Mammography Screening Preferences Among Screening-Eligible Women in Their 40s : A National U.S. Survey.

BACKGROUND: The U.S. Preventive Services Task Force (USPSTF) recently changed its recommendation for mammography screening from informed decision making to biennial screening for women aged 40 to 49 years. Although many women welcome this change, some may prefer not to be screened at age 40 years. OBJECTIVE: To conduct a national probability-based U.S. survey to investigate breast cancer screening preferences among women aged 39 to 49 years. DESIGN: Pre-post survey with a breast cancer screening decision aid (DA) intervention. (ClinicalTrials.gov: NCT05376241). SETTING: Online national U.S. survey. PARTICIPANTS: 495 women aged 39 to 49 years without a history of breast cancer or a known BRCA1/2 gene mutation. INTERVENTION: A mammography screening DA providing information about screening benefits and harms and a personalized breast cancer risk estimate. MEASUREMENTS: Screening preferences (assessed before and after the DA), 10-year Gail model risk estimate, and whether the information was surprising and different from past messages. RESULTS: Before viewing the DA, 27.0% of participants preferred to delay screening (vs. having mammography at their current age), compared with 38.5% after the DA. There was no increase in the number never wanting mammography (5.4% before the DA vs. 4.3% after the DA). Participants who preferred to delay screening had lower breast cancer risk than those who preferred not to delay. The information about overdiagnosis was surprising for 37.4% of participants versus 27.2% and 22.9% for information about false-positive results and screening benefits, respectively. LIMITATION: Respondent preferences may have been influenced by the then-current USPSTF guideline. CONCLUSION: There are women in their 40s who would prefer to have mammography at an older age, especially after being informed of the benefits and harms of screening. Women who wanted to delay screening were at lower breast cancer risk than women who wanted screening at their current age. Many found information about the benefits and harms of mammography surprising. PRIMARY FUNDING SOURCE: National Cancer Institute.

Achieving Public Health Impact: Health Communication Research to Inform Tobacco Regulatory Science.

Health communication research applies communication science to develop generalizable knowledge capable of improving the health and well-being of individuals and communities. But to what extent does the knowledge generated by the health communication field actually achieve public health impact? To answer this question, we discuss the application of health communication science and research within a tobacco regulatory science framework. We describe three areas in which health communication research funded by the Food and Drug Administration (FDA) Center for Tobacco Products (CTP) contributed to 1) youth tobacco prevention campaigns, 2) cigarette health warnings, and 3) regulation of labeling, advertising, and marketing claims. These examples demonstrate how communication regulatory science achieves public health impact in the real world by informing national policies, regulatory actions, and public health practice.

Effect of nicotine corrective messaging on nicotine-related beliefs in US adults: a randomised controlled trial.

INTRODUCTION: Widespread misperceptions of the health risks of nicotine could undermine the public health benefits of the Food and Drug Administration's actions, including modified risk tobacco product authorisations and a reduced nicotine product standard for cigarettes. METHODS: 794 US adults (aged 18+) in NORC's AmeriSpeak panel participated in a randomised controlled trial in Spring 2021 to test the effect of three exposures to eight nicotine corrective messages (NCM) on beliefs about nicotine, nicotine replacement therapy (NRT), e-cigarettes and reduced nicotine content (RNC) cigarettes at 3-month follow-up. Analyses conducted in 2022 examined the effect of study condition (NCM (n=393) vs no message control (n=401)) on nicotine beliefs, use intentions and use of nicotine and tobacco products. RESULTS: Exposure to three NCM doses reduced nicotine (b=-0.33; 95% CI -0.60, -0.07), NRT (b=-0.49; 95% CI -0.85, -0.14), e-cigarette (b=-0.32; 95% CI -0.59, -0.05) and RNC cigarette false beliefs (b=-0.64; 95% CI -1.26, -0.02) compared with the control, controlling for baseline beliefs. Baseline tobacco use and concern about nicotine addiction attenuated intervention effects on false beliefs about RNC cigarettes. There were few intervention effects on intention or use of nicotine and tobacco products. CONCLUSIONS: Repeated exposure to NCM was necessary to reduce false beliefs about nicotine and tobacco products. Future studies will improve understanding of the dose and duration of nicotine education needed to shift intentions and behaviour, as well as tailored content for tobacco product users to achieve similar reductions in false beliefs as non-users. TRIAL REGISTRATION NUMBER: NCT04805515.

