Culturally Tailored Anti-Smoking Messages: A Randomized Trial With U.S. Sexual Minority Young Women

INTRODUCTION

This study evaluated effects of exposure to culturally tailored anti-smoking ads versus control ads on quitting intentions, cigarette purchase intentions, and tobacco industry perceptions among young adult, cisgender and transgender, sexual minority women (SMW).

STUDY DESIGN

An online randomized controlled experiment with 1-month longitudinal follow-up was conducted.

SETTING AND PARTICIPANTS

About 2,214 U.S. SMW ages 18-30 were recruited via online survey panels (The PRIDE Study and Prolific), social media ads and posts, and HER dating app ads. Data were collected in 2021-2022.

INTERVENTION

Participants were randomly assigned to receive up to 20 tailored ads containing LGBTQ+ branding versus 20 control ads without LGBTQ+ branding over 4 weeks. Both conditions used identical anti-smoking statements and photographs (including several photographs of individuals who self-identified as SMW).

MAIN OUTCOME MEASURES

One-month follow-up intention to purchase cigarettes, intention to quit, marketing receptivity, pro-industry attitudes, and pro-industry beliefs were measured. Analyses were conducted in 2022-2023. Linear regression models predicted outcomes at 1-month follow-up with the randomized arm, adjusted for baseline measures of each outcome and stratified by smoking status (those who currently smoked and those who did not smoke).

RESULTS

Among those who smoked, follow-up intention to quit increased and intention to purchase cigarettes, marketing receptivity, pro-industry attitudes, and pro-industry beliefs decreased versus baseline in both arms. Follow-up pro-industry beliefs were significantly lower (B=-0.331, 95% CI -0.652, -0.010, p=0.043) in the tailored versus control arm, adjusted for baseline beliefs. Among those who did not smoke, marketing receptivity, pro-industry attitudes, and pro-industry beliefs decreased versus baseline in both arms. Follow-up outcomes did not differ significantly between arms.

CONCLUSIONS

These findings can inform future anti-smoking campaign development to reduce cigarette smoking-related disparities among young adult, cisgender and transgender, sexual minority women and serve as the basis for developing similar ads for other LGBTQ+ audiences.

TRIAL REGISTRATION

This study was registered in ClinicalTrials.gov (NCT04812795).

Dual-Vaping of Nicotine and Cannabis among Adults who Currently Use Tobacco Products in Five New England States

INTRODUCTION

Current measures of vaping behaviors do not distinguish what substances participants are vaping and to what extent they are dual-vaping nicotine and cannabis. This study describes the use of new survey questions that more specifically ask whether participants who vape are vaping nicotine, cannabis, CBD, or another substance.

METHODS

Adults, who reported any past-30-day tobacco use, from five New England states participated in an online survey from April 2021 to July 2022. Participants who vaped were asked, "Have you used any of the following vape substances in the past 30 days?" with the possible responses of nicotine, cannabis, CBD, other, and "don't know." Dual-use of both nicotine and cannabis was defined as the vaping of both nicotine and cannabis and/or CBD in the past-30-days, operationalized as a dichotomous outcome. Data were collected in monthly, repeated cross-sectional waves. Multinomial logistic regression was used to examine correlates of dual-vaping.

RESULTS

The analytic sample included 1547 adults who reported past-30-day tobacco use (mean age 42.9 years, 62.8% female, 85.4% White, 48.5% income of less than $50,000). Over one-quarter (26.1%) reported dual-vaping in the past-30-days. Identifying as male (p=0.002) and self-rated anxiety (p=0.043) were associated with a higher odds of dual-vaping.

CONCLUSIONS

Our findings show that a sizable proportion of a sample of New England adults who have used tobacco in the past-30-days are dual-vaping nicotine and cannabis. Adequate survey measures for assessing the vaping of multiple substances can help in better screening and characterization of health behaviors around dual-use.

IMPLICATIONS

This study addresses a key gap in adequate survey measures for assessing vaping of multiple substances. We found that among adults with past 30-day tobacco use, dual-vaping was prevalent and associated with different correlates, such as self-reported anxiety and education level, compared to sole-vaping of nicotine or cannabis. Our findings may help in characterizing and targeting future population-level surveillance and intervention efforts for multiple substance use behaviors.

Trust in federal COVID-19 vaccine oversight and parents' willingness to vaccinate their children against COVID-19: a cross-sectional study

BACKGROUND

Over half of the youth population in the United States, aged 6 months to 17 years, have not received the Coronavirus Disease 2019 (COVID-19) vaccine. Given parents' central role in vaccinating their children, we examined associations between parents' trust of the federal oversight of COVID-19 vaccine safety and their willingness to vaccinate their children against COVID-19.

METHODS

This cross-sectional study included 975 parents of minor children residing in Philadelphia who completed the online survey between September 2021 and February 2022. Trust was measured using a four-point Likert scale ranging from 'do not trust' to 'fully trust' for two variables: (1) trust in federal oversight of COVID-19 vaccine safety for children and (2) trust in federal oversight of COVID-19 vaccine safety for the general public. A multiple logistic regression evaluated associations between trust and parents' willingness to vaccinate their children, which was measured on a five-point Likert scale ranging from 'strongly disagree' to 'strongly agree.' The analysis was adjusted for race/ethnicity, age, sexual orientation, gender, education, insurance, and parents' vaccination status.

RESULTS

Analyses included 975 parents whose children had not previously been vaccinated against COVID-19 (mean age 36.79, standard deviation 6.4; 42.1% racial/ethnic minorities; 93.2% heterosexual; and 73.7% with a college degree). Greater trust regarding federal oversight of COVID-19 vaccine safety for children [adjusted odds ratio (aOR) = 1.52, 95% confidence interval (CI): 1.13-2.04] and for the public (aOR = 1.58, 95% CI: 1.17-2.14) were each associated with increased willingness to have their child vaccinated against COVID-19. Unvaccinated parents had decreased willingness compared to parents who had received at least one dose of the vaccine (aOR = 0.14, 95% CI: 0.04-0.41). College-graduate parents exhibited increased willingness compared to those without a college degree (aOR = 2.07, 95% CI: 1.52-2.81). Non-heterosexual parents showed increased willingness compared to heterosexual parents (aOR = 2.30, 95% CI: 1.20-4.76).

