions of Harm: A Crowdsourced Comparison of Modified Packs.

INTRODUCTION: In 2015, the Food and Drug Administration issued warnings to three tobacco manufacturers who label their cigarettes as "additive-free" and/or "natural" on the grounds that they make unauthorized reduced risk claims. The goal of this study was to examine US adults' perceptions of three American Spirit (AS) pack descriptors ("Made with Organic Tobacco," "100% Additive-Free," and "100% US Grown Tobacco") to assess if they communicate reduced risk. METHODS: In September 2012, three cross-sectional surveys were posted on Amazon Mechanical Turk. Adult participants evaluated the relative harm of a Marlboro Red pack versus three different AS packs with the descriptors "Made with Organic Tobacco," "100% Additive-Free," or "100% US Grown Tobacco" (Survey 1; n = 461); a Marlboro Red pack versus these AS packs modified to exclude descriptors (Survey 2; n = 857); and unmodified versus modified AS pack images (Survey 3; n = 1001). RESULTS: The majority of Survey 1 participants rated the unmodified AS packs as less harmful than the Marlboro Red pack; 35.4%-58.8% of Survey 2 participants also rated the modified (no claims) packs as less harmful than Marlboro Red. In these surveys, prior use of AS cigarettes was associated with reduced perceptions of risk (adjusted odds ratio [AOR] 1.59-2.40). "Made with Organic Tobacco" and "100% Additive-Free" were associated with reduced perceptions of risk when comparing the modified versus the unmodified AS packs (Survey 3). CONCLUSIONS: Data suggest that these AS pack descriptors communicate reduced harm messages to consumers. Findings have implications for regulatory actions related to product labeling and packaging. IMPLICATIONS: These findings provide additional evidence that the "Made with Organic Tobacco," "100% Additive-Free," and "100% US Grown" descriptors, as well as other aspects of the AS pack design, communicate reduced harm to non-, current, and former smokers. Additionally, they provide support for the importance of FDA's 2015 warning to Santa Fe Natural Tobacco Company on "100% Additive Free" as an unauthorized modified risk claim.

Design and Feasibility Testing of the truth FinishIt Tobacco Countermarketing Brand Equity Scale.

The original truth campaign was a branded, national smoking prevention mass media effort focused on at-risk youth ages 12-17. Today the truth brand focuses on the goal of finishing tobacco (truth FinishIt). There have been significant changes in the tobacco control landscape, leading FinishIt to focus on 15- to 21-year-olds. The present article reports on formative research and media monitoring data collected to pilot test a new truth FinishIt brand equity scale. The goals of this study were to (a) content analyze truth FinishIt mass media ads, (b) assess truth's social media and followers' perceptions of truth's digital brand identity, and (c) develop and feasibility test a new version of the truth FinishIt brand equity scale using data from an existing Truth Initiative media monitoring study. Through factor analysis, we identified a brand equity scale, as in previous research, consisting of 4 main constructs: brand loyalty, leadership/satisfaction, personality, and awareness. Targeted truth attitudes and beliefs about social perceptions, acceptability, and industry-related beliefs were regressed on the higher order factor and each of the 4 individual brand equity factors. Ordinary least squares regression models generally showed associations in the expected directions (positive for anti-tobacco and negative for pro-tobacco) between targeted attitudes/beliefs and truth FinishIt brand equity. This study succeeded in developing and validating a new truth FinishIt brand equity scale. The scale may be a valuable metric for future campaign evaluation. Future studies should examine the effects of truth FinishIt brand equity on tobacco use behavioral outcomes over time.