Understanding Young Adult Cancer Survivors' Engagement with Cancer Storylines in Entertainment Media Narratives

Purpose: Some young adult cancer survivors (YACS; ages 18-39) struggle to incorporate their cancer experiences into their identities. Using stories, or narratives, is a new approach that could help YACS to integrate cancer and their identity. These stories offer opportunities to experience perspectives outside of oneself, which can build validation and self-compassion. However, little is known about whether stories about cancer (i.e., the threat itself) are beneficial. Method: YACS completed an online survey about their engagement with cancer storylines in entertainment media narratives (e.g., books, movies, and television shows). They also described their reactions to encountering these storylines in entertainment media. Results: Participants (n = 108) were primarily White. Participants who sought cancer storylines reported a more positive impact of cancer on their sense of purpose and identity. Among YACS who had completed treatment, cancer storylines were sought after treatment more than during treatment. In addition, compared with their peers, participants who identified as Black reported greater cancer storyline seeking both during and after treatment. Nearly half of participants (n = 45, 47.4%) described reactions to cancer-related storylines as positive or mixed, primarily owing to feelings of inspiration or validation. Conclusion: Consuming cancer storylines can offer some benefits for YACS, especially among those finished with treatment and those who identify as Black. However, not all YACS responded positively, so future research should investigate which YACS could benefit most from cancer-related storylines. Nonetheless, entertainment media narratives represent a novel approach to supporting YACS' integration of cancer into their identity.

Decisional Conflict Among Patients Newly Diagnosed With Clinical T1 Renal Masses: A Prospective Study

PURPOSE

Because multiple management options exist for clinical T1 renal masses, patients may experience a state of uncertainty about the course of action to pursue (ie, decisional conflict). To better support patients, we examined patient, clinical, and decision-making factors associated with decisional conflict among patients newly diagnosed with clinical T1 renal masses suspicious for kidney cancer.

MATERIALS AND METHODS

From a prospective clinical trial, participants completed the Decisional Conflict Scale (DCS), scored 0 to 100 with < 25 associated with implementing decisions, at 2 time points during the initial decision-making period. The trial further characterized patient demographics, health status, tumor burden, and patient-centered communication, while a subcohort completed additional questionnaires on decision-making. Associations of patient, clinical, and decision-making factors with DCS scores were evaluated using generalized estimating equations to account for repeated measures per patient.

RESULTS

Of 274 enrollees, 250 completed a DCS survey; 74% had masses ≤ 4 cm in size, while 11% had high-complexity tumors. Model-based estimated mean DCS score across both time points was 17.6 (95% CI 16.0-19.3), though 50% reported a DCS score ≥ 25 at least once. On multivariable analysis, DCS scores increased with age (+2.64, 95% CI 1.04-4.23), high- vs low-complexity tumors (+6.50, 95% CI 0.35-12.65), and cystic vs solid masses (+9.78, 95% CI 5.27-14.28). Among decision-making factors, DCS scores decreased with higher self-efficacy (-3.31, 95% CI -5.77 to -0.86]) and information-seeking behavior (-4.44, 95% CI -7.32 to -1.56). DCS scores decreased with higher patient-centered communication scores (-8.89, 95% CI -11.85 to -5.94).

CONCLUSIONS

In addition to patient and clinical factors, decision-making factors and patient-centered communication relate with decisional conflict, highlighting potential avenues to better support patient decision-making for clinical T1 renal masses.

Reel reflections: the role of entertainment media narratives in coping among young adult cancer survivors

INTRODUCTION

Young adult cancer survivors (YACS; ages 18-39) report a significant psychological burden. Entertainment media narratives (e.g., books, movies, shows that are produced for mass consumption) might be an effective tool for reducing this distress, although little is known about present use among YACS.

METHOD

YACS completed a survey about their use of entertainment media narratives to cope with cancer using an adapted version of the Brief COPE. Additionally, YACS reported their use of entertainment media narratives to start conversations about their experience with others, and they described features of entertainment media narratives that they found helpful in coping.

RESULTS

We recruited 108 YACS from three recruitment sites. Most participants were White (n = 65), female (n = 54), and recruited from Prolific (n = 56), an Internet-based, crowdsourced data collection platform. Participants were, on average, 30 years old and 45 months from the completion of their primary cancer treatment. YACS who used entertainment media to cope with cancer (n = 32; 29.6%) were significantly younger and significantly closer to the end of their primary treatment. Compared to nonusers, users of entertainment media narratives to cope were also more likely to identify as Black; identifying as Black was associated with a 2.05-factor increase in using narrative entertainment media to cope with cancer even when controlling for other demographic differences. Additionally, compared to their peers, Black YACS reported greater use of narratives to start cancer-related conversations. Emotional and inspirational storylines were the most helpful story features.

DISCUSSION

Some YACS, especially Black YACS, use stories to cope with their cancer experience. YACS patients could find stories useful in exploring their cancer-related emotions, although the exact benefits are still unknown.

Effects of Modified Risk Tobacco Product Claims on Consumer Responses

INTRODUCTION

US tobacco manufacturers can seek authorization from the US Food and Drug Administration (FDA) to market products using modified risk tobacco product (MRTP) claims. To inform regulatory decisions, we examined the impact of MRTP claim specificity and content, including whether the claims produced halo effects (ie, inferring health benefits beyond what is stated).

AIMS AND METHODS

Participants were 3161 US adult cigarette smokers. Using a two (general vs. specific) × 2 (risk vs. exposure) plus independent control design, we randomized participants to view one message from these conditions: general risk claim (eg, "smoking-related diseases"), general exposure claim (eg, "chemicals in smoke"), specific risk claim (eg, "lung cancer"), specific exposure claim (eg, "arsenic"), or control. Claims described the benefits of completely switching from cigarettes to the heated tobacco product IQOS.

RESULTS

MRTP claims of any sort elicited a higher willingness to try IQOS relative to control (d = 0.09, p = .043). Claims also elicited lower perceived risk of disease and exposure to harmful chemicals for completely switching from cigarettes to IQOS (d = -0.32 and -0.31) and partially switching (d = -0.25 and d = -0.26; all p < .05). Relative to specific MRTP claims, general MRTP claims led to lower perceived risk and exposure for complete switching (d = -0.13 and d = -0.16) and partial switching (d = -0.14 and d = -0.12; all p < .05). Risk and exposure MRTP claims had similar effects (all p > .05).

DISCUSSION

MRTP claims led to lower perceived risk and exposure, and higher willingness to try IQOS. General claims elicited larger effects than specific claims. MRTP claims also promoted unintended halo effects (eg, lower perceived risk of disease and chemical exposure for partial switching).

IMPLICATIONS

We found evidence that MRTP claims promoted health halo effects. In light of these findings, the FDA should require research on halo effects prior to authorization. Further, if an MRTP claim is authorized, FDA should require tobacco manufacturers to conduct post-market surveillance of how the claim affects consumer understanding, including partial switching perceived risk and exposure beliefs, as well as monitoring of dual-use behaviors.

Recognize & Resist: An Online Health Intervention to Promote Writing About Sexual Consent and Egalitarian Gender Roles Among One Direction Fanfiction Writers

This paper focuses on the development and feasibility of a digitally-based educational intervention, titled Recognize & Resist (R&R), for writers of One Direction (1D) fanfiction on Wattpad.com. The goal of R&R is to reduce the prevalence of social norms that are supportive of sexual violence within 1D fanfiction. 1D fanfictions, or fictional romance stories written by fans of this British boy band, have hundreds of millions of views on Wattpad.com. Formative research has found that social norms supportive of sexual violence are prevalent in 1D fanfictions and that some authors have internalized these norms. R&R aims to motivate 1D fanfiction writers to highlight sexual consent and egalitarian gender roles in their writing. To evaluate the intervention's feasibility, 15 1D fanfiction authors completed a survey and participated in an interview or focus group. Results demonstrate R&R's feasibility, with high ratings of its acceptability and demand. Insights from the interviews and focus groups provide suggestions for revising R&R before rigorously evaluating its efficacy. Additionally, results demonstrate the utility of using popular culture as a vehicle for attitude-change regarding sensitive health issues.

'It's Nothing Like Cancer': Young Adults with Cancer Reflect on Memorable Entertainment Narratives

A cancer diagnosis in young adulthood disrupts the achievement of developmental milestones, and young adults struggle to make sense of their cancer experience due to a lack of opportunities to both openly talk about cancer and engage in reflective activities. However, entertainment narratives - or stories - may be an alternative to prompt these activities, as narratives can elicit self-expansion that may help fulfill intrinsic needs. One way to think about these narratives is as memorable messages. These messages stick with a person for a long period of time, have an anticipatory socialization effect, and may prompt the sense-making process through narrative communication. Little is known, though, about the use of entertainment narratives among young adults with cancer. We interviewed 25 young adults with cancer about entertainment narratives that were memorable during their cancer experience and how those narratives affected them. From these in-depth, semi-structured interviews, we found that entertainment narratives were generally helpful if they provided distraction from cancer, were relatable, and/or prompted participants to explore their emotions. We found that entertainment narratives were generally harmful if they worsened participants' emotional state, either by exacerbating fears of death and/or depicting cancer unrealistically. Our findings suggest that entertainment narratives are memorable messages, and that helpful messages increased feelings of competence and validation, which could promote psychological adaptation to the disease. Harmful messages increased fear and invalidated participants' difficult experiences, which could lead to greater illness centrality and internalized stigma. Implications for future research are discussed.

