Modification Mechanisms of Descriptive Norm Perceptions Toward Vaping: The Role of Behavior Prevalence and Group Size in an Online Setting.

We often rely on descriptive norm perceptions as a mental shortcut for decision making. However, less is known about how such perceptions are shaped and modified by our experiences in day-to-day life. The interactive nature of the current media environment offers opportunities for individuals to access others' health behavior choices through online user-generated content. Within a setting of online comment boards, the current study examined the descriptive norm perception modification process toward vaping with a large-scale experiment that systematically varied levels of exposure to online commenters' vaping behavior choice indications. Findings revealed a significant positive effect of behavior prevalence on descriptive norm perceptions, which in turn were positively associated with vaping intention. This set of results was observed only when a sufficient total amount of comment exposures was ensured. The study provided empirical evidence for the underlying mechanism of the "quasi-statistical sense," which helps people draw conclusions about behavior prevalence and may influence their behavioral decision making. Theoretical and practical implications are discussed.

Rating the Valence of Media Content about Electronic Cigarettes Using Crowdsourcing: Testing Rater Instructions and Estimating the Optimal Number of Raters.

Electronic cigarettes (e-cigarettes) are a controversial public health topic due to their increasing popularity among youth and the uncertainty about their risks and benefits. Researchers have started to assess the valence of media content about e-cigarette use, mostly using expert coding. The current study aims to offer a methodological framework and guideline when using crowdsourcing to rate the valence of e-cigarette media content. Specifically, we present (1) an experiment to determine rating instructions that would result in reliable valence ratings and (2) an analysis to identify the optimal number of raters needed to replicate these ratings. Specifically, we compared ratings produced by crowdsourced raters instructed to rate from several different perspectives (e.g., objective vs. subjective) and determined the instructions that led to reliable ratings. We then used bootstrapping methods and a set of criteria to identify the minimum number of raters needed to replicate these ratings. Results suggested that when rating e-cigarette valence, instructing raters to rate from their own subjective perspective produced reliable results, and nine raters were deemed the optimal number of raters. We expect these findings to inform future content analyses of e-cigarette valence. The study procedures can be applied to crowdsourced content analyses of other health-related media content to determine appropriate rating instructions and the number of raters.

Valence of Media Coverage About Electronic Cigarettes and Other Tobacco Products From 2014 to 2017: Evidence From Automated Content Analysis.

INTRODUCTION: As media exposure can influence people's opinions and perceptions about vaping and smoking, analyzing the valence of media content about tobacco products (ie, overall attitude toward tobacco, cigars, electronic cigarettes, etc.) is an important issue. This study advances the field by analyzing a large amount of media content about multiple tobacco products across six different media sources. AIMS AND METHODS: From May 2014 to December 2017, we collected all English-language media items about tobacco products that U.S. young people might see from mass media and websites (long-form) and social media (Twitter and YouTube). We used supervised machine learning to develop validated algorithms to label the valence of these media items. Using the labeled results, we examined the impact of product type (e-cigarettes vs. other tobacco products), source (long-form vs. social media), and time (by month) on the valence of coverage. RESULTS: We obtained 152 886 long-form media texts (20% with more than a passing mention), nearly 86 million tweets, and 12 262 YouTube videos about tobacco products. Most long-form media content opposed, while most social media coverage supported, the use of e-cigarettes and other tobacco products. Over time, within-source valence proportions were stable, though in aggregate, the amount of media coverage against the use of tobacco products decreased. CONCLUSIONS: This study describes the U.S. public communication environment about vaping and smoking for young people and offers a novel big data approach to analyzing media content. Results suggest that content has gradually become less negative toward the use of e-cigarettes and other tobacco products. IMPLICATIONS: This study is the first to examine how the valence of media coverage differs for e-cigarettes versus other tobacco products, across several media sources, and over time using a large corpus of media items. Unlike prior studies, these data allow us to draw conclusions about relative support and opposition for these two categories of products in a variety of media coverage because the same coding scheme was used across products and media sources.

Breadth of Media Scanning Leads to Vaping among Youth and Young Adults: Evidence of Direct and Indirect Pathways from a National Longitudinal Survey.