Effects of advertising features on smokers' and non-smokers' perceptions of a reduced nicotine cigarette modified risk tobacco product.

INTRODUCTION: Research is needed to determine the impact of marketing on perceptions and use of reduced nicotine content (RNC) cigarettes, particularly as US regulators have permitted the sale of an RNC cigarette modified risk tobacco product (MRTP) that seeks further authorisation to advertise using modified risk claims. This study examined the effects of two advertising elements (product name and disclaimer content) on perceptions of an RNC cigarette MRTP. METHODS: Adult participants (n=807, 28.7% smokers, 58.2% male, 74.2% non-Latinx white) completed an online MTurk survey. Participants were randomised to view one of six RNC cigarette advertisements, using a 2×3 between-subject factorial design to manipulate product name ('Moonlight' vs 'Moonrise') and disclaimer content (industry-proposed: 'Nicotine is addictive. Less nicotine does NOT mean a safer cigarette' vs focused: 'Less nicotine does NOT mean a safer cigarette' vs no content), then completed recall and product perception questionnaires. RESULTS: All participants who viewed the industry-proposed disclaimer (vs no content) perceived greater addiction risk (p's<0.05). Non-smokers who viewed this disclaimer also perceived greater health risks and held fewer false beliefs (p's<0.05). Smokers who viewed Moonlight (vs Moonrise) ads perceived lower health risks (p<0.05). CONCLUSIONS: Disclaimer content may effectively inform consumers about addiction risk of a new RNC cigarette MRTP, and further inform non-smokers about health risks. This element, however, had little effect on perceived health risks among smokers, among whom the Moonlight product name was associated with health risk misperceptions similar to the banned 'light' descriptor.

IQOS print magazine advertising characteristics and reach before and after FDA authorisation as a modified risk tobacco product.

INTRODUCTION: IQOS is a heated tobacco product that was authorised as a modified risk tobacco product (MRTP) in July 2020. While it was removed from the US market in 2021 for legal reasons, as the first tobacco product to receive an 'exposure modification' MRTP order, surveillance of IQOS marketing is needed to inform regulation and policy for future MRTPs. The purpose of this study is to expand the current research on IQOS advertising in the USA by examining content and readership characteristics of IQOS ads in print magazines before and after US Food and Drug Administration MRTP authorisation. METHODS: We merged content analysis data with Kantar Media data on magazine placement and expenditures. Magazine readership data were obtained from MRI-Simmons. We compared data from pre-MRTP authorisation with data post-MRTP authorisation. This study was conducted in 2021. RESULTS: There was one unique ad and there were 13 observations pre-MRTP, and eight unique ads and 132 observations post-MRTP. Compared with pre-MRTP ads, more post-MRTP ads featured Marlboro HeatSticks, including Amber HeatSticks, and featured people. All ads contained a warning label-most warning labels were cigarette specific. IQOS ads were featured in magazines that are especially popular among women. CONCLUSIONS: After receiving MRTP authorisation, IQOS increased ad expenditures in print magazines with a readership comprised of primarily women. If IQOS returns to the US market, it will be important for tobacco control to monitor their advertisement content, placement, and expenditures.

Exploring content of misinformation about HPV vaccine on twitter.

Although social media can be a source of guidance about HPV vaccination for parents, the information may not always be complete or accurate. We conducted a retrospective content analysis to identify content and frequencies of occurrence of disinformation and misinformation about HPV vaccine posted on Twitter between December 15, 2019, through March 31, 2020, among 3876 unique, English language #HPV Tweets, excluding retweets. We found that 24% of Tweets contained disinformation or misinformation, and the remaining 76% contained support/education. The most prevalent categories of disinformation/misinformation were (1) adverse health effects (59%), (2) mandatory vaccination (19%), and (3) inefficacy of the vaccine (14%). Among the adverse health effects Tweets, non-specific harm/injury (51%) and death (23%) were most frequent. Disinformation/misinformation Tweets vs. supportive Tweets had 5.44 (95% CI 5.33-5.56) times the incidence rate of retweet. In conclusion, almost one-quarter of #HPV Tweets contained disinformation or misinformation about the HPV vaccine and these tweets received higher audience engagement including likes and retweets. Implications for vaccine hesitancy are discussed.