Toddler milk: a scoping review of research on consumption, perceptions, and marketing practices

Toddler milk is an ultra-processed beverage consisting primarily of powdered milk, caloric sweeteners, and vegetable oil. Pediatric health authorities do not support the use of toddler milk, and emerging evidence suggests that toddler-milk marketing practices may mislead consumers. However, studies have not synthesized the extent of toddler-milk marketing practices or how these practices affect parents' decisions about whether to serve toddler milk. We aimed to summarize the literature about toddler milk to identify what is known about: (1) parents' toddler-milk purchasing and feeding behaviors, (2) toddler-milk marketing, and (3) how marketing practices influence parents' beliefs and perceptions about toddler milk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we systematically searched 8 databases (PubMed, APA PsycINFO, Scopus, Cochrane Central, Embase, CINAHL, Communication & Mass Media Complete, and Business Source Premier). We identified 45 articles about toddler milk. Studies were conducted in 25 countries across 6 continents. Five types of findings emerged: (1) consumption and feeding behaviors, (2) demographic correlates of toddler-milk purchasing and consumption, (3) misperceptions and beliefs, (4) increased sales, and (5) increased marketing and responses to marketing. The included articles suggested that toddler-milk sales are growing rapidly worldwide. Findings also revealed that toddler-milk packages (eg, labels, branding) resemble infant formula packages and that toddler-milk marketing practices may indirectly advertise infant formula. Purchasing, serving, and consumption of toddler milk were higher in Black and Hispanic populations than in non-Hispanic White populations, and parents with higher educational attainment and income were more likely to offer toddler milk to their children. Findings suggest a need for policies to prevent cross-marketing of toddler milk and infant formula, reduce provision of toddler milk to infants and toddlers, and prevent caregivers from being misled about toddler-milk healthfulness.

Health Care Access Barriers and Self-Reported Health Among Adolescent and Young Adult Cancer Survivors

Purpose: Adolescents and young adult (AYA) cancer survivors (15-39 years at diagnosis) are at risk for treatment-related late effects but face barriers in accessing survivorship care. We examined the prevalence of five health care access (HCA) barriers: affordability, accessibility, availability, accommodation, and acceptability. Methods: We identified AYA survivors from the University of North Carolina (UNC) Cancer Survivorship Cohort who completed a baseline questionnaire in 2010-2016. Participants had a history of cancer, were ≥18 years of age, and receiving care at a UNC oncology clinic. The sample was restricted to AYA survivors who were interviewed ≥1 year postdiagnosis. We used modified Poisson regression to estimate prevalence ratios (PRs) for the association between HCA barriers and self-reported fair or poor health, adjusted for sociodemographic and cancer characteristics. Results: The sample included 146 AYA survivors who were a median age of 39 at the time of the survey. The majority (71%)-and 92% of non-Hispanic Black survivors-reported at least one HCA barrier, including acceptability (40%), accommodation (38%), or affordability (31%). More than one-quarter of survivors (28%) reported fair or poor health. Affordability barriers (PR: 1.89, 95% confidence interval [CI]: 1.13-3.18) and acceptability barriers (PR: 1.60, 95% CI: 0.96-2.66) were associated with a higher prevalence of fair/poor health, as were the cumulative effects of multiple HCA dimensions reported as barriers. Conclusions: Barriers across multiple HCA dimensions were prevalent and associated with worse health in AYA survivors. Findings highlight the need to better understand and target specific barriers to care for diverse AYA survivors to improve their long-term health.

The Use of Social Media to Express and Manage Medical Uncertainty in Dyskeratosis Congenita: Content Analysis

BACKGROUND

Social media has the potential to provide social support for rare disease communities; however, little is known about the use of social media for the expression of medical uncertainty, a common feature of rare diseases.

OBJECTIVE

This study aims to evaluate the expression of medical uncertainty on social media in the context of dyskeratosis congenita, a rare cancer-prone inherited bone marrow failure and telomere biology disorder (TBD).

METHODS

We performed a content analysis of uncertainty-related posts on Facebook and Twitter managed by Team Telomere, a patient advocacy group for this rare disease. We assessed the frequency of uncertainty-related posts, uncertainty sources, issues, and management and associations between uncertainty and social support.

RESULTS

Across all TBD social media platforms, 45.98% (1269/2760) of posts were uncertainty related. Uncertainty-related posts authored by Team Telomere on Twitter focused on scientific (306/434, 70.5%) or personal (230/434, 53%) issues and reflected uncertainty arising from probability, ambiguity, or complexity. Uncertainty-related posts in conversations among patients and caregivers in the Facebook community group focused on scientific (429/511, 84%), personal (157/511, 30.7%), and practical (114/511, 22.3%) issues, many of which were related to prognostic unknowns. Both platforms suggested uncertainty management strategies that focused on information sharing and community building. Posts reflecting response-focused uncertainty management strategies (eg, emotional regulation) were more frequent on Twitter compared with the Facebook community group (χ21=3.9; P=.05), whereas posts reflecting uncertainty-focused management strategies (eg, ordering information) were more frequent in the Facebook community group compared with Twitter (χ21=55.1; P<.001). In the Facebook community group, only 36% (184/511) of members created posts during the study period, and those who created posts did so with a low frequency (median 3, IQR 1-7 posts). Analysis of post creator characteristics suggested that most users of TBD social media are White, female, and parents of patients with dyskeratosis congenita.

CONCLUSIONS

Although uncertainty is a pervasive and multifactorial issue in TBDs, our findings suggest that the discussion of medical uncertainty on TBD social media is largely limited to brief exchanges about scientific, personal, or practical issues rather than ongoing supportive conversation. The nature of uncertainty-related conversations also varied by user group: patients and caregivers used social media primarily to discuss scientific uncertainties (eg, regarding prognosis), form social connections, or exchange advice on accessing and organizing medical care, whereas Team Telomere used social media to express scientific and personal issues of uncertainty and to address the emotional impact of uncertainty. The higher involvement of female parents on TBD social media suggests a potentially greater burden of uncertainty management among mothers compared with other groups. Further research is needed to understand the dynamics of social media engagement to manage medical uncertainty in the TBD community.

Terms tobacco users employ to describe e-cigarette aerosol

BACKGROUND

The scientific term for the substance people inhale and exhale from a vaping device is 'aerosol', but whether the public uses this term is unclear. To inform tobacco control communication efforts, we sought to understand what tobacco users call e-cigarette aerosols.

METHODS

Participants were a national convenience sample of 1628 US adults who used e-cigarettes, cigarettes or both (dual users). In an online survey, conducted in spring 2021, participants described what 'people inhale and exhale when they vape', using an open-ended and then a closed-ended response scale. Participants then evaluated warning statements, randomly assigned to contain the term 'aerosol' or 'vapor' (eg, 'E-cigarette aerosol/vapor contains nicotine, which can lead to seizures').

RESULTS

In open-ended responses, tobacco users most commonly provided the terms 'vapor' (31%) and 'smoke' (23%) but rarely 'aerosol' (<1%). In closed-ended responses, the most commonly endorsed terms were again 'vapor' (57%) and 'smoke' (22%) but again infrequently 'aerosol' (2%). In closed-ended responses, use of the term 'vapor' was more common than other terms among people who were older; white; gay, lesbian or bisexual; college educated; or vape users only (all p<0.05). In the experiment, warnings using the terms 'aerosol' and 'vapor' were equally effective (all p>0.05).

CONCLUSIONS

The public rarely uses the term 'aerosol' to describe e-cigarette output, potentially complicating educational efforts that use the term. Future studies should explore public knowledge and understanding of the terms 'aerosol' and the more popular 'vapor' to better inform vaping risk communication.

TikToks Lead to Higher Knowledge and Perceived Severity of Sexual Violence among Adolescent Men

Social media communication is a promising way to deliver important health messages about sexual violence to a key population of adolescent men. The researchers conducted an online, between-participants experiment to examine the impact of personal narrative TikToks about sexual violence on adolescent men. Participants were adolescent men (n = 580) aged 15 to 19 (M = 17.3, SD = 1.43). Participants were randomly assigned to treatment (personal narrative TikToks about sexual violence) or control (hair braiding TikTok tutorials) conditions. Adolescent men who viewed personal narrative TikToks about sexual violence had higher knowledge of consequences and higher perceived severity of sexual violence. Additionally, adolescent men found personal narrative TikToks more attention-grabbing (vs. control) and did not have negative reactions. Findings that short (approximately one-minute) TikTok videos led to differences in knowledge and beliefs among, and were interesting and not aversive to, adolescent men are important for sexual violence prevention research. Health messages on TikTok can help shift adolescent perceptions of sexual violence, which is a key starting point towards changing norms.

The Development and Testing of a Point-of-Sale E-Cigarette Health Communication Campaign

Adolescents and young adults continue to use e-cigarettes, and communication campaigns are needed to decrease use among these populations. We developed and tested a point-of-sale communication campaign focused on e-cigarette chemical exposure. We developed messages based on formative research and tested them (versus text-only messages) in a nationally-representative online survey among adolescents and young adults (16-25) (Phase 1). Based on survey findings, we selected a message focused on nicotine and brain development for the point-of-sale trial (Phase 2). We then conducted a cluster-randomized trial at six gas stations with convenience stores, randomly assigned to the intervention (messages displayed) or no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 participants (ages 16-25) per store, at baseline and a four-week follow-up. Phase 1 included 1,636 participants in the online study. Intervention messages were rated as more attention grabbing than plain text messages (p < .05), though were rated similarly on other outcomes. Exposure to intervention messages resulted in larger changes from pre- to posttest for beliefs about addiction and relative harms versus cigarettes (p < .05). Phase 2 included 586 participants in the point-of-sale study. Real-world campaign exposure was low (31.8%), and no differences were found between conditions. E-cigarette prevention messages focused on nicotine's impact on brain development show promise. However, garnering attention for communication campaigns in saturated point-of-sale environments, often dominated by tobacco advertising, is challenging. Future efforts should utilize additional communication channels to directly target adolescents and young adults.

