Associations Between Noticing E-Cigarette Advertising Features and E-Cigarette Appeal and Switching Interest Among Young Adult Dual Users.

BACKGROUND: E-cigarette advertising, which often includes various features, may prompt e-cigarette use and product switching. This study examined the associations between noticing e-cigarette ad features and perceived product appeal and interest in completely switching from cigarettes to advertised e-cigarettes among young adult dual users of both products. METHODS: We analyzed data from an online heatmap experiment among young adult dual users defined as established cigarette smokers who currently used e-cigarettes (ages 18-34 years; n = 1,821). Participants viewed 12 e-cigarette ads, clicked on ad features (e.g., fruit flavors, nicotine warnings, price promotions, smoker-targeted claims) that attracted their attention (defined as "noticing"), and answered questions about e-cigarette product appeal and interest in completely switching from cigarettes to the e-cigarettes shown. We examined within-person associations between noticing specific ad features and outcomes, controlling for demographic and tobacco use-related characteristics. RESULTS: Noticing fruit flavors (AOR = 1.67 and 1.28) and fruit images (AOR = 1.53 and 1.21) was positively associated with having any e-cigarette product appeal and switching interest. Noticing price promotions (AOR = 1.23) was positively associated with product appeal. In contrast, noticing nicotine warnings (AOR = 0.74 and 0.86), smoker-targeted claims (AOR = 0.78 and 0.89), and tobacco flavors (AOR = 0.92 and 0.90) was negatively associated with product appeal and switching interest. CONCLUSIONS: Noticing certain e-cigarette ad features (e.g., fruit flavors and nicotine warnings) may be associated with product appeal and/or switching interest among young adult dual users. More research is needed to assess the influence of e-cigarette ad features that promote product switching interests among cigarette smokers while discourage interests among tobacco-naïve individuals.

What do young people know about the nicotine in their e-cigarettes?

INTRODUCTION: In recent years, the nicotine in e-cigarettes has been available in either a 'free-base' (unprotonated) or 'nicotine salt' (protonated) form. Additionally, e-cigarette nicotine can be either 'synthetic' or 'tobacco-derived'. These dimensions of nicotine have implications for nicotine absorption, bioavailability and sensory experiences. However, it is unclear if the young people using e-cigarettes are aware of these nicotine dimensions. METHODS: Data came from a cohort of Ohio youth (aged 15-24) who reported using an e-cigarette in the past 4 months (N=271). Participants were enrolled and provided background information in 2021; their 12-month follow-up survey asked about the presence, form and type of nicotine in their usual e-cigarette. Individuals who reported that they could distinguish between tobacco-derived and synthetic nicotine were additionally asked to describe the difference. RESULTS: Of the 247 youth who reported that there was nicotine in their usual e-cigarette, 71.7% did not know whether it was free-base or nicotine salt and 75.7% did not know whether it was synthetic or tobacco-derived. Awareness was higher among youth who were using e-cigarettes at a greater frequency and quantity. The majority reported that they could not detect a difference between the experience of using synthetic vs tobacco-derived nicotine. CONCLUSIONS: These findings indicate the generally limited awareness about nicotine among youth who used e-cigarettes. Improvements in health communications and requirements for e-cigarette industry disclosures are necessary to ensure that consumers are better informed about the dimensions-and the risks-of the nicotine they are consuming.

The Role of Cigarillo Flavor in the Co-Use of Cigarillos and Cannabis among Young Adults.

