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.

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.

Similarities and Differences in Tobacco Control Research Findings From Convenience and Probability Samples.

BACKGROUND: Online convenience samples are a quick and low-cost way to study health behavior, but the comparability to findings from probability samples is not yet well understood. PURPOSE: We sought to compare convenience and probability samples' findings for experiments, correlates, and prevalence in the context of tobacco control research. METHODS: Participants were a probability sample of 5,014 U.S. adults recruited by phone from September 2014 through May 2015 (cost ~U.S.$620,000) and an online convenience sample of 4,137 U.S. adults recruited through Amazon Mechanical Turk (MTurk) in December 2014 (cost ~U.S.$17,000). Participants completed a survey with experiments, measures of tobacco product use and demographic characteristics. RESULTS: MTurk convenience and probability samples showed the same pattern of statistical significance and direction in almost all experiments (21 of 24 analyses did not differ) and observational studies (19 of 25 associations did not differ). Demographic characteristics of the samples differed substantially (1 of 17 estimates did not differ), with the convenience sample being younger, having more years of education, and including more Whites and Asians. Tobacco product use also differed substantially (1 of 22 prevalence estimates did not differ), with the convenience sample reporting more cigarette and e-cigarette use (median error 19%). CONCLUSIONS: Using MTurk convenience samples can yield generalizable findings for experiments and observational studies. Prevalence estimates from MTurk convenience samples are likely to be over- or underestimates.

Cigarette pack messages about toxic chemicals: a randomised clinical trial.

BACKGROUND: The USA can require tobacco companies to disclose information about harmful and potentially harmful chemicals in cigarette smoke, but the impact of these messages is uncertain. We sought to assess the effect of placing messages about toxic chemicals on smokers' cigarette packs. METHODS: Participants were 719 adult cigarette smokers from California, USA, recruited from September 2016 through March 2017. We randomly assigned smokers to receive either factual messages about chemicals in cigarette smoke and their health harms (intervention) or messages about not littering cigarette butts (control) on the side of their cigarette packs for 3 weeks. The primary trial outcome was intention to quit smoking. RESULTS: In intent-to-treat analyses, smokers whose packs had chemical messages did not have higher intentions to quit smoking at the end of the trial than those whose packs had control messages (P=0.56). Compared with control messages, chemical messages led to higher awareness of the chemicals (28% vs 15%, P<0.001) and health harms (60% vs 52%, P=0.02) featured in the messages. In addition, chemical messages led to greater negative affect, thinking about the chemicals in cigarettes and the harms of smoking, conversations about the messages and forgoing a cigarette (all P<0.05). DISCUSSION: Chemical messages on cigarette packs did not lead to higher intentions to quit among smokers in our trial. However, chemical messages informed smokers of chemicals in cigarettes and harms of smoking, which directly supports their implementation and would be critical to defending the messages against cigarette company legal challenges. TRIAL REGISTRATION NUMBER: NCT02785484.

Identifying principles for effective messages about chemicals in cigarette smoke.

US law requires the Food and Drug Administration (FDA) to disclose information on harmful and potentially harmful chemicals in cigarette smoke (i.e., constituents) to the public. To inform this effort, we sought to identify principles for creating constituent messages that effectively discourage smoking. Participants were an online convenience sample of 1148 US smokers ages 18+. We developed a library of 76 messages about constituents only and constituents plus contextualizing information (i.e., toxic products that also contain the chemical, health effects, or both). We randomized smokers to receive 1 message from each of 7 message panels in a mixed between-/within-subjects experiment. Participants rated each message on perceived message effectiveness. Results indicated that smokers perceived messages about arsenic, formaldehyde, lead, uranium, and ammonia as more effective than messages about nitrosamines. Messages that contained information on toxic products, health effects, or both received higher effectiveness ratings than constituent-only messages. Among constituent-only messages, those that referenced multiple constituents received higher effectiveness ratings than those with fewer constituents. We conclude that chemical messages may have more impact if they pair known constituents with toxic product or health effect information. These message principles can be used to inform studies examining the impact of constituent messages on smoking beliefs and behavior.

Frequency and Content of Conversations About Pictorial Warnings on Cigarette Packs.