Natural Claims on Sugary Fruit Drinks: A Randomized Experiment With U.S. Parents

INTRODUCTION

Natural claims on food are largely unregulated in the U.S. This study examined the effects of natural claims on a fruit-flavored drink with added sugar (i.e., fruit drink).

METHODS

In 2019, U.S. parents of children aged 2-12 years (N=1,078) recruited from an online survey panel were randomized to one of three arms: natural claim on a fruit drink, 100% all-natural claim, or a no-claim control. Parents reported their intentions and perceptions regarding fruit drinks using 1-5 response scales. Analysis occurred in 2022-2023.

RESULTS

Both natural claims led parents to have higher intentions to purchase a fruit drink for their child than the control (average differential effect=0.20-0.24, both p<0.05). The natural claim (but not the 100% all-natural claim) also led parents to think that the fruit drink was healthier for their children (average differential effect=0.22, p=0.024). Claims made parents less likely to think that the drink contained added sugar (average differential effect= -0.08 to -0.12, both p<0.05) and led to lower estimated amounts of added sugar in teaspoons (average differential effect= -1.77 to -2.09, both p<0.05). Mediation analyses revealed that the claims led to higher intentions to purchase the fruit drink by increasing perceived healthfulness of the fruit drink and by leading parents to believe that there was no added sugar in the fruit drink.

CONCLUSIONS

Natural claims could increase interest in and perceived healthfulness of fruit drinks. Misperceptions about the nutritional content caused by claims appear to be driving greater purchase intentions. These findings suggest a need for stronger regulation around natural claims to prevent consumer misunderstanding.

Social Media Use for Cancer Support Among Young Adults with Cancer

Purpose: Social media can facilitate peer support among young adults with cancer; however, information is needed about what social media are used, by whom, and how to inform resource and intervention recommendations. Methods: In December 2021, we conducted an online survey with 396 young adults with cancer, ages 18-39, with any diagnosis ages 15-39. Participants reported their social media use to connect with other young adults with cancer, including frequency of use, type of support, and affect (positive to negative) when using to connect with cancer peers. Results: Participants were on average 31 years old (SD = 5.2), with an average age of 27 at diagnosis (63.4% male, 62.1% non-Hispanic White). Almost all (97.5%) reported using social media to connect with other young adults with cancer. Many (48.0%) used three or more social media platforms for cancer support, including Facebook (44.4%), YouTube (43.6%), Instagram (43.4%), Snapchat (36.9%), and Twitter (36.9%). Daily use for cancer support was common (32.9%-60.9%) among those who used social media, particularly among those who were younger; are not transgender; live in urban areas; or had brain, gynecologic, or testicular cancers. Across social media platforms, young adults with cancer reported seeking and sharing emotional support (88.9%), informational support (84.1%), and making connections (81.3%). Conclusion: Young adults with cancer use social media to connect with cancer peers for support. Commonly used existing social media (e.g., Facebook, YouTube, Instagram) should be prioritized in interventions to reach young adults who desire more age-appropriate resources to improve their psychosocial health.

Perceived message effectiveness of cigar warning themes among adults in the United States

Most tobacco warnings focus on health harms to the consumer, but other message themes may be promising. We assessed perceived message effectiveness (PME) among adults who smoke cigars for 12 cigar warning statements to discourage smoking, and measured PME across four message themes: explicit health effects to the consumer, secondhand smoke effects, chemicals/constituents, and toxicity. Between April 23 and May 7, 2020, we conducted an online study with U.S. adults who used any cigar type in the past 30 days (n = 777). Participants were randomly assigned to view two out of 12 warnings and rate each one on PME. We analyzed PME mean ratings (range 1 [low] to 5 [high]). The warning statements for lung cancer (M = 3.91) and heart disease (M = 3.77) had the highest PME ratings; secondhand smoke (M = 3.50) and formaldehyde (M = 3.48) had the lowest PME ratings. Multilevel analyses showed that the explicit health effects theme was associated with higher PME ratings compared to other warning themes (ps < 0.05 for chemicals/constituents and secondhand smoke effects) except toxicity (p =.16). Higher awareness of consequences was associated with higher PME ratings (p <.001). Higher nicotine dependence was also associated with higher PME ratings (p = .004). Warning statements with information addressing the themes of health harms and toxicity could potentially inform those who smoke cigars about the broader harms of cigar use and should be considered in FDA labeling regulations for cigars.

Exposure and Reactions to Cancer Treatment Misinformation and Advice: Survey Study

BACKGROUND

Cancer treatment misinformation, or false claims about alternative cures, often spreads faster and farther than true information on social media. Cancer treatment misinformation can harm the psychosocial and physical health of individuals with cancer and their cancer care networks by causing distress and encouraging people to abandon support, potentially leading to deviations from evidence-based care. There is a pressing need to understand how cancer treatment misinformation is shared and uncover ways to reduce misinformation.

OBJECTIVE

We aimed to better understand exposure and reactions to cancer treatment misinformation, including the willingness of study participants to prosocially intervene and their intentions to share Instagram posts with cancer treatment misinformation.

METHODS

We conducted a survey on cancer treatment misinformation among US adults in December 2021. Participants reported their exposure and reactions to cancer treatment misinformation generally (saw or heard, source, type of advice, and curiosity) and specifically on social media (platform, believability). Participants were then randomly assigned to view 1 of 3 cancer treatment misinformation posts or an information post and asked to report their willingness to prosocially intervene and their intentions to share.

RESULTS

Among US adult participants (N=603; mean age 46, SD 18.83 years), including those with cancer and cancer caregivers, almost 1 in 4 (142/603, 23.5%) received advice about alternative ways to treat or cure cancer. Advice was primarily shared through family (39.4%) and friends (37.3%) for digestive (30.3%) and natural (14.1%) alternative cancer treatments, which generated curiosity among most recipients (106/142, 74.6%). More than half of participants (337/603, 55.9%) saw any cancer treatment misinformation on social media, with significantly higher exposure for those with cancer (53/109, 70.6%) than for those without cancer (89/494, 52.6%; P<.001). Participants saw cancer misinformation on Facebook (39.8%), YouTube (27%), Instagram (22.1%), and TikTok (14.1%), among other platforms. Participants (429/603, 71.1%) thought cancer treatment misinformation was true, at least sometimes, on social media. More than half (357/603, 59.2%) were likely to share any cancer misinformation posts shown. Many participants (412/603, 68.3%) were willing to prosocially intervene for any cancer misinformation posts, including flagging the cancer treatment misinformation posts as false (49.7%-51.4%) or reporting them to the platform (48.1%-51.4%). Among the participants, individuals with cancer and those who identified as Black or Hispanic reported greater willingness to intervene to reduce cancer misinformation but also higher intentions to share misinformation.

CONCLUSIONS

Cancer treatment misinformation reaches US adults through social media, including on widely used platforms for support. Many believe that social media posts about alternative cancer treatment are true at least some of the time. The willingness of US adults, including those with cancer and members of susceptible populations, to prosocially intervene could initiate the necessary community action to reduce cancer treatment misinformation if coupled with strategies to help individuals discern false claims.

How pictorial warnings change parents' purchases of sugar-sweetened beverage for their children: mechanisms of impact

BACKGROUND

Pictorial health warnings on sugar-sweetened beverages (SSBs) are a promising policy for preventing diet-related disease in children. A recent study found that pictorial warnings reduced parents' purchases of SSBs for their children by 17%. However, the psychological mechanisms through which warnings affect parental behavior remain unknown. We aimed to identify the mechanisms that explain how pictorial warnings affect parents' SSB purchasing behavior for their children using secondary data from a randomized trial.

METHODS

In 2020-2021, parents of children ages 2 to 12 years (n = 325) completed a shopping task in a convenience store laboratory in North Carolina, USA. Participants were randomly assigned to a pictorial warnings arm (SSBs displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (SSBs displayed a barcode label). Parents then bought a beverage for their child and took a survey measuring 11 potential psychological mediators, selected based on health behavior theories and a model explaining the impact of tobacco warnings. We conducted simple mediation analyses to identify which of the 11 mechanisms mediated the impact of exposure to pictorial warnings on purchasing any SSBs for their children.

RESULTS

Two of the 11 constructs were statistically significant mediators. First, the impact of pictorial warnings on the likelihood of purchasing any SSB was mediated by parents' perceptions that SSBs were healthier for their child (mediated effect= -0.17; 95% CI = - 0.33, - 0.05). Second, parents' intentions to serve SSBs to their children also mediated the effect of warnings on likelihood of purchasing any SSB (mediated effect= -0.07, 95% CI=-0.21, - 0.003).

CONCLUSIONS

Pictorial warnings reduced parents' purchases of SSBs for their children by making parents think SSBs are less healthful for their children and reducing their intentions to serve SSBs to their children. Communication approaches that target healthfulness perceptions and intentions to serve SSBs may motivate parents to buy fewer SSBs for their children.

Optimising messages and images for e-cigarette warnings

BACKGROUND

The US Food and Drug Administration (FDA) requires electronic cigarettes (e-cigarettes) to have a single addiction warning, but many other health harms are associated with vaping and warnings grow stale over time. We aimed to develop new warning messages and images to discourage e-cigarette use.