Background: Research suggests flavor facilitates cigarillo use, but it is unknown if flavor impacts patterns of co-use of cigarillos and cannabis ("co-use"), which is common among young adult smokers. This study's aim was to determine the role of the cigarillo flavor in co-use among young adults. Methods: Data were collected (2020-2021) in a cross-sectional online survey administered to young adults who smoked ≥2 cigarillos/week (N = 361), recruited from 15 urban areas in the United States. A structural equation model was used to assess the relationship between flavored cigarillo use and past 30-day cannabis use (flavored cigarillo perceived appeal and harm as parallel mediators), including several social-contextual covariates (e.g., flavor and cannabis policies). Results: Most participants reported usually using flavored cigarillos (81.8%) and cannabis use in the past 30 days ("co-use") (64.1%). Flavored cigarillo use was not directly associated with co-use (p = 0.90). Perceived cigarillo harm (ß = 0.18, 95% CI = 0.06, 0.29), number of tobacco users in the household (ß = 0.22, 95% CI = 0.10, 0.33), and past 30-day use of other tobacco products (ß = 0.23, 95% CI = 0.15, 0.32) were significantly positively associated with co-use. Living in an area with a ban on flavored cigarillos was significantly negatively associated with co-use (ß = -0.12, 95% CI = -0.21, -0.02). Conclusions: Use of flavored cigarillos was not associated with co-use; however, exposure to a flavored cigarillo ban was negatively associated with co-use. Cigar product flavor bans may reduce co-use among young adults or have a neutral impact. Further research is needed to explore the interaction between tobacco and cannabis policy and use of these products.

Flavour loyalty may predict cessation or substitution following a cigarillo flavour ban among young adults in the USA.

SIGNIFICANCE: The purpose of this research was to measure flavour loyalty and identify how current cigarillo users may respond to a hypothetical flavour ban in the USA. METHODS: Cigarillo users aged 21-28 (n=531) were recruited between October 2020 and April 2021 to participate in an online survey. Respondents categorised their preferred, usual and current cigarillo flavours. Individuals who preferred tobacco flavours were compared with individuals who preferred any other flavours. Strength of preferences, or flavour loyalty, was defined when an individual's preferred flavour matched what they use both usually and currently creating a spectrum of individuals with a strong tobacco preference (n=34), weak tobacco preference (n=20), weak flavour preference (n=162) and strong flavour preference (n=315). Those preferring tobacco were aggregated into any tobacco preference (n=54). RESULTS: Individuals who preferred any flavour scored higher on a scale of nicotine dependence. There was a dose-response relationship in those who said they would discontinue cigarillos if flavoured options were not available: 11.4% of individuals with any tobacco flavour preference, 27.8% of those with a weak flavour preference and 38.1% of those with a strong flavour preference. A similar trend was noted among those who would switch to another product: 19.2% of those with tobacco flavour preference, 34.3% of those with a weak flavour preference and 43.2% of those with a strong flavour preference. CONCLUSION: Individuals who display strong flavour preferences were more likely to say they would discontinue use or seek out alternative flavoured products following a ban on flavoured cigarillos.

Geographic Differences in JUUL Use and Risk Perceptions.

PURPOSE: The aim of this study was to compare prevalence of JUUL use and JUUL risk perceptions between adolescents living in an urban area versus Appalachian areas of the U.S. METHODS: Data were drawn from a prospective cohort study of adolescent males (the Buckeye Teen Health Study, or BTHS); our cross-sectional analysis used data from one timepoint, collected between January and December 2019 (N = 873). Chi-square tests and multivariable logistic regression compared JUUL use prevalence and risk perceptions between participants in an urban Ohio county and nine predominantly rural Appalachian Ohio counties. RESULTS: Over a quarter of the sample (29.2%) had ever used JUUL. In the unadjusted model, prevalence of JUUL use was similar between regions but Appalachian participants perceived JUUL as more harmful (p < .001) and more addictive (p = .04) than urban participants. In the adjusted model, region was not significantly related to current JUUL use (OR: 1.20, 95% CI: 0.77, 1.87) or ever JUUL use (OR: 1.15, 95% CI: 0.83, 1.60). CONCLUSIONS: JUUL use was similar between urban and Appalachian participants despite regional differences in risk perceptions. Interventions that only target risk perceptions may not be sufficient to prevent adolescent e-cigarette use, particularly in rural communities.

Beyond Strong Enforcement: Understanding the Factors Related to Retailer Compliance With Tobacco 21.