CONCLUSIONS

Trust in federal COVID-19 vaccine oversight was associated with parental willingness to vaccinate their children against COVID-19 among parents whose children have not yet been vaccinated. Identifying and addressing causes of mistrust are crucial next steps to promote child vaccination. Intervention efforts to address trust gaps should remain a public health priority.

Exploring the Influence of E-cigarette Ad Features on Perceived Product Appeal and Use Interest Among Young Adults of Varying Tobacco-Use Behaviors

INTRODUCTION

Exposure to certain features in commercial e-cigarette ads may influence e-cigarette use perceptions. This study explored the reactions toward common features in e-cigarette ads among young adults of various tobacco-use behaviors.

AIMS AND METHODS

We used data from in-depth interviews with U.S. young adults (ages 18-29) who do not use tobacco (n = 26) and who currently smoke cigarettes (n = 26). Participants viewed 30 print e-cigarette ads that included multiple features (eg, fruit flavors, price promotions, smoker-targeted messages) before discussing their perceived influence of memorable ad features. We used reflective thematic analysis to analyze interview data.

RESULTS

Participants from both groups generally noticed fruit and multiple flavors displayed in the ads, which were seen as appealing and were reported to generate product-use interest because of bright colors, sensory appeal, and a variety of flavor options. Participants who smoke perceived price promotions and positive experience testimonials to be appealing, and some reported this generated use interest. Participants from both groups perceived smoker-targeted messages to be unconvincing, and reported this dampened ad and product appeal and use interest. Participants who do not use tobacco perceived nicotine warnings to be unappealing, resulting in reduced perceived appeal of other attractive features (eg, fruit flavors) appearing in the same ads.

CONCLUSIONS

Marketing features appearing in e-cigarette ads may be perceived by young adults of various tobacco-use behaviors in both similar and different ways. Communication and policy strategies that account for these differential perceptions towards various marketing features are needed to reduce the negative impact of e-cigarette marketing.

IMPLICATIONS

This study revealed evidence related to young adults' reactions to and perceived influence of commonly used marketing features (eg, fruit flavors, nicotine warnings, price promotions, smoker-targeted messages) in commercial e-cigarette ads. The results highlight the similar and differential perceived appeal and use interest of e-cigarette products promoted with various marketing features among young adults of different tobacco-use behaviors. The results have implications for informing the design of communication strategies and policies related to e-cigarette marketing aimed at promoting complete product switching among young adults who smoke while simultaneously deterring e-cigarette use interest among those who do not use tobacco.

Effects of reduced nicotine content cigarette advertising with warning labels and social media features on product perceptions among young adults

This study sought to understand reactions to very low nicotine (VLN) cigarette advertising compared with conventional cigarette advertising with consideration of warning labels and social media context. The online experimental study recruited young adult cigarette smokers and nonsmokers (N = 1,608). Participants completed a discrete choice task with a 2 × 2 × 3 mixed design: brand, (VLN, Marlboro), context (Ad only, Ad on social media), and warning (Text-only, Well-known risk pictorial, or Lesser-known risk pictorial). Participants made choices about attention, appeal, harm, buying, and quitting intentions. Social media context increased attention and appeal. A well-known risk pictorial warning outperformed a text-only warning. Smokers had increased odds of quit intentions for VLN ads, yet nonsmokers had increased intentions to buy cigarettes on social media with a text-only warning. Results indicate differences in how young adults react to cigarette ads on social media, especially with the warnings they portray.

Correlates of adolescent sole-, dual- and poly-use of cannabis, vaped nicotine, and combusted tobacco

BACKGROUND

Compared to single substance use, adolescents' use of multiple substances is associated with more severe dependence, cessation outcomes, and health risks. This study examined correlates of use and co-use of e-cigarettes, combusted tobacco, and cannabis among high school-aged (9th-12th grade, approximately aged 14-18) adolescents.

METHODS

We analyzed the 2019 Massachusetts Youth Health Survey (MYHS) data to calculate the weighted means of any past 30-day sole-use of e-cigarettes, sole-use of combusted tobacco, sole-use of cannabis, dual-use of two of the above substances, and poly-use of all three substances. We then used weighted multinomial logistic regression to examine the associations between demographic, social and behavioral factors and sole-, dual-, and poly-use (vs. no use) of these substances.

RESULTS

Among N = 1614 respondents, any past 30-day dual-use of e-cigarettes and cannabis was the most prevalent (17.2%, SE: 1.3%). Sole-use of combusted tobacco was less than 1%, whereas 4.5% (SE: 0.7%) of respondents reported poly-use of e-cigarettes, cannabis, and combusted tobacco. Lower academic grades and self-reported depression (1 item on persistent feelings of sadness or hopelessness) were associated with increased odds of dual-use of e-cigarettes and cannabis and poly-use (vs. sole-use of any substance). Adolescents who self-reported having "any long-term emotional problems or learning disabilities" had greater odds of poly-use.

CONCLUSION

Different sets of correlates were associated with sole-, dual-, and poly-use, suggesting that certain adolescents may be more vulnerable than others to multiple substance use. Future research should examine potentially modifiable upstream influences, such as the home environment and socioeconomic factors that may affect the relationship between adolescent mental health, school performance, and multiple addictive substance use.

Effects of cigarette package colors and warning labels on marlboro smokers' risk beliefs, product appraisals, and smoking behavior: a randomized trial

OBJECTIVE

Plain packaging and graphic warning labels are two regulatory strategies that may impact cigarette risk beliefs and reduce consumption, but data are needed to better understand how smokers respond to such regulations.

METHODS

Adult, daily, Marlboro non-menthol smokers (Red [n = 141] or Gold [n = 43]) completed a mixed factorial randomized trial. Participants smoked their usual cigarettes during baseline (5-days) and were randomized to receive cigarette packs with a warning label manipulation (graphic vs. text-only). Within each warning label condition, participants completed three within-subjects pack color manipulations (red, gold, plain), each lasting 15 days. Participants were blinded to the fact that all packs contained their usual cigarettes. Mixed-effects models examined between- and within-subject differences on risk beliefs, product perceptions, and smoking behavior.