Electronic cigarette use among youth and young adults has reached an epidemic proportion of growth. This study examined the direct and indirect effects of the breadth of media scanning about e-cigarette use on subsequent vaping behavior through interpersonal communication and changes in descriptive norm perceptions. We conducted a nationally representative longitudinal phone survey of 13- to 25-year-olds from June 2014 to March 2017, with 11,013 respondents who completed a baseline survey, among which 3,212 completed a follow-up 6 months later. The results from both cross-sectional and lagged analyses provided robust evidence to suggest that passive routine exposure to e-cigarette use content from more media outlets predicted increased likelihood of vaping among youth and young adults. High scanners were about twice as likely to vape as non-scanners (17% versus 9%). Mediation models using bootstrapping procedures found that breadth of scanning predicted higher descriptive norm perceptions which were associated with subsequent vaping; in addition, interpersonal communication mediated the relationship between breadth of scanning and changes in descriptive norm perceptions. These findings highlight the important roles of scanning, norm perceptions and interpersonal discussions in shaping cognition and behavior changes. The results also suggest an overall pro-e-cigarette public communication environment, which warrants further examination.

Exploring the Effect of Health App Use on Fruit and Vegetable Consumption.

People may use multiple health apps at the same time or in close sequence, and the effect of health apps may vary across different socioeconomic groups. However, in the context of healthy eating, studies have focused on the effect of using a single health app. This study aims to test the relationship of using multiple health apps with fruit and vegetable consumption, assessing moderation by education level. Employing longitudinal survey data from South Korean adults, we conducted regression analyses to test the lagged association between use of health apps and intake of fruits and vegetables, and whether education moderates the relationship. The results supported the positive lagged relationship of health app use with fruit and vegetable consumption, significant after controlling for confounders and baseline fruit and vegetable consumption. The association was smaller among respondents with higher education. Our findings suggest the positive effect of using multiple health apps on fruit and vegetable consumption, implying the importance of finding the best combination of health apps to maximize their effectiveness in promoting healthy eating. Also, the negative interaction of health app use and education support using mobile communication technology to improve the public health of low socioeconomic status individuals.

The Relationship Between Exogenous Exposure to "The Real Cost" Anti-Smoking Campaign and Campaign-Targeted Beliefs.

Though previous evaluations of "The Real Cost" anti-smoking campaign demonstrate effects on anti-smoking beliefs and behaviors, results rely on self-reported recall as a measure of exposure and are thus open to reverse causation concerns. Exogenous measures of exposure, assessed independently of outcomes, support stronger causal inferences. In this study, we examined the relationship between Target Rating Points (TRPs) for specific ads available over four-week periods and anti-smoking beliefs in a national sample of adolescent nonsmokers and experimenters (n = 4,780). Results demonstrate positive relationships between TRPs for ads targeting two of four belief categories tested (Control and Chemical; p < .05) and targeted-belief endorsement. Furthermore, moderation models indicate that ad-specific TRPs affected targeted beliefs more than non-targeted beliefs for those Control- and Chemical-targeted ads (p < .01). Findings support a claim of campaign effects while reducing concerns about reverse causal direction and the influence of unmeasured confounders.

Combining Crowd-Sourcing and Automated Content Methods to Improve Estimates of Overall Media Coverage: Theme Mentions in E-cigarette and Other Tobacco Coverage.

Exposure to media content can shape public opinions about tobacco. Accurately describing content is a first step to showing such effects. Historically, content analyses have hand-coded tobacco-focused texts from a few media sources which ignored passing mention coverage and social media sources, and could not reliably capture over-time variation. By using a combination of crowd-sourced and automated coding, we labeled the population of all e-cigarette and other tobacco-related (including cigarettes, hookah, cigars, etc.) 'long-form texts' (focused and passing coverage, in mass media and website articles) and social media items (tweets and YouTube videos) collected May 2014-June 2017 for four tobacco control themes. Automated coding of theme coverage met thresholds for item-level precision and recall, event validation, and weekly-level reliability for most sources, except YouTube. Health, Policy, Addiction and Youth themes were frequent in e-cigarette long-form focused coverage (44%-68%), but not in long-form passing coverage (5%-22%). These themes were less frequent in other tobacco coverage (long-form focused (13-32%) and passing coverage (4-11%)). Themes were infrequent in both e-cigarette (1-3%) and other tobacco tweets (2-4%). Findings demonstrate that passing e-cigarette and other tobacco long-form coverage and social media sources paint different pictures of theme coverage than focused long-form coverage. Automated coding also allowed us to code the amount of data required to estimate reliable weekly theme coverage over three years. E-cigarette theme coverage showed much more week-to-week variation than did other tobacco coverage. Automated coding allows accurate descriptions of theme coverage in passing mentions, social media, and trends in weekly theme coverage.