INTRODUCTION: Tobacco 21 (T21), which sets the minimum legal sales age for tobacco to age 21, is now a national law in the United States. Although T21 is expected to help curb youth tobacco use, its impact may be dampened due to poor retailer compliance. Even within environments where enforcement is strong (ie, compliance checks are conducted with tough sanctions for violations), compliance might vary due to other factors. AIMS AND METHODS: Three studies were conducted in Columbus, OH, where T21 became strongly enforced in 2018. These studies examined how retailer compliance related to features of the neighborhood in which a retailer was located (Study 1), features of the retailer (Study 2), and features of the retail cashier (Study 3). RESULTS: Study 1 found that, after controlling for race- and age-based factors, retailers located in high (vs. low)-poverty neighborhoods had a lower likelihood of conducting identification (ID) checks. Study 2 found that ID checks were related to whether retailers displayed signage about T21, as required by the city law. Study 3 found that, among cashiers, T21 awareness (which was high) and perceptions about T21 (which were moderate) were not generally related to their retailer's compliance; having (vs. not having) scanners for ID checks was related to a higher likelihood of compliance. CONCLUSIONS: These studies emphasize the many, multilevel factors influencing T21 outcomes. Findings also indicate the potential for T21 to widen disparities in tobacco use, indicating the need for strategies to equitably improve T21 compliance. IMPLICATIONS: T21, which sets the minimum legal sales age for all tobacco products to age 21, is now a national law in the United States. Despite optimistic projections about what T21 could achieve, the ultimate impact may be dampened when it is applied in real-world settings. Our project revealed the many, multilevel factors influencing T21 compliance. Findings also indicate the potential for T21 to widen disparities in tobacco use if gaps in compliance persist. Strategies for equitably improving T21 compliance are discussed. This article is of relevance to areas interested in implementing or improving their local T21 enforcement.

A Year of Child Injury Prevention on Instagram.

Injury is the leading cause of death for children but little is known about what types of injury prevention messages are communicated on Instagram. Conducted in the United States, the aim of this study was to better understand child injury prevention messages on Instagram to develop recommendations for the future. Informed by Social Cognitive Theory, a quantitative content analysis was conducted on all Instagram posts from selected organizations from May 2018 through April 2019. Of the 818 injury prevention posts, almost all included an image (575, 70%) or video (211, 26%). Of the 575 images, 245 (42.46%) had in image that did not match the topic of the post. Regarding injury prevention recommendations, 579 posts (71%) provided a clear action that parents should take. For these posts, 115 (20%) had an image that communicated the desired safety recommendation, but many more (285, 50%) did not; in 23 cases it was not clear if there was a match or not. There are missed opportunities for child health and injury organizations to reach parents and caregivers through Instagram. Posts made during the study period often lacked specificity about action-oriented measures and failed to utilize images that demonstrated the recommended practices. Organizations posting on Instagram and other social media platforms should provide clear action tips and utilize images that depict child injury prevention recommendations.

Pulling Your Mask down to Smoke: Qualitative Themes from Young Adults on Nicotine Use during a Pandemic.

Introduction: The COVID-19 pandemic may have resulted in a change in life routines for tobacco users, but little is known about the rationale underlying these changes. Methods: A convenience sample of young adults ages 21-28 (n = 29) were recruited online May-July 2020 to participate in semi-structured interviews about nicotine use behaviors specific to cigarillos and e-cigarettes. Audio-recorded interviews were 60-90 min long and were conducted remotely. Participants were asked opinions and behavioral effects of the COVID-19 pandemic on tobacco use. Verbatim transcripts and field notes from each interview were coded by a trained researcher using a codebook developed using inductive and deductive approaches. Thematic analysis was used to examine product access, use frequency, stress and use triggers. Results: Most current users reported tobacco use stayed the same or increased since the pandemic and attributed this to being home more with greater time/boredom. COVID-19 impacted purchasing behaviors such as purchasing products in greater quantities, through the Internet, or at a different store due to perceived cleanliness. Few reported using tobacco products less frequently and not smoking in public due to the perception of risks associated with smoking and COVID-19, plus having to take off their mask to smoke. Lack of social use modified shared product use, flavors selected, and setting of use. Financial impacts included increased product costs and job loss. Few mentioned wanting to quit due to the pandemic. Discussion: Current tobacco users have experienced major changes in their tobacco use routines during the COVID-19 pandemic.

Effectiveness of Cessation Messages Targeting Pregnant and Nonpregnant Female Smokers in the United States: A Cross-Sectional Analysis into the Impact of Pregnancy, Self-Efficacy, and Risk Perception.