RESULTS

Warning type and package color did not impact cigarette consumption or subjective ratings. However, use increased in all conditions (2.59-3.59 cigarettes per day) relative to baseline. While smokers largely held correct risk beliefs at baseline (Mean = 6.02, SE = 0.17, Range:0-8), the cumulative number of incorrect or uncertain cigarette risk beliefs increased from baseline in all pack color manipulations in the text (IRR range = 1.70-2.16) and graphic (IRR range = 1.31-1.70) warning conditions. Across all pack color periods, those in the graphic (vs. text) warning condition had reduced odds of reporting their study cigarettes as 'safer' than regular cigarettes (OR range = 0.22-0.32).

CONCLUSIONS

Pack color modification may increase uncertainty about several key cigarette risk beliefs, though graphic warnings may attenuate these effects. Regulatory agencies could consider supporting policy changes with information campaigns to maximize public knowledge.

TRIAL REGISTRATION

November 25, 2014; Registration number: NCT02301351.

Barriers and facilitators to address vaping in Massachusetts schools: a mixed-methods study of school-based stakeholders

We assessed vaping behaviors, environments, COVID-19 influences, and barriers and facilitators of existing approaches that address adolescent vaping in Massachusetts middle and high schools. Findings from this study will provide considerations for individual schools or districts as they advance adolescent vaping prevention and treatment efforts. We analyzed 310 open-ended comments from Massachusetts school administrators who completed a survey between November 2020 and January 2021. Further, we analyzed nine semi-structured interviews with administrators (e.g., principals, vice principals, school nurses) from Massachusetts school systems (n = 6) and school-based anti-tobacco advocates (n = 3); interviews took place between May and December 2021. Informed by Green's PRECEDE model, we conducted a framework analysis using deductive codes based on the model constructs (enabling, reinforcing, and predisposing factors) and inductive codes of key themes emerging from the interviews. Challenges to addressing adolescent vaping included staff capacity, funding, and lack of mental health and counseling supports. The COVID-19 pandemic was a major barrier to conducting usual in-person vaping programs, but also reduced student vaping at school due to new social distancing practices and bathroom use policies. Facilitators of vaping interventions included peer-led initiatives and parental involvement. Participants discussed the importance of educating adolescents on the harms of vaping and the move toward alternatives-to-suspension programs rather than disciplinary action. School-based anti-vaping program implementers-such as school districts, state departments of education, or local health departments-will need to leverage facilitators such as peer-led initiatives, alternatives-to-suspension approaches, and parental involvement, to increase the potential impact of these programs.

Vaping of Cannabis, Cannabidiol, and Synthetic Cannabis Among US Sexual Minority Youths

This cross-sectional study investigates rates of vaping of cannabis, cannabidiol, and synthetic cannabis among US sexual minority youths.

"We're always an afterthought"- Designing tobacco control campaigns for dissemination with and to LGBTQ +-serving community organizations: a thematic analysis

PURPOSE

Evidence-based health communication campaigns can support tobacco control and address tobacco-related inequities among lesbian, gay, bisexual, transgender, and queer (LGBTQ +) populations. Community organizations focused on LGBTQ + health (e.g., nonprofits, community centers, and community health centers) can be prime channels for delivering evidence-based health communication campaigns. However, it is unclear how to balance the goals of a) designing campaigns to support broad adoption/uptake and b) adaptation addressing the needs of diverse communities and contexts. As part of an effort to support "designing for dissemination," we explored the key challenges and opportunities staff and leaders of LGBTQ + -serving community organizations encounter when adopting or adapting evidence-based health communication campaigns.

METHODS

A team of researchers and advisory committee members conducted this study, many of whom have lived, research, and/or practice experience with LGBTQ + health. We interviewed 22 staff members and leaders of community organizations serving LGBTQ + populations in the US in early 2021. We used a team-based, reflexive thematic analysis approach.

RESULTS

The findings highlight the challenges of attempting to use health communication campaigns misaligned with the assets and needs of organizations and community members. The three major themes identified were as follows: (1) available evidence-based health communication campaigns typically do not sufficiently center LGBTQ + communities, (2) negotiation regarding campaign utilization places additional burden on practitioners who have to act as "gatekeepers," and (3) processes of using health communication campaigns often conflict with organizational efforts to engage community members in adoption and adaptation activities.

CONCLUSIONS

We offer a set of considerations to support collaborative design and dissemination of health communication campaigns to organizations serving LGBTQ + communities: (1) develop campaigns with and for LGBTQ + populations, (2) attend to the broader structural forces impacting campaign recipients, (3) support in-house testing and adaptations, and (4) increase access to granular data for community organizations.

Youth tobacco use before and after flavoured tobacco sales restrictions in Oakland, California and San Francisco, California

The tobacco industry has used recent findings from the Youth Risk Behavior Surveillance System Survey (YRBSS) to claim that a sales restriction on flavoured tobacco products might increase youth combustible cigarette use. In this special communication, we examined YRBSS data and reached the opposite conclusion. We observed the patterns in youth cigarette smoking in Oakland, California following its 2017 convenience store flavoured tobacco sales restriction. We also found that 2019 YRBSS data from San Francisco, California cannot be used to evaluate the effect of the sales restriction on all flavoured tobacco products in San Francisco as the YRBSS data for this city were collected prior to enforcement of the sales restriction. For future studies, we suggest triangulating with corroborating sales, behavioural and qualitative data over time to assess the effects of tobacco control policies on youth tobacco use. We recommend that policy enactment and enforcement dates, as well as the exact data collection periods for population health surveys, be published to facilitate more rigorous policy evaluation.

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

INTRODUCTION

IQOS is a heated tobacco product that was authorised as a modified risk tobacco product (MRTP) in July 2020. While it was removed from the US market in 2021 for legal reasons, as the first tobacco product to receive an 'exposure modification' MRTP order, surveillance of IQOS marketing is needed to inform regulation and policy for future MRTPs. The purpose of this study is to expand the current research on IQOS advertising in the USA by examining content and readership characteristics of IQOS ads in print magazines before and after US Food and Drug Administration MRTP authorisation.

METHODS

We merged content analysis data with Kantar Media data on magazine placement and expenditures. Magazine readership data were obtained from MRI-Simmons. We compared data from pre-MRTP authorisation with data post-MRTP authorisation. This study was conducted in 2021.

RESULTS

There was one unique ad and there were 13 observations pre-MRTP, and eight unique ads and 132 observations post-MRTP. Compared with pre-MRTP ads, more post-MRTP ads featured Marlboro HeatSticks, including Amber HeatSticks, and featured people. All ads contained a warning label-most warning labels were cigarette specific. IQOS ads were featured in magazines that are especially popular among women.