The Effect of Repetition on the Perceived Truth of Tobacco-Related Health Misinformation Among U.S. Adults.

As concerns about the effects of health misinformation rise, understanding why misbeliefs are accepted is increasingly important. People believe repeated statements more than novel statements, an effect known as truth by repetition, however this has not been examined in the context of tobacco information. Misbeliefs about tobacco are rampant and novel facts about tobacco are viewed as less believable. This paper examines how repetition of true and false tobacco statements affects truth perceptions. We recruited an online sample of 1,436 U.S. adults in May 2021. In an exposure phase, each participant rated their interest in 30 randomly selected statements about tobacco products and general knowledge trivia, half of them true and half false. The study had a two (tobacco product) by two (familiarity of statement claim) between-subjects design and a two (statement truth) by two (statement repetition) within-subjects design. During the testing phase participants rated the truthfulness of 24 repeated statements and 24 unseen statements. Repetition of true and false tobacco statements increased their subjective truth (diff=.20, p < .001), and the effect was larger for false claims compared to true claims. This underscores the importance of strategies to inoculate people against misinformation and calls for interventions that can stop the repetition of newly generated false claims.

The Role of Information Avoidance in Managing Uncertainty from Conflicting Recommendations about Electronic Cigarettes.

Insufficient scientific evidence about electronic cigarettes (e-cigarettes) has led to conflicting recommendations (CRs) by credible scientific organizations, creating a public health debate that could prove especially difficult to reconcile as current and former smokers make decisions about whether to use e-cigarettes. To investigate how CRs about e-cigarettes may affect intentions to engage in healthy behaviors, 717 former and current smokers were randomly exposed to one of five conditions (varying in the level of conflict in recommendations) in this between-subject experiment. Our results indicated a significant interaction between the message level of conflict and individuals' information avoidance, employed to maintain hope and deniability. These results suggest the effects of CRs stemming from scientific uncertainty vary with subgroups of people, pointing to several pressing theoretical and practical implications.

Impact of Graphic Warning Messages on Intentions to Use Alternate Tobacco Products.

Graphic cigarette warnings increase quit attempts. Perceived message effectiveness and message avoidance are predictive of later quit attempts. We sought to examine whether randomized exposure to warning messages would inadvertently increase intentions to use alternate tobacco products while enhancing attempts to quit cigarettes. An online survey of 1392 adult smokers in the US asked participants to rate six randomly selected tobacco warnings (from a set of 319) on perceived effectiveness and avoidance intentions. These two indicators of message effectiveness were calculated at the message-level and then at the individual campaign-level to facilitate causal inference. After viewing a message campaign of six warning messages, participants indicated their intentions to use alternate tobacco products. Sixty-eight percent of participants reported some intention to use e-cigarettes and intentions to use other alternate tobacco products ranged from 31% to 40%. Campaigns of messages eliciting higher avoidance increased the odds of intending to use hookah (aOR: 4.32), smokeless tobacco (aOR: 4.88), and snus (aOR: 8.06), but not the intention to use electronic cigarettes. These relationships are mediated by intentions to quit smoking (all p <.05). Viewing campaigns with higher campaign-level perceived effectiveness increased the intentions to quit, which in turn increased intentions to try alternate tobacco products. Our findings increase the tobacco control community's understanding of unintended consequences of graphic tobacco warnings.

A neural model of valuation and information virality.

Information sharing is an integral part of human interaction that serves to build social relationships and affects attitudes and behaviors in individuals and large groups. We present a unifying neurocognitive framework of mechanisms underlying information sharing at scale (virality). We argue that expectations regarding self-related and social consequences of sharing (e.g., in the form of potential for self-enhancement or social approval) are integrated into a domain-general value signal that encodes the value of sharing a piece of information. This value signal translates into population-level virality. In two studies (n = 41 and 39 participants), we tested these hypotheses using functional neuroimaging. Neural activity in response to 80 New York Times articles was observed in theory-driven regions of interest associated with value, self, and social cognitions. This activity then was linked to objectively logged population-level data encompassing n = 117,611 internet shares of the articles. In both studies, activity in neural regions associated with self-related and social cognition was indirectly related to population-level sharing through increased neural activation in the brain's value system. Neural activity further predicted population-level outcomes over and above the variance explained by article characteristics and commonly used self-report measures of sharing intentions. This parsimonious framework may help advance theory, improve predictive models, and inform new approaches to effective intervention. More broadly, these data shed light on the core functions of sharing-to express ourselves in positive ways and to strengthen our social bonds.