Recall of "The Real Cost" Anti-Smoking Campaign Is Specifically Associated With Endorsement of Campaign-Targeted Beliefs.

Though previous research suggests the FDA's "The Real Cost" anti-smoking campaign has reduced smoking initiation, the theorized pathway of effects (through targeted beliefs) has not been evaluated. This study assesses the relationship between recall of campaign television advertisements and ad-specific anti-smoking beliefs. Respondents in a nationally representative survey of nonsmoking youths age 13-17 (n = 4,831) reported exposure to four The Real Cost advertisements and a fake ad, smoking-relevant beliefs, and nonsmoking intentions. Analyses separately predicted each targeted belief from specific ad recall, adjusting for potential confounders and survey weights. Parallel analyses with non-targeted beliefs showed smaller effects, strengthening claims of campaign effects. Recall of four campaign ads (but not the fake ad) significantly predicted endorsement of the ad-targeted belief (Mean ß = .13). Two-sided sign tests indicated stronger ad recall associations with the targeted belief relative to the non-targeted belief (p < .05). Logistic regression analyses indicated that respondents who endorsed campaign-targeted beliefs were more likely to have no intention to smoke (p < .01). This study is the first to demonstrate a relationship between recall of ads from The Real Cost campaign and the theorized pathway of effects (through targeted beliefs). These analyses also provide a methodological template for showing campaign effects despite limitations of available data.

Effects of Framing Health Messages in Terms of Benefits to Loved Ones or Others: An Experimental Study.

Many health officials believe the future of public health is in prevention of infectious diseases like pandemic influenza. Vaccine promotion is becoming an increasingly important area for health communication researchers. One strategy health promoters can consider is to emphasize that getting vaccinated protects not only the self, but also loved ones, and unknown others to whom the disease could be spread. The set of experiments described here tested whether such a strategy (called "benefit-target framing") could prove useful in promoting vaccine intentions. In two experiments, subjects from an online panel were randomized to receive a vaccination message focused on the benefits either to the self, to loved ones, or to society as a whole. Outcome measures included intentions to receive the vaccine and intentions to seek more information (n = 495). Results from two virtually identical studies were pooled to maximize power. Results suggest that messages framed in terms of benefits to society were more successful than those focused on the self, but messages focused on loved ones were not different from either of the others. Possible explanations for the findings, and implications for future research, are discussed.

Nonmedical information seeking amid conflicting health information: negative and positive effects on prostate cancer screening.

This study investigates the impact of seeking information about the prostate-specific antigen (PSA) test on men's PSA test use during a period of conflicting recommendations. Analyses used longitudinal survey data collected in 2005 and 2006 from a nationally representative sample of U.S. males aged 40-70 years (n = 777). Cross-sectionally, nonmedical information seeking was significantly associated with increased odds of having a PSA test in the past year (Time 1 odds ratio [OR] = 9.74, p < .01, 95% confidence interval [CI] = 4.37, 21.70; Time 2 OR = 5.78, p < .01, 95% CI = 3.17, 10.55). However, lagged analyses showed that among men who had a PSA at Time 1, active seeking is associated with reduced odds of later having a PSA test (OR = 0.33, p < .05, 95% CI = 0.13, 0.85). Participants who had not had a PSA test in the past year very rarely sought information about PSA tests. Information acquisition in an environment of conflicting recommendations may influence adoption of cancer screening behaviors.

Media Coverage of Pediatric Environmental Health Risks and its Effects on Mothers' Protective Behaviors.