CONCLUSIONS

After receiving MRTP authorisation, IQOS increased ad expenditures in print magazines with a readership comprised of primarily women. If IQOS returns to the US market, it will be important for tobacco control to monitor their advertisement content, placement, and expenditures.

Trusted messengers and trusted messages: The role for community-based organizations in promoting COVID-19 and routine immunizations

We sought to explore the trust and influence community-based organizations have within the communities they serve to inform public health strategies in tailoring vaccine and other health messages. A qualitative study was conducted between March 15 - April 12, 2021 of key informants in community-based organizations serving communities in and around Philadelphia, Pennsylvania. These organizations serve communities with high Social Vulnerability Index scores. We explored four key questions including: (1) What was and continues to be the impact of COVID-19 on communities; (2) How have trust and influence been cultivated in the community; (3) Who are trusted sources of information and health messengers; and (4) What are the community's perceptions about vaccines, vaccinations, and intent to vaccinate in the context of the COVID-19 pandemic. Fifteen key informants from nine community-based organizations who serve vulnerable populations (e.g., mental health, homeless, substance use, medically complex, food insecurity) were interviewed. Five key findings include: (1) The pandemic has exacerbated disparities in existing social determinants of health for individuals and families and have created new concerns for these communities; (2) components of how to build the trust and influence (e.g., demonstrate empathy, create a safe space, deliver on results)resonated with key informants; (3) regardless of the source, presenting health information in a respectful and understandable manner is key to effective delivery; (4) trust and influence can be transferred by association to a secondary messenger connected to or introduced by the primary trusted source; and (5) increased awareness about vaccines and vaccinations offers opportunities to think differently, changing previously held beliefs or attitudes, as many individuals are now more cognizant of risks associated with vaccine-preventable diseases and the importance of vaccines. Community-based organizations offer unique opportunities to address population-level health disparities as trusted vaccine messengers to deliver public health messages.

Tobacco cessation and prevention interventions for sexual and/or gender minority-identified people and the theories that underpin them: A scoping review

INTRODUCTION

This scoping review takes stock of the social and behavior change theories that have underpinned tobacco interventions tailored to sexual and/or gender minority (SGM) people and reflects on the need to target contextually-based drivers of SGM tobacco use inequities.

METHODS

Data sources were Medline (Ovid), Scopus, PubMed, Google Scholar (01/01/1946 - 10/27/2022). Peer-reviewed publications in English from anywhere in the world describing SGM-tailored tobacco cessation and/or prevention interventions were independently identified by a librarian and screened by the first and third authors. 367 articles were extracted; an additional 2 were found by hand searching. 369 articles were assessed for eligibility. Exclusion criteria were: not an intervention, review article, not SGM-tailored or tobacco-focused. We documented intervention name, intervention components, theoretical frameworks cited in reference to intervention design and/or implementation, and evaluation outcomes. All authors provided input on theoretical framework categorization.

RESULTS

We identified 22 publications corresponding to 15 unique interventions. Individual-level behavior change theories (i.e., those focusing on within-person behavior change processes) were the most prominent. Among these, the Transtheoretical Model was the most frequently utilized, while Social Inoculation Theory, Theory of Reasoned Action, and Theory of Psychological Reactance were also employed. A minority of interventions referenced frameworks that more explicitly engaged with SGM people's social contexts, namely, Theory of Diffusion of Innovations and Minority Stress Model.

CONCLUSIONS

Future SGM-tailored tobacco interventions should leverage both the strengths of individual-level behavior change theories and those of frameworks that understand tobacco use inequities as indivisible from place, context, and policy.

IMPLICATIONS

This scoping review describes the theoretical underpinnings of sexual and/or gender minority (SGM)-tailored tobacco interventions published in the peer-review literature in English. It reflects on the need for greater utilization of social and behavior change theoretical frameworks that can engage with unique drivers of SGM tobacco use and barriers to cessation.

Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift

INTRODUCTION

To eliminate tobacco-related disparities, tobacco control research would benefit from a paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s, has the potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use, and improve our ability to address persistent tobacco-related health disparities.

AIMS AND METHODS

In this commentary, we outline the rationale and recommendations for incorporating intersectionality into equity-minded tobacco control research. These recommendations arose from intersectionality webinars organized by the Health Disparities (now Health Equity) Network of the Society for Research on Nicotine & Tobacco (SRNT) in 2019 and 2020.

RESULTS

Specifically, we propose that eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. We summarize priority actions for the tobacco control research field to achieve health equity through the intersectionality framework including acknowledging that structural factors, racism and power dynamics shape lived experiences, integrating critical theoretical frameworks and intersectionality scholarship into research questions, and embracing collaborative community-based approaches at every level of the research process.

CONCLUSIONS

Through these actions, our field can take concrete steps to fundamentally improve our approach to conducting research to achieve health equity.

IMPLICATIONS

Intersectionality is a valuable tool to align our field with our pursuit of health equity. The recommendations aim to improve methods of equity-focused tobacco control, prompt ongoing dialogue on the utility of this tool, and shift paradigms in how the research process is conducted at every level among stakeholders, including researchers, journal editors and reviewers, funders, practitioners, and policy makers.

The effect of vaping cues in e-cigarette advertisements on normative perceptions about cigarettes among young adults who use cigarettes and e-cigarettes in Boston

INTRODUCTION

E-cigarette advertising frequently involves vaping cues-hand to mouth motions and vapor-that physically resemble traditional cigarette smoking cues. There has been concern that these vaping cues could make cigarettes seem more frequently used and acceptable by society. This analysis examined whether exposure to vaping cues in e-cigarette ads influence descriptive and injunctive normative perceptions about cigarettes among young adults who use cigarettes and e-cigarettes (dual use).

METHOD

Secondary analysis was conducted on an experiment that randomly exposed young adults living in Boston who dual used in the past-week to either 1) E-cigarette ads with vaping cues; 2) E-cigarette ads that edited out vaping cues; or 3) Beverage ads. Descriptive and injunctive normative perceptions about cigarettes were compared across participants who viewed e-cigarette ads with vaping cues versus those who viewed ads without vaping cues.