OBJECTIVES: Roughly 10% of pregnant women are current smokers. Improving smoking cessation in this population before and during pregnancy is essential to prevent adverse fetal outcomes. This study aimed to examine cessation messages targeting American women. METHODS: An obstetrics-gynecological clinic-based sample of female, current smokers of reproductive age (18-44 years old) was recruited (n = 135) from January to May 2019; half (51.2%) were currently pregnant. Participants completed a within-subjects study with a randomized set of gain- and loss-framed text-only pregnancy-related cessation messages (5 each). Each individual message was rated on a validated, 10-point scale for perceived effectiveness; responses to the seven items were averaged. Regression analyses examined differences in effectiveness ratings by message framing. RESULTS: Study participants (female smokers) rated the gain-framed messages as slightly more effective than loss-framed messages (7.9 versus 7.7, p < 0.01). After adjusting for quit intention and pregnancy, the relationship between gain- and loss-framing and effectiveness ratings was modified by both self-efficacy and risk perceptions. Women who perceived high risks of smoking during pregnancy had higher effectiveness ratings of both gain- and loss-framed cessation messages, compared to women who perceived low risks. Lower cessation self-efficacy was significantly associated with lower effectiveness ratings for gain- and loss-framed messages (1.53 and 1.92, respectively; p < 0.05). CONCLUSIONS FOR PRACTICE: Women with lower self-efficacy and low risk perception of smoking risks had the lowered effectiveness ratings for both frames of cessation messages. Enhancing self-efficacy and risk perceptions through clinical interventions may improve the effectiveness of targeted messages to promote quitting smoking before or during pregnancy.

When Social Media Images and Messages Don't Match: Attention to Text versus Imagery to Effectively Convey Safety Information on Social Media.

Health organizations can use visuals that support observational learning in social media. The social cognitive theory construct of observational learning illustrates how social media messages can inform health-related behavior change. In a within-subjects design, parents (n = 150) were exposed to real-world social media posts where safety recommendation text and imagery was matched (n = 3) or unmatched (n = 3). Safety topics were relevant to children age seven and younger: infant sleep, poisoning prevention, and bicycling safety. Eye tracking software captured visual attention (in milliseconds) on visual imagery and a post-experiment survey recorded correct answers to safety recommendations. Analyses examined the relationship between the match between text and imagery and visual attention. Participants spent more time on the matched image posts compared to mismatched image posts (5.3 versus 3.3 seconds; p < .001). After accounting for frequency of social media use and health literacy, each second of viewing time on the matched posts was associated with a 2.8% increase in the correct response safety information knowledge score (p < .001). Matched text and visuals on social media posts attracted significantly higher visual attention and improved safety knowledge.

Visual Attention to the Use of #ad versus #sponsored on e-Cigarette Influencer Posts on Social Media: A Randomized Experiment.

Youth and young adults are the largest consumers of social media content. Individuals with large followers are paid to share social media content using specific products for compensation. This type of activity is considered commercial sponsorship and requires a disclosure in order to comply with Federal Trade Commission regulations. Between July and August 2019, youth and young adult (ages 16-24; n = 200) participants were recruited into an eye-tracking laboratory to view their native Instagram feed on a mobile device where a set of posts from e-cigarette influencers were inserted with one of the two potential labeling strategies: #ad and #sponsored. Participants spent an average of 6.6 seconds viewing e-cigarette influencer posts. Youth and young adults spent 3.1 seconds on the area labeled #ad, compared to 2.2 seconds on the area of interest labeled #sponsored (p = .03). After accounting for age, current tobacco use, and dependence, #ad drew 0.93 seconds more than #sponsored on influencer posts (p = .02). Both labeling strategies drew visual attention to Instagram e-cigarette influencer posts, with nearly 1 second more attention paid to the presence of #ad. Labeling commercially sponsored content on social media is a viable strategy to attract the attention of youth and young adults.

The Influence of Health Numeracy and Health Warning Label Type on Smoking Myths and Quit-Related Reactions.