This study explores the relationship between exposure to U.S. media coverage of chemical threats to pediatric environmental health and mothers' behaviors to protect their children. Prior content analytic work revealed that media coverage volume from September 2012 to February 2013 differed significantly by type of chemical (i.e., pesticides = high coverage volume; bisphenol A [BPA] = moderate; and arsenic = low). Survey data collected from new and expecting mothers in March 2013 (n = 822) revealed mothers incidentally encountered-or scanned-this information in the media in the prior six months, and after adjusting for a series of potential confounders, such scanning was positively associated with mothers' self-reported behaviors to reduce chemical exposures. To test the hypothesis that coverage volume moderates the relationship between scanning and behavior, content analysis and survey data were combined in mixed effects regression analyses. Results showed significant differences between the effects of media scanning at different levels of coverage volume, but in a direction not entirely consistent with the study's hypothesis. The relationship between scanning and behavior was strongest for BPA, suggesting that a characteristic of media coverage other than volume may drive maternal responses to environmental health threats. Implications of these findings for risk communication research and practice are discussed.

Are young people's beliefs about menthol cigarettes associated with smoking-related intentions and behaviors?

INTRODUCTION: Little is known about the beliefs that youth and young adults hold about menthol cigarettes or the influence of these beliefs on tobacco use initiation. METHODS: Online cross-sectional surveys with 13- to 17-year-old current nonsmokers (n = 553) and 18- to 25-year-old never (n = 586) and current tobacco users (n = 307) in the United States assessed the association between endorsing each of 9 pro-menthol beliefs and (a) intentions to smoke menthol cigarettes over the next year, (b) current use of menthol cigarettes, (c) intentions to use tobacco in general over the next year, and (d) current use of tobacco products in general. RESULTS: Menthols were perceived to be less harmful and addictive than nonmenthol cigarettes by between 13% and 23% of respondents. Between 20% and 58% believed that menthols had favorable sensory properties, and 7%-25% believed that menthol smokers were more popular and attractive than nonmenthol smokers. Logistic regression analyses (adjusting for confounders) indicated that, on the whole, those who endorsed pro-menthol beliefs were more likely to intend to use, and to currently use, both menthols and tobacco products in general. For example, respondents who believed that menthol cigarettes were more refreshing in sensation (one of the most frequently endorsed beliefs) were significantly more likely to (a) intend to smoke menthol cigarettes (13- to 17-year-olds, odds ratio [OR] = 2.12, 95% confidence interval [CI] = 1.03, 4.34; 18- to 25-year olds, OR = 2.62, 95% CI = 1.04, 6.60), (b) currently use menthol cigarettes (18- to 25-year olds, OR = 3.40, 95% CI = 2.20, 5.26), (c) intend to use tobacco (13- to 17-year-olds OR = 1.74, 95% CI = 1.14, 2.65), and (d) currently use tobacco (18- to 25-year olds, OR = 2.06, 95% CI = 1.44, 2.93). CONCLUSIONS: Youth and young adults who do not currently smoke and who hold favorable beliefs about menthol cigarettes are at greater risk for beginning to use tobacco products, indicating that the availability of menthol cigarettes may contribute to tobacco use initiation. These findings support recent claims that the elimination of menthol cigarettes would improve public health in the United States.

Talking About Quitting: Interpersonal Communication as a Mediator of Campaign Effects on Smokers' Quit Behaviors.

This study examined the role of interpersonal communication in the context of a mass media anti-smoking campaign. Specifically, it explored whether conversations about campaign ads and/or about quitting mediated campaign exposure effects on 2 quitting behaviors (sought help to quit and tried to quit smoking completely), as well as the relation between ad-related and quitting-related conversations. Data were collected before the campaign and monthly for 16 months during the campaign through cross-sectional telephone surveys among a sample of 3,277 adult Philadelphia smokers. Follow-up interviews were conducted among 877 participants 3 months after their first survey. Cross-sectional and longitudinal mediation models with bootstrap procedures assessed the indirect effects of campaign exposure on outcomes through conversations, and the indirect effects of conversations about ads on outcomes through conversations about quitting. In addition, lagged regression analyses tested the causal direction of associations between the variables of interest. The results partially support hypotheses that conversations about quitting mediate campaign effects on quitting-related behaviors and, in line with previous research, that conversations about the ads have indirect effects on quitting-related behaviors by triggering conversations about quitting. These findings demonstrate the importance of considering interpersonal communication as a route of campaign exposure effects when evaluating and designing future public health campaigns.