RESULTS

Those who viewed e-cigarette ads with vaping cues had decreased perceptions that cigarette smoking was common compared to those who viewed e-cigarette ads without vaping cues. Exposure to e-cigarette ads with vaping cues also led to increased perceptions of other peoples' unfavorable views toward cigarette smoking in general and their own cigarette smoking.

CONCLUSION

Contrary to renormalization concerns, vaping cues in e-cigarette ads increased anti-smoking normative perceptions among people who dual used in the past week. Further research is needed to examine the impact of vaping cues in e-cigarette ads on normative perceptions among those who don't smoke or quit smoking cigarettes.

Intersectionality of Sexual Orientation With Race and Ethnicity and Associations With E-Cigarette Use Status Among U.S. Youth

INTRODUCTION

Although structural discrimination against sexual and racial/ethnicity minorities is a putative risk factor for youth tobacco use, understanding health disparities in youth E-cigarette use at the intersection of sexual orientation, race, and ethnicity is still lacking. This study aims to examine the differences in E-cigarette use prevalence among U.S. youth at the intersections of sexual orientation with race and ethnicity.

METHODS

E-cigarette use status (never, experimental, or current use) was analyzed among 38,510 U.S. youth using a pooled data set from the Youth Risk Behavior Surveillance System 2015-2019. The weighted E-cigarette use status between youth at the intersections of sexual orientation with race and ethnicity was reported, stratified by sex. Multivariable multinomial regression adjusting for relevant covariates was further conducted. Data analyses were performed in April 2022.

RESULTS

After controlling for other covariates, the RRR of current E-cigarette use compared with never use between lesbian Black girls (and heterosexual Black girls) was higher than between lesbian White girls (and heterosexual White girls) (adjusted RRR=6.99; 95% CI=2.21, 22.14). The RRR of current E-cigarette use compared with never use between lesbian other race/multiracial girls (and heterosexual other race/multi-racial girls) was higher than between lesbian White girls (and heterosexual White girls) (adjusted RRR=3.60; 95% CI=1.06, 12.26).

CONCLUSIONS

This study has shown that sexual minority Black girls were more likely to currently use E-cigarettes than heterosexual Black girls. Future studies should examine the underlying reasons for current E-cigarette use among girls with intersectional identities, including race and sexual orientation.

U.S. Trends in Age of Cigar Smoking Initiation by Race/Ethnicity and Education

INTRODUCTION

Younger age of initiating cigar smoking is associated with greater nicotine dependence and current use. Age of initiating cigarette smoking has increased over time, whereas trends in age of initiating cigar smoking remain understudied. These trends were examined by race/ethnicity, by education, and at their intersection.

METHODS

The analytic sample included U.S. Hispanic, Black, and White cigar-ever-smokers aged 24‒25 years (n=29,715) from the 2002‒2019 National Survey on Drug Use and Health. Participants reported their age, race/ethnicity, sex, education (≤high school; some college; ≥bachelor's degree), age of initiating cannabis use, and cigar smoking. Weighted multivariable linear regressions adjusted for sex and age of cannabis use initiation were used to examine trends in age of initiating cigar smoking by race/ethnicity, education, and education Χ year interactions within racial/ethnic groups. Age of initiating cigar smoking comparisons across race/ethnicity and education were examined using the most recent 2019 data.

RESULTS

During 2002‒2019, across education, White cigar-ever-smokers started smoking cigars at an older age, whereas it remained unchanged among Hispanic cigar-ever-smokers. Among Black cigar-ever-smokers, age of initiating cigar smoking did not change among those with ≤high school and some college, and was older among those with ≥bachelor's degree. In 2019, age of initiating cigar smoking did not vary by educational level among Hispanic and White cigar-ever-smokers. Black cigar-ever-smokers with ≥bachelor's degree initiated cigar smoking at older ages than their White counterparts.

CONCLUSIONS

Black individuals experienced widening education-related disparities, and Hispanic individuals had no progress in delaying age of initiating cigar smoking. Regulatory action banning cigar flavors may impact these trends.

Comparing COVID-19 Vaccination Outcomes with Parental Values, Beliefs, Attitudes, and Hesitancy Status, 2021-2022

Despite the availability of safe and effective COVID-19 vaccines, vaccine acceptance has been low, particularly among parents. More information is needed on parental decision-making. We conducted a prospective cohort study from October 2021 to March 2022 among 334 parents in a large urban/suburban pediatric primary care network and linked longitudinal survey responses about attitudes and beliefs on vaccination, social norms, and access to vaccination services for COVID-19 to electronic health-record-derived vaccination outcomes for their eldest age-eligible children in June 2022. The odds of accepting two doses of COVID-19 vaccine for their child was higher in respondents who indicated the COVID-19 vaccine would be very safe (aOR [CI]: 2.69 [1.47−4.99], p = 0.001), as well as those who previously vaccinated their child against influenza (aOR [CI]: 4.07 [2.08−8.12], p < 0.001). The odds of vaccinating their child were lower for respondents who attended suburban vs. urban practices (aOR [CI]: 0.38 [0.21−0.67], p = 0.001). Parents in the cohort were active users of social media; the majority (78%) used their phone to check social media platforms at least once per day. Our findings suggest that healthcare providers and policymakers can focus on improving vaccination coverage among children living in suburban neighborhoods through targeted mobile-based messaging emphasizing safety to their parents.

Factors Influencing Parental and Individual COVID-19 Vaccine Decision Making in a Pediatric Network

Aspects of the COVID-19 vaccination campaign differed from routine vaccines, including emergency use authorizations, the prioritization of access, and the politicization of messaging. Subsequently, many parents reported lower vaccine confidence relative to routine vaccines, and vaccination coverage stalled below targets. This study aimed to understand parental vaccine decision making and compare COVID-19 versus routine vaccine decision making. We conducted nine virtual focus groups between 25 February 2022-11 March 2022 with parents (n = 41) of the Children's Hospital of Philadelphia's patients, recruited via email and stratified by vaccine hesitancy status (non-hesitant vs. hesitant). Transcripts were analyzed using the vaccine hesitancy matrix domains. Of 41 total participants, 25 (61.0%) were non-hesitant, 16 (39.0%) were hesitant or their children were not up-to-date on adolescent vaccines, and most self-identified as female (95.1%) and White/Caucasian (61.0%). Most participants (87.5%) were fully vaccinated against COVID-19 and many of their first children (n = 26, 63.4%) were vaccinated against influenza. Several themes emerged regarding decision making: individual influences, group influences, vaccine and vaccine program influences, and contextual influences. While some influences were similar for routine and COVID-19 vaccine decision making (e.g., needing evidence-based information), other factors were vaccine- or situation-specific. Building trust requires a multi-faceted concerted effort that involves addressing the complex vaccine decision-making process.