Does Interest in Smoking Affect Youth Selection of Pro-smoking Videos? A Selective Exposure Experiment.

BACKGROUND: Many pro-smoking videos on YouTube reach view counts in the hundreds of thousands and more. Yet, there is limited information on who is viewing these potentially misleading videos. This study attempts to understand the viewership of online pro-smoking videos to examine if youth at high risk for smoking are more likely to watch these videos. METHODS: We conducted a selective exposure experiment with a national sample of youths (ages 15-21 years; n = 614) to identify characteristics that make individuals more likely to select pro-smoking videos. During a 10-min browsing session, participants were given a set of 16 videos (eight smoking and eight nonsmoking) and were asked to view video(s) of their choice. Exposure to videos was unobtrusively logged. View count was manipulated such that smoking videos had either high or low views. RESULTS: Behavioral data revealed that youth with higher interest in smoking were more likely to select and spend more time watching pro-smoking videos than youth with lower interest in smoking. The view count manipulation did not affect selection patterns. However, exposure to high view count smoking videos was associated with more positive attitudes toward smoking. CONCLUSIONS: The findings of this study call into question the existence and prominence of pro-smoking videos on YouTube and bring to attention the need for regulatory or monitoring efforts of such content. IMPLICATIONS: Given the presence and prevalence of misleading pro-smoking videos online, this is the first study to ask the practical and important question of who is viewing these videos. Using behavioral data, we are able to demonstrate that youth who are high at risk for smoking are more susceptible to select and spend more time viewing pro-smoking videos than youth who are low at risk for smoking. Findings also show that when pro-smoking videos appear to be "popular," they affect attitudes toward smoking. Our findings provide policy implications regarding regulation of smoking promotion videos online.

Temporal Effects of Message Congruency on Attention to and Recall of Pictorial Health Warning Labels on Cigarette Packages.

OBJECTIVES: Recent research has shown that message congruency is beneficial to recall of pictorial health warning label (PWL) content after initial exposure. Despite less attention to the text warning, smokers exposed to congruent PWLs were more likely to recall the text and the message. This study aimed to replicate these findings and to examine whether congruency also affects recall after multiple exposures over time. METHODS: A total of 320 daily smokers (39.7% female; cigarettes/day: M = 15.31, SD = 7.15) were randomized to one congruent or incongruent PWL and attended 4 laboratory sessions over 10 days. During each session, eye movements were recorded while viewing the PWL and open-ended recall of label content was assessed after exposure. RESULTS: Smokers who were exposed to a congruent PWL were more likely to recall the text (p = .01) and the message (p = .02) and less likely to recall the image (p = .003) of the PWL after initial exposure. By day 4, incongruent PWLs were recalled equally well as congruent PWLs. Independent of condition, image recall was initially high and remained high whereas text and message recall was relatively low initially but increased over time. It was not until day 7 that about 80% of text and message recall was observed. CONCLUSIONS: Even when exposed to the same PWL over time, smokers require multiple exposures to recall the text and the message of a PWL. More research on the effects of congruency in the natural environment, where smokers are exposed to multiple PWLs, is needed. IMPLICATIONS: The findings of this study, and of previous work showing that message congruency in PWLs is beneficial to initial recall of PWL content, could potentially help to address legal challenges regarding the implementation of PWLs in the United States. Factually correct text warnings have been uncontested on US cigarettes packages since 1966. Congruent PWLs simply provide a means to visually support the same information as the existing text using a medium that better garners attention to the health information. Investigating and understanding longer-term effects of congruency are important and can empirically inform future warning label development, both in the United States via the Family Smoking Prevention and Tobacco Control Act, and via other governing bodies.

Regulating language, not inference: an examination of the potential effectiveness of Natural American Spirit advertising restrictions.