METHODS

Participants were 1629 US adults who vaped or smoked. We randomised each participant to evaluate 7 of 28 messages on newly developed warning themes (metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, addiction), and the current FDA-required warning (total of 8 messages). Then, participants evaluated images of hazards (eg, metal), internal harms (eg, organ damage) or people experiencing harms.

RESULTS

Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<0.001), led to greater negative affect (all p<0.001) and led to more anticipated social interactions (all p<0.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<0.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<0.001), although unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<0.001).

DISCUSSION

Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. Images of internal harm or people experiencing harms may be particularly effective at discouraging vaping.

Point-of-Sale Health Communication Campaigns for Cigarillos and Waterpipe Tobacco: Effects and Lessons Learned from Two Cluster Randomized Trials

Many adolescents and young adults hold erroneous beliefs that cigarillos and waterpipe tobacco (WT) are safer than cigarettes, contributing to use. Communication campaigns can correct misperceptions and increase risk beliefs. We tested point-of-sale (POS) communication campaigns focused on chemical exposure for cigarillos and WT. We conducted two cluster randomized trials at 20 gas stations with convenience stores (10 stores for cigarillos, 10 for WT) in North Carolina between June and November 2017. Within each trial, stores were randomly assigned to either the intervention (campaign messages displayed) or a no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 adolescents and young adults (ages 16-25) per store, at baseline and follow-up. There were 978 participants (mean age = 20.9 years) in the cigarillo trial, and 998 participants (mean age = 21.0 years) in the WT trial. Rates of campaign exposure were low (26% for cigarillos; 24.3% for WT). The cigarillo campaign increased knowledge that ammonia is in cigarillo smoke (p < .01). There were also significant increases in knowledge about ammonia and cyanide in cigarillo smoke and arsenic in WT smoke (p < .05) in the sub-sample who reported exposure to the campaign. No differences were found in outcome expectancies, product attitudes, worry about chemical exposure, or behavioral intentions in either campaign. Garnering attention for communication campaigns in saturated POS environments, often dominated by tobacco advertising, is challenging. Our study demonstrates the feasibility of anti-tobacco campaigns at the POS and points to several lessons learned for future POS campaigns.

What Cigarillo Companies are Putting on Instagram: A Content Analysis of Swisher Sweets' Marketing from 2013 to 2020

INTRODUCTION

Tobacco marketing includes text and visual content, which conveys important meaning to consumers and influences use. Little is known about the marketing tactics used by a popular brand of cigarillos on social media to promote their products, including their visual design.

METHODS

A content analysis was conducted to analyze text and visuals for all posts on Swisher Sweets' official Instagram account from Jan 23, 2013 to Feb 28, 2020. We assessed product depictions (e.g. warnings, smoking cues), presence of FDA-prohibited or potentially misleading claims (e.g. lower risk, organic), marketing tactics (e.g. celebrities, selling propositions), flavors, and demographic representation.

RESULTS

We coded 1402 posts. Smoking cues (e.g. images of people smoking, product imagery) were in 764 posts (54.5%), and a warning appeared in 690 (49.2%) posts, but obscured in 29.4% of those instances (n = 203). No posts included FDA-prohibited claims, but some potentially misleading language was identified, including the use of words or visual depictions of smooth (n = 254, 18.1%) and quality/well-made (n = 239, 17%). Marketing tactics such as scarcity (n = 159, 11.3%), event promotion (n = 586, 41.8%), and alcohol depictions (n = 171, 12.2%) were common, and flavor names appeared in 598 posts (42.7%). People depicted were often young adults (n = 709, 50.6%), Black/African American (n = 549, 39.2%), and in groups (n = 473, 33.7%).

CONCLUSIONS

Both text and visuals are used to market Swisher Sweets on their Instagram account. Using social images of young adults, especially Black individuals, signals the intended use of the product. These images of visual-based social media may influence appeal, glamorization, and normalization of cigarillo smoking among vulnerable populations.

IMPLICATIONS

Tobacco marketing, including from popular cigarillo brands like Swisher Sweets, is widely used to influence consumer perceptions and behavior. Social media marketing includes text and visual, both of which increase product appeal and encourage use. Visual-based social media from the industry itself have been understudied, particularly for cigarillos. This study characterizes the ways in which Swisher Sweets uses text and visuals to market their products through their Instagram account, including smoking cues, potentially misleading language, use of celebrity endorsers, and promotion and sponsorship of events.

How do current tobacco warnings compare to the WHO FCTC guidelines: a content analysis of combustible tobacco warnings worldwide

OBJECTIVE

Many countries have adopted warning labels for combustible tobacco products, yet little research exists describing tobacco warning characteristics globally and to what extent they meet the WHO Framework Convention for Tobacco Control (FCTC) Guidelines. This study evaluates characteristics of combustible tobacco warnings.

DESIGN

We conducted a content analysis to describe the overall landscape of warnings using descriptive statistics and compared to the WHO FCTC Guidelines.

SETTING

We searched existing warning databases for combustible tobacco warnings from English-speaking countries. We compiled warnings meeting inclusion criteria and coded for message and image characteristics using a pre-defined codebook.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Characteristics of combustible tobacco warning text statements and warning images were the primary study outcomes. There were no secondary study outcomes.

RESULTS

We identified a total of 316 warnings from 26 countries or jurisdictions worldwide. Of these warnings, 94% included warning text and an image. Warning text statements most often described health effects to the respiratory (26%), circulatory (19%) and reproductive systems (19%). Cancer was the most frequently mentioned health topic (28%). Fewer than half of warnings included a Quitline resource (41%). Few warnings included messages about secondhand smoke (11%), addiction (6%) or cost (1%). Of warnings with images, most were in colour and showed people (88%), mostly adults (40%). More than 1 in 5 warnings with images included a smoking cue (ie, cigarette).

CONCLUSIONS

While most tobacco warnings followed WHO FCTC guidance on effective tobacco warnings, such as communicating health risks and inclusion of images, many did not include local Quitline or cessation resources. A sizeable minority include smoking cues that could inhibit effectiveness. Full alignment with WHO FCTC guidelines will improve warnings and better achieve the WHO FCTC objectives.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults

BACKGROUND

The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings.

METHODS

Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME).

RESULTS

Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46).

CONCLUSIONS

Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

Should messages discourage sugary drinks, encourage water, or both? A randomized experiment with U.S. parents

Campaigns to improve beverage consumption typically focus on discouraging unhealthy beverages (e.g., soda), encouraging healthy beverages (e.g., water), or both. It remains unclear which of these strategies is most effective. We recruited a national convenience sample of U.S. parents of children ages 2-12 (n = 1078, 48% Latino[a]) to complete an online survey in 2019. We randomly assigned participants to view: 1) a control message, 2) a soda discouragement message, 3) a water encouragement message, or 4) both soda discouragement and water encouragement messages shown side-by-side in random arrangement. Intervention messages mimicked New York City's "Pouring on the Pounds" campaign. Participants rated messages on perceived effectiveness for discouraging soda consumption and encouraging water consumption (1-5 response scales) and reported feelings and intentions about drinking soda and water (1-7 scales). Compared to those with no exposure, participants who viewed the soda discouragement message reported higher perceived discouragement from drinking soda (Average Differential Effect [ADE] = 1.18), more negative feelings toward drinking soda (ADE = 0.83) and stronger intentions to avoid drinking soda (ADE = 0.45) (ps < 0.001). The soda discouragement message also exerted beneficial effects on perceived effectiveness, feelings, and intentions related to water consumption (ADEs = 0.33-0.68; ps < 0.001). Exposure to the water encouragement message had beneficial effects on outcomes related to water consumption (ADEs = 0.28-0.81, ps < 0.001), but limited impact on outcomes related to soda consumption. Across outcomes, results indicated diminishing returns from exposure to both message types. Messaging campaigns discouraging unhealthy beverages may be more promising for improving beverage consumption than messages only promoting healthier beverages.

Social Media Communication About Sexual Violence May Backfire: Online Experiment with Young Men

Sexual violence harms millions of individuals each year in the United States. Survivors of sexual violence endure long-term hardships such as significant financial setbacks, physical and mental health consequences, academic challenges, and stunted career achievement. Digital feminist activism (DFA) has created space online where women can disclose experiences of sexual violence. Research thus far has been limited to documenting the existence and value of DFA for those who participate and has not addressed whether DFA can influence a key demographic for prevention, young men. We conducted an experiment to examine the impact of DFA on college-aged men's reactance to messaging, rape myth acceptance, knowledge about severity, and susceptibility to perpetrate sexual violence. University men (n=230, 18-29 years old) were randomized to one of three conditions: (1) tweets from women challenging rape myths, (2) tweets from women providing information about sexual violence harms, or (3) no exposure control. Tweets challenging rape myths or providing information did not impact rape myth perceptions, knowledge, or susceptibility. Participants had greater reactance (unintended outcome) to tweets challenging rape myths, and subsequently higher rape myth acceptance and lower knowledge about the severity of sexual violence. Rape myth acceptance was associated with susceptibility to perpetrate sexual violence overall. Our finding that some forms of DFA have a negative, indirect influence among college-aged males highlights important unintended consequences and the need for more efficacious communication to prevent sexual violence perpetration.