Presence of Content Appealing to Youth on Cannabis-Infused Edibles Packaging

BACKGROUND

There is a lack of consistent regulation of cannabis edibles packaging to restrict youth-appealing content in the United States.

OBJECTIVE

To describe content appealing to youth on U.S. cannabis-infused edibles packaging.

METHODS

We analyzed 256 photos of cannabis-infused edibles packaging collected from U.S. adults from 25 states, District of Columbia, and Puerto Rico between May 2020 to August 2021. We coded the presence of product knockoffs, human and non-human creatures, images indicating flavor, text indicating flavor, and the number of colors. We compared these codes across states' legalization status (medical and non-medical cannabis, medical cannabis only, or limited cannabis legalization).

RESULTS

Overall, 15% of packages resembled product knockoffs, 23% contained human/non-human creatures, 35% contained flavor images, 91% contained flavor text, and median number of colors was 5 (range from 1 to 10+). Packages purchased in states with medical and non-medical cannabis, medical cannabis only, or limited cannabis legalization differed significantly on product knockoffs (11%, 26%, 38%, p = 0.007), human/non-human creatures (19%, 33%, 63%, p = 0.002), flavor text (93%, 81%, 100%, p = 0.046), and number of colors (median of 5, 5, and 10, p = 0.022).

CONCLUSIONS

Existing laws have not adequately limited content appealing to youth on U.S. cannabis-infused edibles packaging. Robust and consistent regulations in the U.S. are needed to ensure that the packaging of such products does not contain content that appeal to youth and lead to initiation or inadvertent ingestion.

Smokers' Likelihood to Engage With Information and Misinformation on Twitter About the Relative Harms of e-Cigarette Use: Results From a Randomized Controlled Trial

Background

Information and misinformation on the internet about e-cigarette harms may increase smokers’ misperceptions of e-cigarettes. There is limited research on smokers’ engagement with information and misinformation about e-cigarettes on social media.

Objective

This study assessed smokers’ likelihood to engage with—defined as replying, retweeting, liking, and sharing—tweets that contain information and misinformation and uncertainty about the harms of e-cigarettes.

Methods

We conducted a web-based randomized controlled trial among 2400 UK and US adult smokers who did not vape in the past 30 days. Participants were randomly assigned to view four tweets in one of four conditions: (1) e-cigarettes are as harmful or more harmful than smoking, (2) e-cigarettes are completely harmless, (3) uncertainty about e-cigarette harms, or (4) control (physical activity). The outcome measure was participants’ likelihood of engaging with tweets, which comprised the sum of whether they would reply, retweet, like, and share each tweet. We fitted Poisson regression models to predict the likelihood of engagement with tweets among 974 Twitter users and 1287 non-Twitter social media users, adjusting for covariates and stratified by UK and US participants.

Results

Among Twitter users, participants were more likely to engage with tweets in condition 1 (e-cigarettes are as harmful or more harmful than smoking) than in condition 2 (e-cigarettes are completely harmless). Among other social media users, participants were more likely to likely to engage with tweets in condition 1 than in conditions 2 and 3 (e-cigarettes are completely harmless and uncertainty about e-cigarette harms).

Conclusions

Tweets stating information and misinformation that e-cigarettes were as harmful or more harmful than smoking regular cigarettes may receive higher engagement than tweets indicating e-cigarettes were completely harmless.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 16082420; https://doi.org/10.1186/ISRCTN16082420

Emotional Responses and Perceived Relative Harm Mediate the Effect of Exposure to Misinformation about E-Cigarettes on Twitter and Intention to Purchase E-Cigarettes among Adult Smokers

There is a gap in knowledge on the affective mechanisms underlying effects of exposure to health misinformation. This study aimed to understand whether discrete emotional responses and perceived relative harm of e-cigarettes versus smoking mediate the effect of exposure to tweets about the harms of e-cigarettes on Twitter and intention to purchase e-cigarettes among adult smokers. We conducted a web-based experiment in November 2019 among 2400 adult smokers who were randomly assigned to view one of four conditions of tweets containing different levels of misinformation. We fitted mediation models using structural equation modeling and bootstrap procedures to assess the indirect effects of exposure to tweets through perceived relative harm of e-cigarettes and six discrete emotions. Our findings support that exposure to tweets about harms of e-cigarettes influence intention to purchase e-cigarettes through perceived relative harm, discrete emotional responses, and serially through emotional responses and perceived relative harm. Feeling worried, hopeful, and happy mediated the effects of condition on intention to purchase e-cigarettes. Feeling scared, worried, angry, and hopeful mediated the effects serially through perceived relative harm. Affective responses and perceived relative harm following exposure to misinformation about e-cigarette harm may mediate the relationship with intention to purchase e-cigarettes among adult smokers.

Trust, influence, and community: Why pharmacists and pharmacies are central for addressing vaccine hesitancy

In 2019, the World Health Organization listed vaccine hesitancy, defined as the reluctance or refusal to vaccinate against preventable infectious diseases, as one of the top ten threats to global health. To address hesitancy, we must focus our attention on building vaccine confidence, trust in the vaccine itself, in providers who administer vaccines, and in the process that leads to vaccine licensure and the recommended vaccination schedule. Building vaccine confidence, particularly in communities that have higher levels of distrust of vaccines and low vaccination coverage rates, is a critical public health priority, particularly in the current climate as the United States and the global public health community grapple with the coronavirus disease 2019 pandemic. In this commentary, we focus on the central role that pharmacists play in promoting the health and wellness of the local communities in which they are embedded, how they are one of the most trusted sources for their communities when it comes to health information and care, and their unique position in making a profound contribution to building vaccine confidence. We propose to arm all health professionals with a tool, the ASPIRE framework, which serves as a series of actionable steps to facilitate conversations with communities. This framework is intended to assist pharmacists in communicating with community members who may have concerns about vaccines by sharing trustworthy health information about vaccines to increase vaccine adoption. We conclude that it is insufficient to merely relay accurate health information about vaccines to the public and expect dramatic increases to vaccination rates. Accurate health information needs to be conveyed by trusted sources. Open engagement and dialogue layered on top of fundamental facts and messages are central to building confidence. Pharmacists and other providers can use tools such as ASPIRE to guide their conversations with community members to increase vaccine adoption.