AIDS in black and white: the influence of newspaper coverage of HIV/AIDS on HIV/AIDS testing among African Americans and White Americans, 1993-2007.

This study examined the effect of newspaper coverage of HIV/AIDS on HIV testing behavior in a U.S. population. HIV testing data were taken from the Center for Disease Control and Prevention's National Behavioral Risk Factor Surveillance System from 1993 to 2007 (N = 265,557). The authors content-analyzed news stories from 24 daily newspapers and 1 wire service during the same time period. The authors used distributed lagged regression models to estimate how well HIV/AIDS newspaper coverage predicted later HIV testing behavior. Increases in HIV/AIDS newspaper coverage were associated with declines in population-level HIV testing. Each additional 100 HIV/AIDS-related newspaper stories published each month was associated with a 1.7% decline in HIV testing levels in the subsequent month. This effect differed by race, with African Americans exhibiting greater declines in HIV testing subsequent to increased news coverage than did Whites. These results suggest that mainstream newspaper coverage of HIV/AIDS may have a particularly deleterious effect on African Americans, one of the groups most affected by the disease. The mechanisms driving the negative effect deserve further investigation to improve reporting on HIV/AIDS in the media.

Systematic review of the effectiveness of mass media interventions for child survival in low- and middle-income countries.

Through a systematic review of the literature, this article summarizes and evaluates evidence for the effectiveness of mass media interventions for child survival. To be included, studies had to describe a mass media intervention; address a child survival health topic; present quantitative data from a low- or middle-income country; use an evaluation design that compared outcomes using pre- and postintervention data, treatment versus comparison groups, or postintervention data across levels of exposure; and report a behavioral or health outcome. The 111 campaign evaluations that met the inclusion criteria included 15 diarrheal disease, 8 immunization, 2 malaria, 14 nutrition, 1 preventing mother-to-child transmission of HIV, 4 respiratory disease, and 67 reproductive health interventions. These evaluations were then sorted into weak (n = 33), moderate (n = 32), and stronger evaluations (n = 46) on the basis of the sampling method, the evaluation design, and efforts to address threats to inference of mass media effects. The moderate and stronger evaluations provide evidence that mass media-centric campaigns can positively impact a wide range of child survival health behaviors.

The role of patient-clinician information engagement and information seeking from nonmedical channels in fruit and vegetable intake among cancer patients.

Previous research suggests positive effects of health information seeking on prevention behaviors such as diet, exercise, and fruit and vegetable consumption. The present study builds upon this research and strengthens causal claims from it by examining the lagged effect of patient-clinician information engagement on fruit and vegetable consumption as well as the indirect effect on the outcome through seeking information from nonmedical channels. The results are based on data collected from a randomly drawn sample of breast, prostate, and colorectal cancer patients from the Pennsylvania Cancer Registry who completed mail surveys in the Fall of 2006 and 2007. There was a 65% response rate for baseline subjects (resulting n = 2,013); of those, 1,293 were interviewed 1 year later, and 1,257 were available for our analyses. Results show a positive lagged main effect of patient-clinician information engagement at baseline on fruit and vegetable consumption at follow-up (B = 0.26, SE = 0.10, p = .01). The mediation analysis shows that patient-clinician information engagement leads to increased fruit and vegetable consumption among cancer patients, in part through patients' information seeking from nonmedical channels. Implications of these findings for the cancer patient population and for physicians are discussed.

Navigating the cancer information environment: The reciprocal relationship between patient-clinician information engagement and information seeking from nonmedical sources.

Prior theory has argued and empirical studies have shown that cancer patients rely on information from their health care providers as well as lay sources to understand and make decisions about their disease. However, research on the dynamic and interdependent nature of cancer patients' engagement with different information sources is lacking. This study tested the hypotheses that patient-clinician information engagement and information seeking from nonmedical sources influence one another longitudinally among a representative cohort of 1,293 cancer survivors in Pennsylvania. The study hypotheses were supported in a series of lagged multiple regression analyses. Baseline seeking information from nonmedical sources positively predicted subsequent patient-clinician information engagement at 1-year follow-up. The reverse relationship was also statistically significant; baseline patient-clinician information engagement positively predicted information seeking from nonmedical sources at follow-up. These findings suggest that cancer survivors move between nonmedical and clinician sources in a dynamic way to learn about their disease.