CBD Retailers in NC Promote CBD Online to Treat Pain Violating FDA Rules About Medical Claims and Offer Low-CBD/High-Price Products

Introduction

Cannabidiol (CBD) products are available nearly nationwide in the US and can coexist with medical or recreational programs. North Carolina (NC) is an example of a state with a program dedicated to integrating hemp cultivation and medicinal CBD exclusively, containing a multitude of retailers selling it as a primary product. The Food and Drug Administration (FDA) mandates that non-FDA approved CBD products cannot be marketed using medical or health-related claims and has sent warning letters to retailers violating these terms. We aim to characterize the online content of the NC CBD market by analyzing retailers' websites to determine whether hemp/CBD shops comply with FDA regulations in terms of medical claims and analyze the claimed CBD content and price of products offered online.

Methods

We randomly selected three CBD retailers from the ten most populated cities of NC. We analyzed their website content: product type, medical claims, other disclaimers, price, and CBD content.

Results

We found that edible, oral, inhalable, and topical products are offered in similar proportions. Word analysis of product description revealed that "pain" and "pain relief" were the most common medical claim, followed by inflammation and anxiety. Health claims were mostly related to wellbeing. Other attributes indicate that products are associated with pleasant flavors or sensations (ie, cool, lavender, delicious, honey, menthol), which resembles the strategies used for tobacco advertisement. Most products (61%) claimed to contain less than 1000 mg of CBD. The median price of products ranged from $15-30 per 300 mg. We found a positive correlation between CBD content and price.

Discussion

Our data demonstrate that the NC online CBD market does not comply with FDA regulations, primarily targets patients with pain, inflammation, or anxiety, and offers products with low CBD concentration and high prices. New policies should limit the access and online promotion of non-pharmaceutical grade CBD products.

Is a cigarette brand with fewer chemicals safer? Public perceptions in two national US experiments

By law, the US government must publicly display the quantities of harmful chemicals in cigarettes by brand, but doing so could mislead people to incorrectly think that some cigarettes are safer than others. We evaluated formats for presenting chemical quantities side-by-side to see if any were misleading. We recruited US convenience (n = 604) and probability (n = 1440) samples. We randomized participants to 1 of 5 formats: checklist, point estimates, ranges, a visual risk indicator, or no-quantity control. Participants were far more likely to incorrectly endorse one cigarette brand as riskier than the other in the checklist (65% made error), point estimate (67-70%), range (64-67%), or risk indicator (68-75%) conditions as compared to the no-quantity control (1%, all p < .001). Among smokers, erroneous risk perceptions mediated the impact of quantity format on interest in switching brands. People viewing chemical quantities for cigarette brands side-by-side misperceived differences in risk, suggesting limited public health value of this information.

Do sugar warning labels influence parents' selection of a labeled snack for their children? A randomized trial in a virtual convenience store

Despite growing evidence that warning labels reduce purchases of sugary drinks, less is known about warnings' impact on purchases of sugary snacks. This paper aimed to experimentally test whether a front-of-package label warning about high sugar content ("sugar warning label") would reduce parents' likelihood of selecting a labeled snack versus a non-labeled snack for their child in a food store setting. Participants (n = 2,219 parents of at least one child aged 1-5y) were recruited via an online panel and asked to complete a shopping task in a virtual convenience store. Participants were randomized to one of three labeling conditions: barcode control, text-only sugar warning label, or pictorial sugar warning label. Participants viewed two granola snacks, one labeled and one unlabeled, and selected one for purchase. A post-shopping survey measured secondary outcomes. Predictions and analyses were preregistered on www.clinicaltrials.gov (NCT04381481). Participants exposed to the text or pictorial sugar warning labels were less likely to select the labeled snack than those in the barcode control group (21%, 18%, and 34% respectively; p < 0.001 for both comparisons of warning to control). Relative to the barcode control label, the text and pictorial sugar warning labels resulted in greater attention, anticipated social interactions, negative affect, cognitive elaboration, and perceived message effectiveness, as well as lower perceptions of healthfulness, appeal, and intentions to purchase or consume the product (p < 0.001 for all comparisons of warnings to control). There were no differences in outcomes between text and pictorial sugar warning labels. In conclusion, text and pictorial sugar warning labels reduced parents' likelihood of selecting a labeled granola snack for their children. These results contribute to a growing body of evidence showing that warning labels influence food purchasing behaviors.

Exploring the acceptability of text messages to inform and support shared decision making for colorectal cancer screening (Preprint)

BACKGROUND

While online portals may be helpful to engage patients in shared decision-making at the time of cancer screening, because of known disparities in patient portal use, sole reliance on portals to support cancer screening decision-making could exacerbate well-known disparities in this health care area. Innovative approaches are needed to engage patients in health care decision-making and to support equitable shared decision-making.

OBJECTIVE

We assessed the acceptability of text messages to engage sociodemographically diverse individuals in colorectal cancer (CRC) screening decisions and support shared decision-making in practice.

METHODS

We developed a brief text message program offering educational information consisting of components of shared decision-making regarding CRC screening (eg, for whom screening is recommended, screening test options, and pros/cons of options). The program and postprogram survey were offered to members of an online panel. The outcome of interest was program acceptability measured by observed program engagement, participant-reported acceptability, and willingness to use similar programs (behavioral intent). We evaluated acceptability among historically marginalized categories of people defined by income, literacy, and race.

RESULTS

Of the 289 participants, 115 reported having a low income, 146 were Black/African American, and 102 had less than extreme confidence in their health literacy. With one exception, we found equal or greater acceptability, regardless of measure, within each of the marginalized categories of people compared to their counterparts. The exception was that participants reporting an income below US $50,000 were less likely to engage with sufficient content of the program to learn that there was a choice among different CRC screening tests (difference -10.4%, 95% CI -20.1 to -0.8). Of note, Black/African American participants reported being more likely to sign up to receive text messages from their doctor's office compared to white participants (difference 18.7%, 95% CI 7.0-30.3).

CONCLUSIONS

Study findings demonstrate general acceptance of text messages to inform and support CRC screening shared decision-making.

Nutrition-related claims lead parents to choose less healthy drinks for young children: a randomized trial in a virtual convenience store

BACKGROUND

Consumption of sugar-sweetened beverages, including fruit drinks (i.e., fruit-flavored drinks containing added sugar), contributes to childhood obesity.

OBJECTIVES

We aimed to examine whether nutrition-related claims on fruit drinks influence purchasing among parents and lead to misperceptions of healthfulness.

METHODS

We conducted an experiment in a virtual convenience store with 2219 parents of children ages 1-5 y. Parents were randomly assigned to view fruit drinks displaying 1 of 3 claims ("No artificial sweeteners," "100% Vitamin C," and "100% All Natural") or no claim (i.e., control group). Parents selected among each of 2 drinks for their young child: 1) a fruit drink or 100% juice (primary outcome), and 2) a fruit drink or water.

RESULTS

When choosing between a fruit drink and 100% juice, 45% of parents who viewed the fruit drink with the "No artificial sweeteners" claim, 51% who viewed the "100% Vitamin C" claim, and 54% who viewed the "100% All Natural" claim selected the fruit drink, compared with 32% in the no-claim control group (all P < 0.001). "No artificial sweeteners" (Cohen's d = 0.13, P < 0.05) and "100% All Natural" (d = 0.15, P < 0.05) claims increased the likelihood of parents choosing the fruit drink instead of water but "100% Vitamin C" did not (P = 0.06). All claims made parents more likely to incorrectly believe that the fruit drinks contained no added sugar and were 100% juice than the control (d ranged from 0.26 to 0.84, all P < 0.001), as assessed in a posttest survey. The impact of claims on selection of the fruit drink (compared with 100% juice) did not vary by any of the moderators examined (e.g., race/ethnicity, income; all moderation P > 0.05).

CONCLUSIONS

Nutrition-related claims led parents to choose less healthy beverages for their children and misled them about the healthfulness of fruit drinks. Labeling regulations could mitigate misleading marketing of fruit drinks.This trial was registered at clinicaltrials.gov as NCT04381481.

Barriers to and Facilitators of COVID-19 Prevention Behaviors Among North Carolina Residents

COVID-19 was the third leading cause of death in the United States in 2020. Prior to the wide dissemination of SARS-CoV-2 vaccines, individual prevention behaviors, such as wearing face masks, have been the primary non-pharmaceutical interventions to reduce infections. We surveyed 404 North Carolina residents recruited through Amazon MTurk in July 2020 to assess adherence to key prevention behaviors (6-foot distancing, mask wearing, and gathering limits) and barriers to and facilitators of adherence. Participants reported past 7-day prevention behaviors and behavioral barriers and facilitators informed by the Integrated Behavior Model and the Health Belief Model (perceived risk, perceived severity, behavioral attitudes, injunctive and descriptive norms, and personal agency). Reported adherence to each behavior in the past 7 days was generally high, with lower adherence to 6-foot distancing and mask wearing in the work context. The most commonly endorsed barriers to 6-foot distancing included physical impediments, forgetting, and unfavorable descriptive norms. For mask wearing, ability to keep a distance, discomfort/inconvenience, and forgetting were most commonly endorsed. In logistic regression models, injunctive social norms followed by perceived personal agency were the strongest independent correlates of 6-foot distancing. Behavioral attitudes and injunctive social norms were independently associated with mask wearing. For gathering size limit adherence, perceived personal agency was the strongest independent predictor followed by perceived severity of COVID-19. Messaging campaigns targeting these barriers and facilitators should be tested. Interventions improving the convenience and salience of physical distancing and mask wearing in high-density public places and places of work may also promote prevention behaviors.

The impact of pictorial health warnings on purchases of sugary drinks for children: A randomized controlled trial

BACKGROUND

Pictorial warnings on tobacco products are promising for motivating behavior change, but few studies have examined pictorial warnings for sugary drinks, especially in naturalistic environments. This study aimed to examine the impact of pictorial warnings on parents' purchases of sugary drinks for their children in a naturalistic store laboratory.