OBJECTIVE: In 2017, the United States Food and Drug Administration (FDA) reached an agreement with Santa Fe Natural Tobacco Company (SFNTC) stipulating that SFNTC will remove 'natural' and 'additive-free' from Natural American Spirit (NAS) marketing to combat misperceptions that NAS is a healthier cigarette. The purpose of this study was to assess experimentally the potential effectiveness of the agreement in addressing NAS misperceptions. METHODS: In an online experiment, 820 current and former smokers were assigned randomly to advertising conditions with existing claims from NAS advertisements, modified claims or a no-exposure control. Advertising conditions included (1) 'original' NAS advertising text before the agreement; (2) '2017 agreement' language permissible under the FDA-SFNTC agreement (removing 'natural', 'additive-free'); (3) more restrictive ('stricter') language representing additional regulation (removing 'natural' from the brand name and the phrases 'tobacco+water', 'no chemicals'). Participants completed outcome measures assessing misinformed beliefs and intentions towards NAS. RESULTS: One-way ANOVA showed that relative to the 'original' language, the '2017 agreement' language reduced misconceptions about NAS addictiveness, but not about health or constituent composition. Yet 'stricter' language significantly reduced all categories of misinformed beliefs, which in turn mediated effects on (lower) intentions to use NAS. CONCLUSION: The 2017 agreement helps dispel some misconceptions about NAS addictiveness, but does not sufficiently rectify misinformation about health or composition. Since 'stricter' language more effectively corrects misinformed beliefs, our results suggest the need for further regulations in addressing misinformation that drives intentions towards NAS.

Perceived effectiveness of objective features of pictorial warning messages.

BACKGROUND: Previous research shows that pictorial warning messages (PWMs) for tobacco cigarettes increase quit attempts and smoking-related knowledge. However, few studies have investigated what specific features within PWMs are most effective. The current study sought to examine the specific features of PWMs associated with effectiveness using four outcome measures as indicators. METHOD: A sample of n=319 PWMs was collected and underwent systematic content analysis on 48 different content features. A sample of n=1392 current smokers each rated a subset of the labels on perceived effectiveness, negative emotional engagement, intentions to enact avoidance behaviours and intentions to forego a cigarette. Multilevel random-effects models were fitted with all coded content features and each of the outcome measures. RESULTS: Analysis across all four outcome measures shows that PWMs depicting diseased and damaged body parts and employing a testimonial format were most effective. Additional mediation analysis showed that image-level negative emotionality partially mediated the relationship between PWM features and perceived effectiveness. CONCLUSION: The effectiveness of graphic imagery, testimonials and images that elicit negative emotions provides guidance for researchers as well as for future implementation of more effective PWMs.

An Efficient Message Evaluation Protocol: Two Empirical Analyses on Positional Effects and Optimal Sample Size.

Reliable and valid message evaluation has a central role in effective health communication and message effects research. The authors have employed a message testing protocol to efficiently acquire valid and reliable message evaluation results: (a) use multiple messages, (b) recruit evaluators from the target population, (c) use valid and reliable effectiveness measures, (d) expose an evaluator to multiple messages, and (e) ensure enough evaluations per message. Two secondary analyses of anti-tobacco message evaluation studies provide evidence for reliability and validity regarding points (d) and (e). Seven studies where adult smokers evaluated the effectiveness of various anti-smoking campaign messages were examined. The first analysis shows that the position in which a message appears has little or no impact on its evaluation, supporting the validity of multiple-exposure design. The second analysis suggests having 25 evaluations per message can achieve a fair balance between accuracy and efficiency.

Communication Regulatory Science: Mapping a New Field.

Communication regulatory science is an emerging field that uses validated techniques, tools, and models to inform regulatory actions that promote optimal communication outcomes and benefit the public. In the opening article to this special issue on communication and tobacco regulatory science, we 1) describe Food and Drug Administration (FDA) regulation of tobacco products in the US; 2) introduce communication regulatory science and provide examples in the tobacco regulatory science realm; and 3) describe the special issue process and final set of articles. Communication research on tobacco regulatory science is a burgeoning area of inquiry, and this work advances communication science, informs and potentially guides the FDA, and may help to withstand legal challenges brought by the tobacco industry. This research has the potential to have a major impact on the tobacco epidemic and population health by helping implement the most effective communications to prevent tobacco initiation and increase cessation. This special issue provides an example of 10 studies that exemplify tobacco regulatory science and demonstrate how the health communication field can affect regulation and benefit public health.

Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products.

Warning labels on tobacco products sometimes feature images and stories of real people whose health has been affected by smoking. We examined effects of some of the design elements that may contribute to the effectiveness of these testimonial pictorial warning labels (PWLs). Beginning with a testimonial PWL that contained an image of a person and a basic warning statement (e.g., "Smoking can kill you"), we examined the impact of adding: (a) text detailing the person's name, age and health status (identifiers); and (b) explanatory statements that elaborated on the basic warning using a testimonial or non-testimonial message. In an online experiment, 1255 adult smokers in the United States were randomly assigned to one of six experimental conditions (2 [identifier: none/identifier] × 3 [explanatory statement: none/non-testimonial/testimonial]), or a control condition (text only warning labels that currently appear on packs in the United States). In each condition, participants were exposed to multiple labels each focused on a different health effect. Effectiveness was assessed using emotional responses, engagement and behavioral intentions measured immediately post-exposure, and quit attempts measured at five-week follow up. Testimonial PWLs were more effective than the text only labels. However, there was little evidence that adding identifiers or the explanatory statements enhanced effectiveness; rather, there was some evidence that testimonial explanatory statements reduced effectiveness. These findings suggest that the most effective design for testimonial PWLs may be to combine a basic warning statement with an image of a real person, without any additional textual components.

Delivering Effective Messages in the Patient-Clinician Encounter.

This JAMA Insights discusses the importance of effective patient-clinician communication and provides strategies for clinicians that can enhance accurate information gathering and exchange, encourage patient engagement, enhance comprehension, and ensure retention of the information.

The Effects of Graphic Warning Labels' Vividness on Message Engagement and Intentions to Quit Smoking.

The current study examined the effects of manipulating the level of vividness through the presence of various textual and visual components in the context of tobacco warning labels. An online experiment was conducted (N=2165) to examine whether increasing the vividness of warning labels, using narrative and non-narrative components, increased engagement with the messages, and the subsequent effects of vividness and engagement on intentions to quit smoking. Results showed that more vivid warning labels led to increased engagement, which in turn was linked to increased intentions to quit smoking. Specifically, the indirect effect of vividness on intentions to quit smoking was largely driven by the emotional component of engagement. Indirect effects of cognitive engagement were only apparent at higher levels of vividness.

A Randomized Trial of the Effect of Youth Appealing E-Cigarette Advertising on Susceptibility to Use E-Cigarettes Among Youth.

Introduction: Very little is known about how e-cigarette marketing is being perceived by youth, and the potential effect it will have on youth vaping and smoking behaviors. This limits the ability to identify youth-focused marketing efforts and to design effective policies for the regulation of e-cigarette marketing content and placement. Methods: A sample of 417 nonsmoking youth (mean age = 15, SD = 1.3) were randomly assigned to either view four e-cigarette ads with low youth appeal, four e-cigarette ads with high youth appeal or four control ads. After exposure, participants completed covert and overt measurements of e-cigarette and tobacco cigarette attitudes and susceptibility to use. Results: Youth in an e-cigarette ad condition were more likely to select an e-cigarette item in a product choice task compared to control, and had more positive e-cigarette beliefs. Contrary to hypotheses, youth in the low youth appeal condition reported greater susceptibility to trying e-cigarettes and tobacco cigarettes compared to control. Conclusions: Exposure to any e-cigarette advertising may play a role in teens' decision to initiate e-cigarette and tobacco cigarette use. As the Food and Drug Administration now has regulatory authority over the marketing of e-cigarettes, regulations on e-cigarette advertising are suggested. Implications: Teens are increasingly being exposed to e-cigarette advertising, and many places are considering e-cigarette regulations, yet we know very little about how e-cigarette advertisements might influence youth tobacco use. This study utilized a novel dataset of e-cigarette ads coded for youth appeal and presented them to a sample of 417 nonsmoking teens in a randomized controlled design to test the effect of features on youth susceptibility to initiating e-cigarette and tobacco cigarette use. The findings inform evidence-based recommendations for regulating the marketing of e-cigarettes.