How the Expansion of the U.S. Preventive Services Task Force Lung Cancer Screening Eligibility May Improve Health Equity Among Diverse Sexual and Gender Minority Populations

This article discusses the potential implications of addressing lung cancer disparities among diverse sexual and gender minority (SGM) populations based on the recently expanded U.S. Preventive Services Task Force 2021 guidelines on lung cancer screening using low-dose computed tomography to include adults aged 50-80 years who have a 20 pack-year smoking history (one pack-year equals smoking one pack or 20 cigarettes per day for 1 year) and currently smoke or have quit within the past 15 years. Research on lung cancer screening barriers and facilitators and efforts to increase awareness and screening uptake among SGM populations are proposed.

Effects of brief exposure to misinformation about e-cigarette harms on twitter: a randomised controlled experiment

OBJECTIVES

To assess the effect of exposure to misinformation about e-cigarette harms found on Twitter on adult current smokers' intention to quit smoking cigarettes, intention to purchase e-cigarettes and perceived relative harm of e-cigarettes compared with regular cigarettes.

SETTING

An online randomised controlled experiment conducted in November 2019 among USA and UK current smokers.

PARTICIPANTS

2400 adult current smokers aged ≥18 years who were not current e-cigarette users recruited from an online panel. Participants' were randomised in a 1:1:1:1 ratio using a least-fill randomiser function.

INTERVENTIONS

Viewing 4 tweets in random order within one of four conditions: (1) e-cigarettes are just as or more harmful than smoking, (2) e-cigarettes are completely harmless, (3) e-cigarette harms are uncertain, and (4) a control condition of tweets about physical activity.

PRIMARY OUTCOMES MEASURES

Self-reported post-test intention to quit smoking cigarettes, intention to purchase e-cigarettes, and perceived relative harm of e-cigarettes compared with smoking.

RESULTS

Among US and UK participants, after controlling for baseline measures of the outcome, exposure to tweets that e-cigarettes are as or more harmful than smoking versus control was associated with lower post-test intention to purchase e-cigarettes (β=-0.339, 95% CI -0.487 to -0.191, p<0.001) and increased post-test perceived relative harm of e-cigarettes (β=0.341, 95% CI 0.273 to 0.410, p<0.001). Among US smokers, exposure to tweets that e-cigarettes are completely harmless was associated with higher post-test intention to purchase e-cigarettes (β=0.229, 95% CI 0.002 to 0.456, p=0.048) and lower post-test perceived relative harm of e-cigarettes (β=-0.154, 95% CI -0.258 to -0.050, p=0.004).

CONCLUSIONS

US and UK adult current smokers may be deterred from considering using e-cigarettes after brief exposure to tweets that e-cigarettes were just as or more harmful than smoking. Conversely, US adult current smokers may be encouraged to use e-cigarettes after exposure to tweets that e-cigarettes are completely harmless. These findings suggest that misinformation about e-cigarette harms may influence some adult smokers' decisions to consider using e-cigarettes.

TRIAL REGISTRATION NUMBER

ISRCTN16082420.

Differences in Tobacco Product Use by Sexual Orientation and Violence Factors Among United States Youth

OBJECTIVE

To assess differences in the relationship between violence factor exposure and tobacco product pattern use (exclusive and poly), we hypothesized that compared with heterosexuals, sexual minority youth would be more likely to report exclusive-tobacco and poly-tobacco use patterns, and controlling for violence factors would attenuate these associations.

STUDY DESIGN

Data from 27 513 US high-school youth were analyzed from the Centers for Disease Control and Prevention's Youth Risk Factor Surveillance System from 2015 and 2017. We fit sex-stratified, weighted, adjusted log-Poisson models to compare past 30-day exclusive combustible, exclusive e-cigarette, and poly-tobacco use in across sexual orientation. Then, models were adjusted for past-year experiences of physical fighting, bullying, attempting suicide, and physical and sexual dating violence.

RESULTS

Compared with heterosexual girls with other-sex partners, sexual minority girls were more likely to use exclusive combustible, exclusive e-cigarette, or poly-tobacco products. When adjusting for violence factors, most tobacco use associations were partially attenuated for all sexual minority girls, and completely attenuated for exclusive e-cigarette use among all sexual minority girls.

CONCLUSIONS

Sexual minority girls have greater exclusive- and poly-tobacco use compared with heterosexual girls. Tobacco interventions for sexual minority youth should address the risks of poly-tobacco use as well as violence-based risk factors.

Association Between Social Media Use and Vaping Among Florida Adolescents, 2019

INTRODUCTION

With the growing popularity of vaping, evidence has emerged about the association between social media use and vaping among adolescents, possibly because of the proliferation of e-cigarette advertisements and other related content on social media. Our study examined the association between social media use and vaping among adolescents.

METHODS

Using data from the 2019 Florida Youth Tobacco Survey (N = 10,776), we conducted logistic regression models on adolescent vaping status (experimental and current vaping) by nondaily and daily use of social media platforms - Facebook, Instagram, Twitter and Snapchat, controlling for other confounders.

RESULTS

Use of all 4 selected social media platforms was significantly associated with vaping status (P <.001 for all). Once jointly analyzed, daily use of Instagram was significantly associated with increased relative risks of experimental (adjusted relative risk ratio [aRRR] = 1.76; 95% CI, 1.38-2.25) and current vaping (aRRR = 1.51; 95% CI, 1.16-1.95); nondaily use of Snapchat was significantly associated with increased relative risk of experimental (aRRR = 1.57; 95% CI, 1.17-2.10) and current vaping (aRRR = 1.87; 95% CI, 1.31-2.66); daily use of Snapchat was associated with increased relative risk of experimental (aRRR = 2.38; 95% CI, 1.85-3.08) and current vaping (aRRR = 5.09; 95% CI, 3.78-6.86); nondaily use of Facebook was associated with increased relative risk of current vaping (aRRR = 1.20; 95% CI, 1.00-1.43), and nondaily use of Twitter was associated with increased relative risk of current vaping (aRRR = 1.29; 95% CI, 1.07-1.56).