METHODS AND FINDINGS

Parents of children ages 2 to 12 (n = 325, 25% identifying as Black, 20% Hispanic) completed a shopping task in a naturalistic store laboratory in North Carolina. Participants were randomly assigned to a pictorial warnings arm (sugary drinks displayed pictorial health warnings about type 2 diabetes and heart damage) or a control arm (sugary drinks displayed a barcode label). Parents selected 1 beverage and 1 snack for their child, as well as 1 household good; one of these items was selected for them to purchase and take home. The primary outcome was whether parents purchased a sugary drink for their child. Secondary outcomes included reactions to the trial labels, attitudes toward sugary drinks, and intentions to serve their child sugary drinks. Pictorial warnings led to a 17-percentage point reduction in purchases of sugary drinks (95% CI for reduction: 7% to 27%), with 45% of parents in the control arm buying a sugary drink for their child compared to 28% in the pictorial warning arm (p = 0.002). The impact of pictorial warnings on purchases did not differ by any of the 13 participant characteristics examined (e.g., race/ethnicity, income, education, and age of child). Pictorial warnings also led to lower calories (kcal), purchased from sugary drinks (82 kcal in the control arm versus 52 kcal in the pictorial warnings arm, p = 0.003). Moreover, pictorial warnings led to lower intentions to serve sugary drinks to their child, feeling more in control of healthy eating decisions, greater thinking about the harms of sugary drinks, stronger negative emotional reactions, greater anticipated social interactions, lower perceived healthfulness of sugary drinks for their child, and greater injunctive norms to limit sugary drinks for their child (all p < 0.05). There was no evidence of difference between trial arms on noticing of the labels, appeal of sugary drinks, perceived amount of added sugar in sugary drinks, risk perceptions, or perceived tastiness of sugary drinks (all p > 0.05).

CONCLUSIONS

Pictorial warnings reduced parents' purchases of sugary drinks for their children in this naturalistic trial. Warnings on sugary drinks are a promising policy approach to reduce sugary drink purchasing in the US.

TRIAL REGISTRATION

The trial design, measures, power calculation, and analytic plan were registered before data collection at www.clinicaltrials.gov NCT04223687.

App Designs and Interactive Features to Increase mHealth Adoption: User Expectation Survey and Experiment

Background

Despite the ubiquity of smartphones, there is little guidance for how to design mobile health apps to increase use. Specifically, knowing what features users expect, grab their attention, encourage use (via predicted use or through positive app evaluations), and signal beneficial action possibilities can guide and focus app development efforts.

Objective

We investigated what features users expect and how the design (prototypicality) impacts app adoption.

Methods

In a web-based survey, we elicited expectations, including presence and placement, for 12 app features. Thereafter, participants (n=462) viewed 2 health apps (high prototypicality similar to top downloaded apps vs low prototypicality similar to research interventions) and reported willingness to download, attention, and predicted use of app features. Participants rated both apps (high and low) for aesthetics, ease of use, usefulness, perceived affordances, and intentions to use.

Results

Most participants (425/462, 92%) expected features for navigation or personal settings (eg, menu) in specific regions (eg, top corners). Features with summary graphs or statics were also expected by many (395-396 of 462, 86%), with a center placement expectation. A feature to “share with friends” was least expected among participants (203/462, 44%). Features fell into 4 unique categories based on attention and predicted use, including essential features with high (>50% or >231 of 462) predicted use and attention (eg, calorie trackers), flashy features with high attention but lower predicted use (eg, links to specific diets), functional features with modest attention and low use (eg, settings), and mundane features with low attention and use (eg, discover tabs). When given a choice, 347 of 462 (75%) participants would download the high-prototypicality app. High prototypicality apps (vs low) led to greater aesthetics, ease of use, usefulness, and intentions, (for all, P<.001). Participants thought that high prototypicality apps had more perceived affordances.

Conclusions

Intervention designs that fail to meet a threshold of mHealth expectations will be dismissed as less usable or beneficial. Individuals who download health apps have shared expectations for features that should be there, as well as where these features should appear. Meeting these expectations can improve app evaluations and encourage use. Our typology should guide presence and placement of expected app features to signal value and increase use to impact preventive health behaviors. Features that will likely be used and are attention-worthy—essential, flashy, and functional—should be prioritized during app development.

How Narrative Engagement with Young Adult Literature Influences Perceptions of Anorexia Nervosa

Narratives have been shown to alter health beliefs through a process called narrative engagement; however, this process has yet to be empirically investigated for how the increasingly popular young adult (YA) novel format can impact health beliefs about anorexia nervosa among emerging adults. Using an experimental design, we found that the YA format fosters narrative engagement through mechanisms of transportation, which is associated with greater endorsement of accurate social and emotional beliefs about anorexia nervosa. Compared to an informational brochure, the narrative format where the main character was a "supportive peer" (but not experiencing the illness herself) increased self-referencing and was perceived as more relevant among emerging adult participants. Results suggest narratives may be viable tools to communicate about little understood social and emotional aspects of chronic diseases with emerging adults, who are more likely to provide support for sick peers than experience chronic illnesses. Encouraging narrative engagement could facilitate a better understanding of the social and emotional complexity of anorexia nervosa and improve the quality of peer interactions.

Using Social Media for Peer-to-Peer Cancer Support: Interviews With Young Adults With Cancer

Background

Web-based social support can address social isolation and unmet support needs among young adults with cancer (aged 18-39 years). Given that 94% of young adults own and use smartphones, social media can offer personalized, accessible social support among peers with cancer.

Objective

This study aims to examine the specific benefits, downsides, and topics of social support via social media among young adults with cancer.

Methods

We conducted semistructured interviews with young adults with cancer, aged between 18 and 39 years, who were receiving treatment or had completed treatment for cancer.

Results

Most participants (N=45) used general audience platforms (eg, Facebook groups), and some cancer-specific social media (eg, Caring Bridge), to discuss relevant lived experiences for medical information (managing side effects and treatment uncertainty) and navigating life with cancer (parenting and financial issues). Participants valued socializing with other young adults with cancer, making connections outside their personal networks, and being able to validate their emotional and mental health experiences without time and physical constraints. However, using social media for peer support can be an emotional burden, especially when others post disheartening or harassing content, and can heighten privacy concerns, especially when navigating cancer-related stigma.

Conclusions

Social media allows young adults to connect with peers to share and feel validated about their treatment and life concerns. However, barriers exist for receiving support from social media; these could be reduced through content moderation and developing more customizable, potentially cancer-specific social media apps and platforms to enhance one’s ability to find peers and manage groups.

Narrative Vs. Standard of Care Messages: Testing How Communication Can Positively Influence Adolescents with Type 1 Diabetes

Adolescents with type 1 diabetes (T1D) face a variety of challenges in disease management, and many struggle to achieve optimal glycemic control. Health communication through didactic messaging about the importance of self-management is a commonly used strategy for this population, but narratives have been underutilized. The purpose of this study was to determine if narratives would provide a better tool to improve disease management for adolescents overcoming T1D-specific issues. Adolescent ages 12-17 (N = 191) were enrolled in an online experiment and viewed sets of narratives or standard of care messages. Outcomes were broken into three categories: message evaluation, specifically perceived message effectiveness (PME), and positive emotional reactions; beliefs such as self-efficacy, outcome expectations, and stress and burnout perceptions, and behaviors including disease management and interpersonal communication. Narratives did not significantly outperform standard of care messages, but both message types scored high on PME and other outcomes. We conclude that both narrative and didactic formats may offer utility for healthcare providers working with adolescents, in that narratives provide stories that may inspire positive emotions while standard of care messages provide the necessary clinical information needed to set goals for self-management.

Using a Naturalistic Store Laboratory for Clinical Trials of Point-of-Sale Nutrition Policies and Interventions: A Feasibility and Validation Study

Point-of-sale policies such as warnings and taxes are promising tools for improving the nutritional quality of food purchases. Research studies conducted in naturalistic store laboratories could improve the quality of evidence about point-of-sale interventions by allowing for realistic exposure in a controlled setting. This study aimed to assess whether purchasing behavior in a naturalistic store laboratory setting was similar to real-life purchasing behavior and to evaluate participants’ perceptions of store realism and the acceptability of research study protocols in this setting. In a longitudinal observational study in 2019, Latinx parents in North Carolina (n = 61) attended five weekly visits at the UNC Mini Mart, a naturalistic store laboratory that resembled a small convenience store. At each visit, participants purchased a week’s supply of beverages. Purchases of beverages in the Mini Mart were compared to participants’ purchases from receipts submitted the week prior to the study. Analyses compared the percentage of participants buying sugary drinks and non-sugary drinks in the Mini Mart vs. in real stores using Chi-Square tests with Fisher’s p. The percentage of parents who purchased sugary drinks in the Mini Mart (93%) was not significantly different from the percentage who purchased sugary drinks during the week before the study (74%, p = 0.28). The percentage purchasing non-sugary drinks was similar in the two settings (85% in the Mini Mart vs. 85% from receipts, p = 0.33). Nearly all participants reported that their Mini Mart purchases were similar to real-life purchases (96%); the Mini Mart felt like a real store (94%); they could find all the beverages they were looking for (92%); and they could imagine doing their real-life beverage shopping in the Mini Mart (92%). Moreover, retention was high, with 97% of participants attending the final study visit. These results indicate that naturalistic store laboratories are a promising method for increasing the ecological validity of trials to evaluate point-of-sale interventions.