Introduction: Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings. Methods: A controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits. Results: Smokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p<.01). The highest number of conversations occurred during the first week. Smokers with pictorial warnings were more likely than those with text-only warnings to discuss the health effects of smoking, whether the warnings would make them want to quit and whether the warnings would make others want to quit (all p < .05). Smokers were more likely to describe pictorial warnings as scary, gross, or depressing and gloomy during conversations than text-only warnings (all p < .05). Conclusions: Pictorial warnings sparked more conversations about the warnings, the health effects of smoking, and quitting smoking than text-only warnings. These social interactions may extend the reach of pictorial warnings beyond the targeted smoker and may be one of the processes by which pictorial warnings have impact. Implications: Health communication can influence behavior by changing social interactions. Our trial characterized social interactions about pictorial cigarette pack warnings with a large longitudinal sample in a real-world setting. Understanding these conversations can inform the United States and other countries as they improve existing warnings and help tobacco control policy makers and health communication theorists understand how social interactions triggered by warnings affect smoking.

Effective Message Elements for Disclosures About Chemicals in Cigarette Smoke.

Introduction: Cigarette smoke contains at least 93 chemicals or "constituents" that the Food and Drug Administration has identified as harmful and potentially harmful constituents to human health. Our study sought to identify which constituent disclosure message elements are most effective in discouraging people from smoking. Methods: Three hundred eighty eight current smokers aged 18 and older completed an online survey in February 2015. We randomized participants to respond to one of two sets of 13 toxic products that contain cigarette constituents and 25 health effects associated with cigarette constituents. Results: Products that elicited the most discouragement were those with lower chances of exposure (e.g., explosives), followed by products with possible exposure (e.g., rat poison), and products with a high likelihood of exposure (e.g., floor cleaner). Awareness of toxic products that constituents are found in (p < .001) and low exposure products (p < .001) were associated with higher discouragement. Health effects that people had heard are caused by cigarette smoke constituents elicited higher discouragement from smoking cigarettes (p < .001). Cancer was associated with higher discouragement relative to respiratory, cardiovascular, and reproductive health effects (all p < .001). Conclusions: Cigarette smoke constituent messages may be more effective at discouraging smoking if they include information about carcinogenic health effects (e.g., mouth cancer and lung tumors) and low exposure toxic products (e.g., explosives and radioactive material) as message elements. Implications: Our study identified health effects and toxic products, especially cancers and rarely encountered toxic products, that may discourage smoking when included in disclosure messages. By constructing messages that communicate the harms associated with tobacco use by contextualizing those harms in terms of specific constituents, tobacco education messaging efforts may be increasingly successful.

How people think about the chemicals in cigarette smoke: a systematic review.

Laws and treaties compel countries to inform the public about harmful chemicals (constituents) in cigarette smoke. To encourage relevant research by behavioral scientists, we provide a primer on cigarette smoke toxicology and summarize research on how the public thinks about cigarette smoke chemicals. We systematically searched PubMed in July 2016 and reviewed citations from included articles. Four central findings emerged across 46 articles that met inclusion criteria. First, people were familiar with very few chemicals in cigarette smoke. Second, people knew little about cigarette additives, assumed harmful chemicals are added during manufacturing, and perceived cigarettes without additives to be less harmful. Third, people wanted more information about constituents. Finally, well-presented chemical information increased knowledge and awareness and may change behavior. This research area is in urgent need of behavioral science. Future research should investigate whether educating the public about these chemicals increases risk perceptions and quitting.

"My First Thought was Croutons": Perceptions of Cigarettes and Cigarette Smoke Constituents Among Adult Smokers and Nonsmokers.

INTRODUCTION: Understanding what people think about harmful and potentially harmful constituents in cigarettes and cigarette smoke has new urgency given legislation requiring US Food and Drug Administration (FDA) to disclose constituent information. Our study sought to obtain qualitative information on what people think about these constituents and the language they use to talk about them. METHODS: We conducted six focus groups in 2014 with 40 adults in North Carolina. Open-ended questions focused on cigarette and cigarette smoke constituents in general and on the 18 constituents on the FDA's abbreviated list. We coded the transcripts for emergent themes, and all four coders discussed themes until we reached consensus. RESULTS: Participants knew that cigarette smoke contains chemicals but did not know how many chemicals nor what those chemicals are, beyond tar and nicotine. Dangers of constituents mentioned included "chemicals," physical disease, and addiction. Participants incorrectly believed harmful constituents came primarily from tobacco companies' additives. For unfamiliar constituents, people tried to make associations based on similar-sounding words. Recognizable constituents that participants associated with health harms most discouraged them from wanting to smoke. Most participants wanted to know health harms associated with constituents and what else the chemicals were in. CONCLUSIONS: Participants showed enthusiasm for learning more information about constituents, and also showed substantial misunderstandings about the source of harmful constituents. Our findings contribute to the limited body of research on adults' knowledge and perceptions of cigarette smoke constituents and can aid the FDA as it plans to disclose constituent information to the public. IMPLICATIONS: Our study provides information about adults' understanding of cigarette smoke constituents and what adults would like to know about these constituents. This information can help communication campaigns describe cigarette smoke constituents in a way that discourages people from wanting to smoke.