Information seeking from media and family/friends increases the likelihood of engaging in healthy lifestyle behaviors.

The amount of cancer-related information available to the general population continues to grow; yet, its effects are unclear. This study extends previous cross-sectional research establishing that cancer information seeking across a variety of sources is extensive and positively associated with engaging in health-related behaviors. The authors studied how active information seeking about cancer prevention influenced three healthy lifestyle behaviors using a 2-round nationally representative sample of adults ages 40-70 years (n = 1,795), using propensity scoring to control for potential confounders including baseline behavior. The adjusted odds of dieting at follow-up were 1.51 (95% CI: 1.05, 2.19) times higher for those who reported baseline seeking from media and interpersonal sources relative to nonseekers. Baseline seekers ate 0.59 (95% CI: 0.28, 0.91) more fruits and vegetable servings per day and exercised 0.36 (95% CI: 0.12, 0.60) more days per week at 1-year follow-up compared with nonseekers. The effects of seeking from media and friends/family on eating fruits and vegetables and exercising were independent of seeking from physicians. The authors offer several explanations for why information seeking predicts healthy lifestyle behaviors: information obtained motivates these behaviors; information sought teaches specific techniques; and the act of information seeking may reinforce a psychological commitment to dieting, eating fruits and vegetables, and exercising.

Anxiety and depression among cancer survivors: the role of engagement with sources of emotional support information.

This study explores cancer survivors' engagement with information about emotional support from doctors, interpersonal sources, and the media and examines to what extent such engagement affects subsequent self-reported anxiety and depression. Patients with colorectal, breast, or prostate cancer (n = 1,128) were surveyed over 3 years following diagnosis. Using lagged logistic regression, we predicted the odds of experiencing anxiety or depression based on earlier engagement with sources of emotional support, adjusting for prior symptoms and confounders. Among those reporting anxiety or depression (n = 476), we also asked whether information engagement affected the severity of those symptoms. Participants obtained information about emotional support from multiple sources, but most often from physicians. Discussions with physicians about emotional support increased the odds of cancer survivors subsequently reporting anxiety or depression by 1.58 times (95% CI: 1.06 to 2.35; p = 0.025), adjusted for prior symptoms and confounders. Scanning from media sources was also significantly associated with increased odds of reporting emotional symptoms (OR=1.72; 95% CI: 1.03 to 2.87; p = 0.039). However, among those who reported symptoms, doctor-patient engagement predicted slightly reduced interference of these symptoms with daily activities (B = -0.198; 95% CI: -0.393 to -0.003; p = 0.047). Important implications for health communication research and practice are discussed.

Patient-clinician information engagement improves adherence to colorectal cancer surveillance after curative treatment: results from a longitudinal study.

Introduction. Follow-up surveillance after curative treatment for colorectal cancer (CRC) patients is recommended to detect early cancer recurrences and improve survival outcomes. However, a substantial proportion of CRC patients do not undergo cancer surveillance. Several demographic and disease-related factors have been associated with cancer surveillance adherence. Thus far, patient-centered communication has not been studied as a determinant for undergoing cancer surveillance. The purpose of this study is to determine whether patient-clinician information engagement (PCIE) influences patients' self-reported adherence to recommended CRC surveillance procedures. Methods. The study was a longitudinal survey among Pennsylvanian patients diagnosed with CRC in 2005. CRC patients who were eligible for surveillance and participated in both the baseline and 1-year follow-up surveys were included in this analysis (n = 305). The main outcome measure was self-reported adherence to physical examination, carcinoembryonic antigen testing, and colonoscopy according to recommended guidelines. Results. Controlling for potential confounders, higher PCIE at baseline predicted a higher odds for CRC patients reporting adherence to recommended surveillance 1 year later by 2.8 times. Other significant predictors of adhering to recommended surveillance were a higher education level and having received systemic therapy. Discussion. In this longitudinal study among CRC patients who received curative treatment, greater patient engagement with clinicians about cancer-related information was found to improve patients' subsequent adherence to recommended surveillance. This finding provides support for encouraging greater patient-physician communication among CRC patients.