Development and Application of an Interdisciplinary Rapid Message Testing Model for COVID-19 in North Carolina

INTRODUCTION

From the onset of the COVID-19 pandemic, public health officials have sought to develop evidence-based messages to reduce COVID-19 transmission by communicating key information to media outlets and the public. We describe the development of an interdisciplinary rapid message testing model to quickly create, test, and share messages with public health officials for use in health campaigns and policy briefings.

METHODS

An interdisciplinary research team from the University of North Carolina at Chapel Hill assembled in March 2020 to assist the state health department in developing evidence-based messages to influence social distancing behaviors in the state. We developed and iteratively executed a rapid message testing model; the components of the 4-step model were message creation, survey development, survey administration, and analysis and presentation to health department officials. The model was executed 4 times, each during a 7-day period in April and May, and each subsequent survey included new phrasing and/or messaging informed by the previous week's survey. A total of 917 adults from North Carolina participated in the 4 surveys.

RESULTS

Survey participants rated messages focused on protecting oneself and others higher than messages focused on norms and fear-based approaches. Pairing behaviors with motivations increased participants' desire to social distance across all themes and subgroups. For example, adding "Protect your grandmother, your neighbor with cancer, and your best friend with asthma," to messaging received a 0.9-point higher score than the base message, "Stay 6 feet apart from others when out in public."

PRACTICE IMPLICATIONS

Our model to promote social distancing in North Carolina during the COVID-19 pandemic can be used for rapid, iterative message testing during public health emergencies.

Initiation and changes in use of social media for peer support among young adult cancer patients and survivors

PURPOSE

Social isolation is a prominent challenge for many young adults with cancer. Despite desires for peer-to-peer connections through technology, little is known about how young adults initiate or use social media for support over time.

METHODS

We interviewed young adults with cancer (n = 45; age 18-39, in or post cancer treatment) to explore their initiation of social media for support, changes in use over time, and types of connections sought.

RESULTS

Young adults with cancer learn about online support through individual personal recommendations, advocacy organizations, or searching on Google or social media. Most were reluctant to use social media support initially because of feeling overwhelmed-from diagnoses, abundance of online information, or demands of participation-and joined when informational and emotional needs arose. Many wished they had joined earlier. Some participants use social media to make close connections while others simply want to "see" others' shared experiences or crowdsource information.

CONCLUSION

Young adults with cancer often haphazardly find online support from personal recommendations or Internet searches. Desires for social media connections are not one-size-fits-all; there are important audience segmentations for the degree and type of peer support.

IMPLICATIONS FOR CANCER SURVIVORS

Better promotion of online social support options and benefits-early in one's cancer timeline and systematically through healthcare providers, cancer organizations, or family and friends-could improve access to helpful peer-to-peer support.

Health Claims About Cannabidiol Products: A Retrospective Analysis of U.S. Food and Drug Administration Warning Letters from 2015 to 2019

Background: Cannabidiol (CBD) products are increasingly available to consumers in the United States and are subject to regulation by the U.S. Food and Drug Administration (FDA). CBD products cannot be marketed as unapproved new drugs with claims of therapeutic benefit. In addition, because CBD is the active ingredient in a FDA-approved CBD product, Epidiolex, CBD cannot be marketed as, or in, food products or dietary supplements. The FDA has issued Warning Letters to promote voluntary regulatory compliance. These letters provide insights as to the types of violations for CBD products detected in the U.S. market. Objective: The goal of this retrospective study was to content analyze Warning Letters issued by the FDA to identify illicit marketing of CBD products. Design: Warning Letters issued by the FDA between 2015 and 2019 were content analyzed using a deductive approach. We extracted year of issuance, issuing office, and claim types that are currently prohibited by the FDA, including (i) unapproved new drug, (ii) misbranded drug, (iii) false and/or misleading, (iv) FDA-approved/endorsed, (v) dietary supplement, and (vi) adulterated food product. In addition, we documented the disease or conditions the product claimed to affect, pharmacological effects, and location of violation. Results: Of the 39 Warning Letters issued, 97% were for violations made on company websites and 56% were for social media accounts. Almost all letters (97%) cited violations of marketing CBD as an unapproved new drug. These illicit therapeutic claims were made for >125 unique health problems, including cancer (87.2%), diabetes (71.8%), inflammation (66.7%), pain (66.7%), and arthritis (66.7%). The majority of letters (79.5%) also cited illicit marketing of CBD as a dietary supplement or food product. CBD was promoted as having 16 unique pharmacological effects, including anti-inflammatory (53.8%), anticancer (43.6%), and antipsychotic (30.8%). Conclusions: CBD products have been unlawfully advertised online as unauthorized drugs with health claims that promote therapeutic benefits and as dietary supplements. Efforts are needed to regulate and monitor illicit advertising so consumers are not misled about the risks and benefits of CBD use.

Health Claims, Marketing Appeals, and Warnings on Popular Brands of Waterpipe Tobacco Packaging Sold in the United States

INTRODUCTION

Waterpipe tobacco (WT) smoking is associated with misperceptions of harm, especially among users. WT packaging contains imagery, flavor descriptors, and text claims that may contribute to misperceptions. The study goal was to characterize visual and text elements of WT packaging.

AIMS AND METHODS

Using data from the U.S. Population Assessment on Tobacco and Health Study Wave 2 (October 2014-October 2015), we identified the 10 most popular WT brands. For each brand, we identified available flavors, including flavor collections with unique packaging elements. We randomly selected 10 flavors per brand for purchase (March-April 2018). We conducted descriptive content analysis to code all textual and visual design elements of each package.

RESULTS

Over half (54%) of WT packages had modified risk tobacco product (MRTP) claims prohibited by federal law, including substance-free MRTP claims (43%) and the descriptor "natural" (11%). No MRTP reduced exposure or reduced risk claims were found. Over a quarter (26%) of packaging including one or more of terms that may imply reduced harm including "fresh," "premium," "quality," and "pure." All packages included a text-only warning, yet none appeared on the primary display panel. Almost all packaging (99%) included imagery, with 72% including flavor imagery. The majority of packages (72%) included a smoking cue. The most popular marketing appeals were "well-made" (57%), "enjoyable" (55%), and "patriotic" (47%).

CONCLUSIONS

Prohibited MRTP claims, other descriptors, and flavor imagery are common on WT packaging, despite federal law. Future research is needed to evaluate if this marketing contributes to misperceptions of reduced harm.

IMPLICATIONS

Tobacco packaging is used to convey health-related messages, both explicitly and implicitly; however, information about WT packaging is virtually nonexistent. We conducted a content analysis of WT packaging from the 10 most popular US brands. Over half (54%) of packages had prohibited MRTP claims and over a quarter (26%) included one or more descriptors that may be perceived as implying reduced harm. Use of imagery, including smoking cues, was common. The widespread use of prohibited MRTP claims, other descriptors, and imagery on WT packaging may contribute to misperceptions of reduced harm.

Waterpipe Tobacco Warnings: An Experimental Study among a Nationally Representative Sample of U.S. Young Adults

BACKGROUND

Waterpipe tobacco (WT) smoking by young adults remains high and misperceptions are common. Product warnings can increase knowledge of harms and reduce use. The goal of this study was to test warning statements, including the FDA-required nicotine warning (prior to implementation), on young adults' thinking about harms of and discouragement from WT smoking.

METHODS

We conducted a between-subjects experiment in a nationally representative telephone survey of 1,152 young adults ages 18-29. Participants were randomly assigned to hear one of five warning statements and reported how much, on a 4-point scale, the warning made them think about the harms and discouraged them from WT smoking.

RESULTS

The sample was 36.8% female, 57.8% white, 20.2% Black, 24.1% Hispanic, with a mean age of 23.2 (SE=0.25). Under half (43.5%) had ever smoked WT. There were significant differences among the statements on both thinking about harms (p<.0001) and discouragement (p<.0001). The FDA-required 'nicotine' warning led to the lowest thinking about harms (M=2.85, SE=0.08) and was the least discouraging (M=2.86, SE=0.08), while the '100 cigarettes' warning resulted in the greatest thinking about harms (M=3.62, SE=0.05) and was the most discouraging (M=3.56, SE=0.06).

CONCLUSION

The nicotine warning resulted in the lowest levels of thinking about harms and discouragement from WT smoking, suggesting limited impact. However, a warning focused on comparing smoke inhalation from WT smoking to cigarettes seems promising. Warnings should cover a broad range of WT health effects, and possibly comparisons to cigarettes. Findings also have implications for the content of international waterpipe warnings.

IMPLICATIONS

This study indicates that the nicotine warning is the least effective at making young adults think about the harms of and discouraging waterpipe tobacco smoking. The FDA and other countries should consider requiring warnings to cover a broader range of health harms, misperceptions, and possibly comparisons to cigarettes.

Negative Perceptions of Young People Using E-cigarettes on Instagram: An Experiment with Adolescents

BACKGROUND

Although e-cigarette marketing on social media increases positive attitudes and experimentation, little is known about non-influencer e-cigarette portrayals of young people.

METHODS

High school adolescents (n=928, 15-18) were recruited by Lightspeed Health for an online experiment and randomized to view an Instagram post with or without e-cigarette use. Outcomes were positive and negative perceptions (prototypes), social distance, and willingness to use.

RESULTS

Half (50%) of participants were susceptible to e-cigarette use. E-cigarettes shown (vs. not) led to less positive prototypes, p=.017, more negative prototypes, p=.004, and more social distance, p<.001. Negative prototypes and social distance were moderated by susceptibility (both p<.05); effects among non-susceptible adolescents only. Showing e-cigarettes did not impact willingness to use if offered.