Public understanding of cigarette smoke constituents: three US surveys.

INTRODUCTION: The Tobacco Control Act requires public disclosure of information about toxic constituents in cigarette smoke. To inform these efforts, we studied public understanding of cigarette smoke constituents. METHODS: We conducted phone surveys with national probability samples of adolescents (n=1125) and adults (n=5014) and an internet survey with a convenience sample of adults (n=4137), all in the USA. We assessed understanding of cigarette smoke constituents in general and of 24 specific constituents. RESULTS: Respondents commonly and incorrectly believed that harmful chemicals in cigarette smoke mostly originate in additives introduced by cigarette manufacturers (43-72%). Almost all participants had heard that nicotine is in cigarette smoke, and many had also heard about carbon monoxide, ammonia, arsenic and formaldehyde. Less than one-quarter had heard of most other listed constituents being in cigarette smoke. Constituents most likely to discourage respondents from wanting to smoke were ammonia, arsenic, formaldehyde, hydrogen cyanide, lead and uranium. Respondents more often reported being discouraged by constituents that they had heard are in cigarette smoke (all p<0.05). Constituents with names that started with a number or ended in 'ene' or 'ine' were less likely to discourage people from wanting to smoke (all p<0.05). DISCUSSION: Many people were unaware that burning the cigarette is the primary source of toxic constituents in cigarette smoke. Constituents that may most discourage cigarette smoking have familiar names, like arsenic and formaldehyde and do not start with a number or end in ene/ine. Our findings may help campaign designers develop constituent messages that discourage smoking.

Screening anxiety in the HIV clinic.

Individuals with HIV experience fluctuating levels of distress throughout the course of their infection. This cross-sectional study was conducted to examine the prevalence of and associations between anxiety symptoms, sociodemographic, and biomedical markers among individuals presenting for care. A total of 635 individuals were screened, the majority of whom was male and African American. Younger individuals, African Americans, individuals with less education, and those who were unemployed were more likely to express more severe anxiety symptoms. Individuals who were not currently receiving antiretroviral therapy (ART) were 1.61 times more likely to experience higher anxiety symptoms. Among individuals receiving ART, higher levels of anxiety were associated with less adherence, higher viral loads and lower CD4 cell counts. Current smokers were 1.66 times more likely to have higher rates of anxiety. When controlling for these significant factors, younger, unemployed, and less educated individuals were more likely to express more severe anxiety symptoms. These findings highlight the importance of screening and management of anxiety as an integral component of HIV care.

Small media and client reminders for colorectal cancer screening: current use and gap areas in CDC's Colorectal Cancer Control Program.

INTRODUCTION: CDC's Colorectal Cancer Control Program (CRCCP) funds 25 states and 4 tribal organizations to promote and increase colorectal cancer screening population-wide. The CRCCP grantees must use evidence-based strategies from the Guide to Community Preventive Services, including small media and client reminders. METHODS: To assess the existing resources and needs to promote colorectal cancer screening, we conducted 2 web-based surveys of CRCCP grantees and their community partners. Survey 1 sought to identify priority populations, the number and quality of existing colorectal cancer resources for different population subgroups, and the types of small media and client reminder they were most interested in using. Survey 2 assessed screening messages that were used in the past or might be used in the future, needs for non-English-language information, and preferences for screening-related terminology. RESULTS: In survey 1 (n = 125 from 26 CRCCPs), most respondents (83%) indicated they currently had some information resources for promoting screening but were widely dissatisfied with the quality and number of these resources. They reported the greatest need for resources targeting rural populations (62% of respondents), men (53%), and Hispanics (45%). In survey 2 (n = 57 from 25 CRCCPs), respondents indicated they were most likely to promote colorectal cancer screening using messages that emphasized family (95%), role models (85%), or busy lives (83%), and least likely to use messages based on faith (26%), embarrassment (25%), or fear (22%). Nearly all (85%) indicated a need for resources in languages other than English; 16 different languages were mentioned, most commonly Spanish. CONCLUSION: These findings provide the first picture of CRCCP information resources and interests, and point to specific gaps that must be addressed to help increase screening.