INTRODUCTION: Health numeracy helps individuals understand risk information, but limited data exist concerning numeracy's role in reactions to varying types of health warning labels (HWLs) for cigarettes. METHODS: A nationally representative online panel of adult current smokers received two exposures (1 week apart) to nine HWLs with either text-only or pictorial images with identical mandated text. Following the second exposure, participants (n = 594) rated their beliefs in smoking myths (eg, health-promoting behaviors can undo the risks of smoking) and how much the warnings made them want to quit smoking. Generalized estimating equation regression examined the relation of objective health numeracy and its interaction with HWL type to smoking-myth beliefs and quit-related reactions. RESULTS: Health numeracy was not significantly associated with smoking-myth beliefs; the interaction with HWL type was also nonsignificant. Adult smokers with lower health numeracy had higher quit-related reactions than those with higher numeracy following exposure to HWLs. The type of HWL significantly modified numeracy's associations with quit-related reactions; no significant association existed between text-only HWLs and quit-related reactions, whereas among those who viewed the pictorial warnings, lower numeracy was associated with greater quit-related reactions (ß = -.23; p < .001). CONCLUSIONS: Lower as compared to higher health numeracy was significantly associated with higher quit-related reactions to HWLs and especially with pictorial HWLs. Health numeracy and HWL type were not associated with the endorsement of smoking myths. The role of health numeracy in effectively communicating risks to smokers warrants thoughtful consideration in the development of tobacco HWLs. IMPLICATIONS: Health numeracy plays an important role in an individual's ability to understand and respond to health risks. Smokers with lower health numeracy had greater quit-related reactions to pictorial health warnings than those who viewed text-only warning labels. Development and testing of health warning labels should consider health numeracy to most effectively communicate risk to US smokers.

Quitting Behaviors Among Dual Cigarette and E-Cigarette Users and Cigarette Smokers Enrolled in the Tobacco User Adult Cohort.

PURPOSE: We examined quitting behaviors among a cohort of dual users (cigarettes and electronic cigarettes [e-cigarettes]) and exclusive cigarette smokers for: (1) cigarette smoking reduction, (2) quit attempts, (3) abstinence from cigarettes, and (4) abstinence from all tobacco products. METHODS: Participants enrolled in the Tobacco User Adult Cohort and categorized as "daily" user of cigarettes and "daily" or "some days per week" use of e-cigarettes (ie, dual users; n = 88) or "daily" user of cigarettes only (ie, cigarette smokers; n = 617) served as the analytic sample. Participants were interviewed face to face every 6 months, through 18 months. Data on self-reported current product(s) used, cessation interest, quit attempts and abstinence from cigarettes, and all tobacco products were collected. RESULTS: No difference in reduction of cigarette consumption over time was noted between groups. Rates of reporting an attempt to quit all tobacco products (≥ 24 hours of not using any tobacco in an attempt to quit) also did not differ by group. Compared to cigarette smokers, dual users were more likely to report abstinence from cigarettes at 6 months (OR = 2.54, p = .045) but not at 12 or 18 months. There was no significant difference in abstinence from all tobacco products by group at 6, 12, or 18 months. CONCLUSIONS: Although dual use of e-cigarettes has been cited as a potential cessation tool for cigarette smokers, our findings indicated that this association was only observed in the short term. We also found no evidence of any association between dual use and eventual abstinence from all tobacco products. IMPLICATIONS: Our study observed that, in the natural environment, dual users of cigarettes and e-cigarettes were more likely than cigarette smokers to quit cigarettes in the short term but no more likely to quit using cigarettes and all tobacco products over time.

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.

Cost-Effectiveness of Community-Based Tobacco Dependence Treatment Interventions: Initial Findings of a Systematic Review.