DISCUSSION

Negative perceptions of e-cigarettes use challenge assumptions that vaping online is universally admirable. Highlighting unfavorable opinions of vaping or negative impacts for adolescents' social image are potential strategies for tobacco counter-marketing.

IMPLICATIONS

Despite daily use of visual-based social media by most adolescents, little is known about the influence of e-cigarette use among young people online. Adolescent negative perceptions and desired distance from non-influencers using e-cigarettes on Instagram indicate digital e-cigarette portrayals are not universally accepted. Negative impacts for adolescents' social image present a counter-marketing strategy.

Motivations, barriers, and communication recommendations for promoting face coverings during the COVID-19 pandemic: Survey findings from a diverse sample

State and local health departments have been tasked with promoting the use of face coverings to decrease the spread of COVID-19 in their respective communities. However, little is known about motivations and barriers to wearing face coverings in the context of COVID-19 prevention, particularly among communities of color who are at an increased risk of serious illness from the disease. The purpose of this study was to identify common motivations and barriers to face covering use, as well as explore perceptions of messages encouraging the use of face coverings among a racially and ethnically diverse sample. A survey was distributed electronically to North Carolina (NC) residents through NC Department of Health and Human Services listservs in July 2020. Participants self-categorized as Latino/a (33.5%), Black (39.1%), or white or another race (27.5%). The most commonly endorsed motivations for wearing face coverings were to avoid spreading COVID-19 (77%), as well as to protect people who are vulnerable (76%) and one's community (72%). Being uncomfortable (40%) was the most commonly endorsed barrier. Messages that included a clear request (ex. please wear a face covering) and a direct benefit (ex. keep community safe) were more commonly endorsed than those that did not. Commonly endorsed motivations, behaviors, and messages differed by race and ethnicity. Increased attention to message content, message structure, and access to information and resources may aid local officials in increasing consistent use of face coverings.

Developing Pictorial Cigarillo Warnings: Insights From Focus Groups

INTRODUCTION

The Food and Drug Administration (FDA) selected six text-only warnings for cigarillos to be implemented on packaging and advertising. Pictorial warnings are more effective at discouraging cigarette use than text-only warnings, yet no research exists for cigarillos. We sought to understand what types of images might be most effectively paired with the cigarillo text warnings to inform broad principles for developing pictorial warnings, with a focus on young adults, who have the highest rate of cigarillo use.

METHODS

We conducted five focus groups with a total of N = 30 young adult cigarillo users and susceptible nonusers (53% female, 50% White, and 33% Black). Participants were shown four to eight unique images for each of the six text statements and were asked about visual-verbal congruency, emotional and cognitive reactions, and perceived effectiveness of each image. Sessions were recorded and transcribed; two investigators independently coded transcripts for emergent themes.

RESULTS

Participants reported images that were graphic or "gross" would best grab attention and discourage use of cigarillos. Participants preferred images that were a direct illustration of the information in the warning text, rather than abstract images that required more cognitive effort to understand. Participants also highlighted that including people in the images, especially youth and young adults making eye contact, helped them relate to the warnings, garner their attention, and positively influence their reactions.

CONCLUSIONS

We identified several principles to inform the selection of images to pair with the FDA-required cigarillo text statements. These insights may also apply to pictorial warnings for other tobacco products.

IMPLICATIONS

This focus group study identified principles for selecting images to develop pictorial warnings for the six FDA text-only cigarillo warnings. We found that young adult cigarillo users and susceptible nonusers preferred images that were graphic and gross, believable, congruent to the warning text, and included people. Images that match young adults' visual expectations of a disease and are emotion-provoking may be most effective in pictorial warnings and highlight challenges for developing pictorial warnings for health effects that do not have a visible health consequence.

Awareness of and reactions to the health harms of sugary drinks: An online study of U.S. parents

Evidence about the health problems associated with sugary drink consumption is well-established. However, little is known about which sugary drink health harms are most effective at changing consumers' behavior. We aimed to identify which harms people were aware of and most discouraged them from wanting to buy sugary drinks. Participants were a national convenience sample of diverse parents (n = 1,058), oversampled for Latino parents (48%). Participants rated a list of sugary drink-related health harms occurring in children (7 harms) and in adults (15 harms). Outcomes were awareness of each harm and how much each harm discouraged parents from wanting to purchase sugary drinks. Most participants were aware that sugary drinks contribute to tooth decay in children (75%) and weight gain in both children (73%) and adults (69%). Few participants were aware that sugary drinks contribute to adult infertility (16%), arthritis (18%), and gout (18%). All health harms were rated highly in terms of discouraging parents from wanting to buy sugary drinks (range: 3.59-4.11 on a 1-5 scale), with obesity, pre-diabetes, and tooth decay eliciting the highest discouragement ratings. Harm-induced discouragement was higher for participants who were aware of more health harms (B = 0.05, p < 0.0001), identified as female (B = 0.15 compared to male, p = 0.02), or had an annual household income of $50,000 or more (B = 0.16 compared to less than $50,000, p = 0.03). These findings suggest health messages focused on a variety of health harms could raise awareness and discourage sugary drink purchases.

Harnessing Neuroimaging to Reduce Socioeconomic Disparities in Chronic Disease: A Conceptual Framework for Improving Health Messaging

Socioeconomic status (SES)-related health disparities persist for numerous chronic diseases, with lower-SES individuals exhibiting greater risk of morbidity and mortality compared to their higher-SES counterparts. One likely contributor is disparities in health messaging efforts, which are currently less effective for motivating health behavior change among those lower in SES. Drawing on communication neuroscience and social neuroscience research, we describe a conceptual framework to improve health messaging effectiveness in lower SES communities. The framework is based on evidence that health-message-induced activity in the ventral striatum (VS) and subdivisions of the medial pre-frontal cortex (MPFC) predicts behavior change. Additionally, we draw from social neuroscience work showing that activity in these regions during valuation and the processing of self-related vs. social information, differs as a function of SES. Bringing together these previously disparate lines of work, we argue that health messages emphasizing the benefits to close others (vs. the self) of engaging in behavior change will be more effective among lower SES individuals. We also outline a research agenda based on our framework. Ultimately, we hope that this framework utilizing a “brain-as-predictor” approach generates novel insights about the neural underpinnings of message-induced behavior change among lower SES individuals, and helps to close the gap in SES-based health disparities by harnessing the power of neuroimaging.

Social Media Message Designs to Educate Adolescents About E-Cigarettes

PURPOSE

E-cigarette use is increasing among adolescents, despite potential harms. Social media messages are a promising way to educate youth about e-cigarettes, yet little is known about what message topics and formats will have beneficial impacts for message reception, reach, e-cigarette knowledge, and beliefs about harms.

METHODS

A national convenience sample of adolescents (n = 928, aged 15-18 years) in high school was recruited for an online experiment. In October 2019, participants were randomized to view one of three social media formats (visual based, quiz, and text only) or a no-message control. Participants in format conditions viewed six unique topics in a random order. Outcomes were e-cigarette knowledge and beliefs. Message reactions and sharing preferences were also assessed among youth who saw social media messages.

RESULTS

Social media messages led to greater knowledge (Cohen's f = .19; p < .001) and beliefs (f = .16; p < .001) about harms of e-cigarettes compared with the control, regardless of format. Almost four in five adolescents (79%) reported they would share the social media messages, most likely in person (49%) and with friends (52%). Message topics for missing out because of lung damage, having uncontrolled moods, and ingesting specific harmful chemicals elicited higher intended message reactions.

CONCLUSIONS

Social media messages can educate about e-cigarette harms. Social media campaigns are a promising e-cigarette education strategy to reach youth, directly and potentially through peer-to-peer sharing.

Motivations and Barriers for the Use of Face Coverings during the COVID-19 Pandemic: Messaging Insights from Focus Groups

Widespread use of face coverings is a key public health strategy to prevent the spread of COVID-19. However, few studies have examined why Americans use or do not use face coverings, and little is known about the most effective messaging strategies. This study explored perceptions of face coverings, including motivations and barriers for use, and examined reactions to messaging promoting the use of face coverings. Six virtual focus groups were conducted with 34 North Carolina residents in July 2020. Participants reported high compliance with face covering recommendations but often did not wear them around family, friends, and colleagues. The most prevalent motivation for the use of face coverings was to protect or respect other people, including high-risk populations and individuals. Other motivators were self-protection, responsibility, desire for control, requirements, and expert advice. Barriers included physical and social discomfort, confusion or misinformation, low perceived susceptibility to COVID-19, and perceptions of identity and autonomy. Even among individuals who frequently wear face coverings, there are opportunities to improve compliance. Messaging should highlight how face coverings protect the wearer and others around them, normalize the use of face coverings in social settings, and emphasize requirements. Positive messages that focus on unity, personal experiences and the rationale for face coverings are recommended.

Advancing Visual Health Communication Research to Improve Infodemic Response

During public health crises like the ongoing novel coronavirus pandemic, there is a need to amplify and improve critical health communication messages. This need is due to pandemics producing infodemic conditions, meaning the public information environment is oversaturated with information of questionable accuracy and utility. The strategic use of visuals can be leveraged to improve the quality of health communication during public health crises and lessen the unintended effects of infodemic conditions. In this essay, we review previous visual communication theorizing and research that provide insights for effective and efficient use of graphical (e.g., data visualizations) and illustrative (e.g., photos, illustrations, and content features) visuals. We also discuss and advocate for more systematic research on visual misinformation and visual narratives, as there are significant gaps in the literature about how people interpret, act on, and engage with these visual content types. More systematic research about these areas of visual health communication research will improve public communication during future public health crises.