The impact of cigarette pack anti-littering messages.

OBJECTIVE: Tobacco butts are the most littered item worldwide and pose a critical environmental and public health hazard. Given the positive impact of required graphic warnings on smoking, we sought to assess the impact of a policy requiring cigarette pack anti-littering messages on smokers' littering intentions. METHODS: We randomly assigned US adult smokers (n = 719) to receive labels on the side of their cigarette packs for three weeks: anti-littering messages or messages about chemicals in cigarette smoke. RESULTS: Anti-littering messages elicited higher intentions to refrain from littering in the next month compared to chemical messages (p < .05). Anti-littering messages also led to increased knowledge about cigarette butts being the most common form of litter, the number of conversations about littering, and thinking about the proper disposal of cigarettes (all p < .05). Finally, smoking from packs labeled with anti-littering messages led to fewer weeks littering from car windows compared to packs labeled with chemical messages (p < .05), but did not affect completely refraining from littering cigarette butts. Mediators of the messages' impact on littering intentions were thinking about proper cigarette butt disposal and perceived message effectiveness (both p < .05). CONCLUSIONS: Policies requiring anti-littering messages on cigarette packs would raise awareness about the problem of cigarette butt litter and bolster intentions to not litter.

How did beliefs and perceptions about e-cigarettes change after national news coverage of the EVALI outbreak?

INTRODUCTION: Exposure to media content can shape public opinions about tobacco. In early September 2019, the outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) became headline news in the United States. METHODS: In August and September 2019, we conducted two cross-sectional online surveys with current and former smokers assessing attitudes and beliefs about e-cigarettes. Study one (n = 865) was collected before the EVALI outbreak was widely covered and study two (n = 344) was collected after the outbreak had become nation-wide news. We examined differences in perceptions and beliefs between time points. RESULTS: E-cigarette harm perceptions increased between study one (mean = 2.67) and study two (mean = 2.90, p < .05). Ever-users of e-cigarettes largely account for this change. Endorsement of the belief that e-cigarettes were risky and more likely to cause lung damage compared to cigarettes increased between studies (p < .05). Seventy eight percent of participants at study two were aware of the vaping illness story. Being aware of the story was associated with more endorsement of the belief that e-cigarettes were risky to use, but not that using e-cigarettes would make the participant more likely to get damaged lungs. DISCUSSION: When the stories about the health and safety of tobacco products dominate the public information environment, it presents an opportunity to change beliefs that are frequently targeted by paid health campaigns. Changes in participant's perceptions of e-cigarettes were associated with coverage of this large news story, underscoring the importance of working to ensure that coverage is a scientifically accurate as possible.

Harm Perceptions and Beliefs about Potential Modified Risk Tobacco Products.

Under US law, tobacco products may be authorized to claim lower exposure to chemicals, or lower risk of health harms. We sought to examine the harm perceptions and beliefs about potential modified risk tobacco products (MRTPs). We recruited 864 adult current and former smokers in August 2019. Participants read a paragraph describing the potential for the FDA to authorize MRTPs and a brief description of MRTPs. The most endorsed beliefs for each product were that they contained nicotine and that they were risky. Believing that e-cigarettes can help smokers quit smoking, that they tasted good, and looked cool were associated with greater odds of intending to try e-cigarettes after controlling for demographic and use factors. For snus, the beliefs that the product was not addictive and tasted good were associated with increased odds of intending to try snus. The beliefs that heated tobacco would taste good and would be a good quit aid was associated with increased odds of intentions to try heated tobacco products. Understanding what the public believes about products currently or potentially authorized to be marketed as modified risk tobacco products can inform communication efforts.

Limiting and Promoting Resident Self-Care in Assisted Living.