INTRODUCTION: Scientific literature evaluating the cost-effectiveness of tobacco dependence treatment programs delivered in community-based settings is scant, which limits evidence-based tobacco control decisions. The aim of this review was to systematically assess the cost-effectiveness and quality of the economic evaluations of community-based tobacco dependence treatment interventions conducted as randomized controlled trials in the United States. METHODS: We searched 8 electronic databases and gray literature from their beginning to February 2018. Inclusion criteria were economic evaluations of community-based tobacco dependence treatments conducted as randomized controlled trials in the United States. Two independent researchers extracted data on study design and outcomes. Study quality was assessed by using Drummond and Jefferson's economic evaluations checklist. Nine of 3,840 publications were eligible for inclusion. Heterogeneity precluded formal meta-analyses. We synthesized a qualitative narrative of outcomes. RESULTS: All 9 studies used cost-effectiveness analysis and a payer/provider/program perspective, but several study components, such as abstinence measures, were heterogeneous. Study participants were predominantly English speaking, middle aged, white, motivated to quit, and highly nicotine dependent. Overall, the economic evaluations met most of Drummond and Jefferson's recommendations; however, some studies provided limited details. All studies had a cost per quit at or below $2,040 or an incremental cost-effectiveness ratio (ICER) at or below $3,781. When we considered biochemical verification, sensitivity analysis, and subgroups, the costs per quit were less than $2,050 or the ICERs were less than $6,800. CONCLUSION: All community-based interventions included in this review were cost-effective. When economic evaluation results are extrapolated to future savings, the low cost per quit or ICER indicates that the cost-effectiveness of community-based tobacco dependence treatments is similar to the cost-effectiveness of clinic-based programs and that community-based interventions are a valuable approach to tobacco control. Additional research that more fully characterizes the cost-effectiveness of community-based tobacco dependence treatments is needed to inform future decisions in tobacco control policy.

Cigarette Graphic Warning Labels Are Not Created Equal: They Can Increase or Decrease Smokers' Quit Intentions Relative to Text-Only Warnings.

INTRODUCTION: Cigarette graphic-warning labels elicit negative emotion. Research suggests negative emotion drives greater risk perceptions and quit intentions through multiple processes. The present research compares text-only warning effectiveness to that of graphic warnings eliciting more or less negative emotion. METHODS: Nationally representative online panels of 736 adult smokers and 469 teen smokers/vulnerable smokers were randomly assigned to view one of three warning types (text-only, text with low-emotion images, or text with high-emotion images) four times over 2 weeks. Participants recorded their emotional reaction to the warnings (measured as arousal), smoking risk perceptions, and quit intentions. Primary analyses used structural equation modeling. RESULTS: Participants in the high-emotion condition reported greater emotional reaction than text-only participants (bAdult = 0.21; bTeen = 0.27, p's < .004); those in the low-emotion condition reported lower emotional reaction than text-only participants (bAdult = -0.18; bTeen = -0.22, p's < .018). Stronger emotional reaction was associated with increased risk perceptions in both samples (bAdult = 0.66; bTeen = 0.85, p's < .001) and greater quit intentions among adults (bAdult = 1.00, p < .001). Compared to text-only warnings, low-emotion warnings were associated with reduced risk perceptions and quit intentions whereas high-emotion warnings were associated with increased risk perceptions and quit intentions. CONCLUSION: Warning labels with images that elicit more negative emotional reaction are associated with increased risk perceptions and quit intentions in adults and teens relative to text-only warnings. However, graphic warnings containing images which evoke little emotional reaction can backfire and reduce risk perceptions and quit intentions versus text-only warnings. IMPLICATIONS: This research is the first to directly manipulate two emotion levels in sets of nine cigarette graphic warning images and compare them with text-only warnings. Among adult and teen smokers, high-emotion graphic warnings were associated with increased risk perceptions and quit intentions versus text-only warnings. Low-emotion graphic warnings backfired and tended to reduce risk perceptions and quit intentions versus text-only warnings. Policy makers should be aware that merely placing images on cigarette packaging is insufficient to increase smokers' risk perceptions and quit intentions. Low-emotion graphic warnings will not necessarily produce desired population-level benefits relative to text-only or high-emotion warnings.

Health Warning Labels for Smokeless Tobacco: The Impact of Graphic Images on Attention, Recall, and Craving.

INTRODUCTION: Little research has examined the impacts of graphic health warnings on the users of smokeless tobacco products. METHODS: A convenience sample of past-month, male smokeless tobacco users (n = 142; 100% male) was randomly assigned to view a smokeless tobacco advertisement with a graphic health warning (GHW) or a text-only warning. Eye-tracking equipment measured viewing time, or dwell time, in milliseconds. Following the advertisement exposure, participants self-reported smokeless tobacco craving and recalled any content in the health warning message (unaided recall). Linear and logistic regression analyses evaluated the proportion of time viewing the GHW, craving, and GHW recall. RESULTS: Participants who viewed a GHW spent a significantly greater proportion of their ad viewing time on GHWs (2.87 seconds or 30%), compared to those viewing a text-only warning (2.05 seconds or 24%). Although there were no significant differences by condition in total advertisement viewing duration, those participants viewing a GHW had increased recall of health warning messages compared to the text-only warning (76% had any warning message recall compared to 53%; p < .05). Self-reported craving after advertisement exposure was lower in the GHW compared to text-only condition, but the difference was not statistically significant (a rating of 4.4 vs. 5.3 on a 10-point scale; p = .08). CONCLUSIONS: GHWs attracted greater attention and greater recall of health warning messages compared to text-only warnings among rural male smokeless tobacco users. IMPLICATIONS: Among a sample of rural smokeless tobacco users, GHWs attracted more attention and recall of health warning messages compared to text-only warnings when viewed within smokeless tobacco advertising. These findings provide additional empirical support that GHWs are an effective tobacco control tool for all tobacco products and advertisements.

Ending tobacco sales in pharmacies: A qualitative study.

OBJECTIVE: The states of California and Massachusetts are leading the effort to prohibit the sale of tobacco products in pharmacies in the United States. The process of adopting these tobacco-free pharmacy laws remains understudied. This study qualitatively explores the process of adopting and enforcing tobacco-free pharmacy laws. METHODS: Researchers performed qualitative semistructured telephone interviews with 23 key informants who were involved in the effort to adopt and implement tobacco-free pharmacy laws in California and Massachusetts. A content analysis was used to study the process of adopting tobacco-free pharmacy laws as well as barriers and facilitators during the process. Two researchers independently coded the interview transcripts and written responses to identify key categories and themes that emerged from the interviews. RESULTS: The qualitative study results suggest that the process of adopting the tobacco-free pharmacy laws was fairly smooth, with a few barriers. Local youth groups and independent pharmacies played an important role in raising public awareness and attracting media attention. The results also highlighted the need to regulate the sale of e-cigarettes as a part of tobacco-free pharmacy laws. CONCLUSION: As the number of cities that have adopted tobacco-free pharmacy laws grows, banning tobacco sales in pharmacies is becoming less controversial and more normative to both pharmacy retailers and the public. Our findings inform the ongoing discussion about tobacco-free pharmacy laws and are useful for decision-makers from communities that are considering such laws.

Evidentiary Support in Public Comments to the FDA's Center for Tobacco Products.

Electronic Nicotine Delivery Systems (ENDS) were introduced into the US market in 2007, and until recently these devices were unregulated at the federal level. In 2014, the US Food and Drug Administration (FDA) published a Notice of Proposed Rulemaking asserting its intention to regulate ENDS and requesting public comments on numerous related issues, including potential limits on the sale of flavored ENDS. This article analyzes key comments submitted to the FDA on the issue of flavor regulation in ENDS and examines the weight and credibility of the evidence presented by both supporters and opponents of regulation. It also describes the final deeming rule, published in May 2016, and the FDA's response to the evidence submitted. This is the first study to examine public comments submitted to the FDA's Center for Tobacco Products, and it concludes that opponents of regulation were more likely to rely on sources that were not peer reviewed and that were affected by conflicts of interest. In light of these findings, the FDA and the research community should develop processes to carefully and critically analyze public comments submitted to the FDA on issues of tobacco regulation.

Tobacco-Free Pharmacy Laws and Trends in Tobacco Retailer Density in California and Massachusetts.

OBJECTIVES: To examine the impact of local laws prohibiting tobacco sales in pharmacies in California and Massachusetts, the only 2 US states in which such municipal laws exist. METHODS: We analyzed longitudinally the tobacco retailer density at the city level from tobacco retailer license data in California (2005-2013) and Massachusetts (2004-2014). RESULTS: After adjustments, the reduction in tobacco retailer density over time was 1.44 (95% confidence interval [CI] = 1.37, 1.51) to 3.18 (95% CI = 1.11, 5.25) times greater in cities with a tobacco-free pharmacy law than in cities without such a law. CONCLUSIONS: Tobacco-free pharmacy laws are associated with a greater reduction in tobacco retailer density over time in California and Massachusetts.