OBJECTIVES: Assisted living (AL) residents often manage multiple chronic conditions, functional and/or cognitive decline along with their individual needs and preferences for a full life. Although residents participate in their own care, little is known about their self-care activities and how to support them. This analysis focuses on residents' self-care and theorizing the dynamic, socially embedded process of negotiating self-care. METHODS: We analyze data from a grounded theory study informed by the Convoys of Care model. Participants included 50 focal residents and 169 paid and unpaid convoy members in eight AL homes; each resident convoy was followed up for 2 years. Data collection included participant observation, interviews, and resident record review. RESULTS: To the extent possible, most AL residents were involved in self-care related to activities of daily living, health promotion, and social, emotional, and mental well-being. Residents and care partners engaged in a dynamic process of limiting and promoting self-care activities. Multiple factors influenced self-care, including residents' past self-care behaviors, caregiver fear and availability, and the availability of services and supports. DISCUSSION: Strategies for promoting self-care must involve residents and care partners and include convoy education in collaborative goal-setting, prioritizing care that supports the goals, and putting resources in place to support goal achievement.

Disparities by race and ethnicity in cancer survivor stories available on the web.

BACKGROUND: The rapid growth of eHealth could have the unintended effect of deepening health disparities between population subgroups. Most concerns to date have focused on population differences in access to technology, but differences may also exist in the appropriateness of online health content for diverse populations. OBJECTIVE: This paper reports findings from the first descriptive study of online cancer survivor stories by race and ethnicity of the survivor. METHODS: Using the five highest-rated Internet search engines and a set of search terms that a layperson would use to find cancer survivor stories online, we identified 3738 distinct sites. Of these, 106 met study criteria and contained 7995 total stories, including 1670 with an accompanying photo or video image of the survivor. Characteristics of both websites and survivor stories were coded. RESULTS: All racial minority groups combined accounted for 9.8% of online cancer survivor stories, despite making up at least 16.3% of prevalent cancer cases. Also notably underrepresented were stories from people of Hispanic ethnicity (4.1%), men (35.7%), survivors of colon cancer (3.5%), and older adults. CONCLUSIONS: Because racial/ethnic minority cancer survivors are underrepresented in survivor stories available online, it is unlikely that this eHealth resource in its current form will help eliminate the disproportionate burden of cancer experienced by these groups.

Increasing Effectiveness of Messages about Chemicals in Cigarette Smoke.

OBJECTIVES: Federal law requires informing the public on toxic chemicals in cigarette smoke. We sought the public's advice about communicating information about these chemicals. METHODS: Adolescents, young adults, and adults (N = 59), including smokers and non-smokers, participated in 9 focus groups that discussed inclusion of messages about toxic chemicals on cigarette packs, in media campaigns, and on a website. We transcribed, coded, and analyzed focus group audio-recordings. RESULTS: Participants had 3 suggestions for message content to increase the impact of messages about cigarette smoke chemicals. First, they wanted to see messages rotated more frequently to increase message novelty. Second, they recommended using stories and pictures to help connect people to the abstract idea of chemicals in smoke. Third, they cautioned against making messages that might seem overblown and could appeal to the rebellious nature of adolescents. Some participants mentioned that chemical information on a website might discourage people from smoking; others mentioned that people might use it to choose which brand to smoke. CONCLUSIONS: Legislation provides the impetus to design new chemical disclosure messages for cigarette packs and other media. Our findings can help increase the impact of these messages.

Conversations about pictorial cigarette pack warnings: Theoretical mechanisms of influence.

BACKGROUND: Social interactions are a key mechanism through which health communication campaigns influence behavior. Little research has examined how conversations about pictorial warnings motivate behavior. PURPOSE: We sought to establish whether and how smokers' conversations explain the effect of pictorial warnings on quit attempts. METHODS: US adult smokers (n = 2149) participated in a controlled trial that randomly assigned them to have their cigarette packs labeled with pictorial or text-only warnings for four weeks. Surveys assessed the number of conversations sparked by pictorial warnings and the theoretical mechanisms cognitive elaboration and social norms at each visit. Analyses used structural equation modeling to test our theorized mediation models. RESULTS: The number of conversations about the warnings mediated the relationship between exposure to pictorial warnings and quit attempts (p < .001). In serial mediation analysis examining possible theoretical mechanisms, the number of conversations was associated with greater cognitive elaboration, which in turn was associated with being more likely to make a quit attempt (p < .05). Social norms did not explain the influence of conversations on quit attempts. CONCLUSIONS: Pictorial warnings increased conversations about the warnings, which led to greater cognitive elaboration, which led to greater quit attempts. Our findings suggest designing warnings that increase conversations in order to better inform and motivate smokers. Furthermore, these findings improve our understanding of why conversations matter in health communication.