CONCLUSION

Multilevel efforts are warranted to monitor social media use and vaping status among adolescents, including media use monitoring plans, developing counter-marketing campaigns, and strict regulatory action on social media.

Nicotine and cannabis vaping among adolescents in treatment for substance use disorders

This study examined nicotine and cannabis vaping among adolescents in treatment for substance use disorders. Participants were 363 adolescents aged 12-17 (66% male, mean age = 15.5 [SD = 1.3], 46% non-Hispanic white) seen for a specialty addiction intake evaluation between 2017 and 2019 at one of six medical offices of a large, integrated health care system in Northern California. Multivariable logistic regression models tested for associations of sociodemographics, cigarette smoking, and substance use disorders with vaping behaviors. A majority of adolescents reported ever (68%) or current vaping (60%) of nicotine and/or cannabis; current vaping was similar for nicotine (50%) and cannabis (51%); 40% reported current vaping of both. Current smokers (6% of the sample) had higher odds of ever vaping (aOR = 3.95, 95%CI: 1.04-14.95). Black (versus non-Hispanic white) adolescents had lower odds of current nicotine vaping (aOR = 0.08, 95%CI: 0.02-0.37) and current vaping of both nicotine and cannabis (aOR = 0.12, 95%CI: 0.03-0.60). Having an alcohol use disorder was associated with current vaping (aOR = 2.14, 95%CI: 1.06-4.33). Those who endorsed that most friends get drunk/high (aOR = 1.87, 95%CI: 1.02-3.42) or that cannabis was their substance of choice (aOR = 2.36, 95%CI: 1.16-4.81) had higher odds of current cannabis vaping. Higher neighborhood household income ($80,000-$120,000 and >$120,000 vs. <$80,000, aORs = 2.05-9.48), never versus ever blunt use (aORs = 2.47-8.68), and intakes in 2018 and 2019 versus 2017 (aORs = 2.18-5.38) were associated with higher odds of all vaping outcomes. Vaping was common among adolescents in addiction treatment and varied with sociodemographics and substance-related factors. Research should assess how vaping impacts the development of substance use disorders and whether it interferes with addiction treatment.

Association of Coming Out as Lesbian, Gay, and Bisexual+ and Risk of Cigarette Smoking in a Nationally Representative Sample of Youth and Young Adults

Importance

Coming out as lesbian, gay, bisexual, or other identities besides heterosexual (LGB+) may represent a susceptible period for cigarette smoking initiation in youth and young adults.

Objective

To assess whether young people who change their sexual identity have higher risk of cigarette smoking initiation and current smoking compared with those with consistent sexual identities.

Design, Setting, and Participants

This cohort study used data from the nationally representative Population Assessment of Tobacco and Health study (wave 1, 2013-2014; wave 2, 2014-2015; wave 3, 2015-2016; wave 4, 2016-2018). Youth and young adults aged 14 to 29 years who were never smokers at wave 1 were included in this study. Analysis began October 2018 and ended June 2020.

Exposures

Consistent sexual identity (consistently heterosexual, consistently LGB+) vs changing sexual identity (coming out as LGB+, other LGB+ patterns) based on 4 waves of sexual identity data. Identities were further classified by distinguishing between bisexual and lesbian, gay, and other nonheterosexual identities.

Main Outcomes and Measures

Smoking initiation and current cigarette smoking at wave 4.

Results

Among 7843 individuals who never smoked at wave 1, 6991 (90.7%) reported a consistent sexual identity, and 852 (9.3%) changed sexual identity across waves. The mean (SE) baseline age of participants who reported consistent heterosexuality was 20.1 (0.8) years; consistently LGB+, 20.0 (3.7) years; coming out as LGB+, 18.0 (2.9) years, and other LGB+ pattern, 20.3 (3.8) years. A total of 14.1% (weighted) initiated smoking, and 6.3% were current smokers at wave 4. Compared with consistently heterosexual identities, coming out as LGB+ (23% vs 13%; odds ratio [OR], 1.72; 95% CI, 1.34-2.20), consistently LGB+ identities (17% vs 13%; OR, 1.45; 95% CI, 1.03-2.04), and other LGB+ patterns (17% vs 13%; OR, 1.47; 95% CI, 1.04-2.08) were positively associated with smoking initiation by wave 4. Compared with consistently heterosexual identities, ORs for smoking initiation were 2.24 (28% vs 13%; 95% CI, 1.72-2.92) for coming out as bisexual, 1.99 (23% vs 13%; 95% CI, 1.20-3.29) for consistently LGB+ with change to/from bisexual, and 2.20 (23% vs 13%; 95% CI, 1.40-3.46) for other LGB+ patterns with change to/from bisexual identity. Current smoking estimates were similar to those for smoking initiation.

Conclusions and Relevance

Compared with consistently heterosexual identities, changing sexual identity over follow-up was associated with smoking initiation and current smoking. The risk associated with changing sexual identities was concentrated among participants coming out as bisexual or reporting other changes in their identity to/from being bisexual. More research is needed on mechanisms underlying the association between changing sexual identity and smoking initiation to inform tailored prevention programs and tobacco regulations.

Inequities in tobacco advertising exposure among young adult sexual, racial and ethnic minorities: examining intersectionality of sexual orientation with race and ethnicity

OBJECTIVE

This study examined sexual orientation differences in encoded exposure to tobacco product ads and intersections with race and ethnicity.

METHODS

We analysed data from young adults (18-24) from the US Population Assessment of Tobacco and Health Study in 2013 and 2014 (N=9110). First, we compared encoded exposure to cigarette, electronic cigarette (e-cigarette), cigar and smokeless tobacco ads between sexual minorities (lesbian/gay, bisexual and something else) versus heterosexual young adults. We then analysed encoded ad exposure across sexual orientation, racial and ethnic subgroups. Analyses controlled for demographic and tobacco use variables.

RESULTS

Bisexual women had significantly higher prevalence of encoded exposure to cigarette and cigar ads compared with heterosexual women, and significantly higher prevalence of encoded e-cigarette ad exposure compared with both heterosexual and lesbian/gay women. There were no significant differences in encoded ad exposure between lesbian versus heterosexual women and between gay or bisexual men versus heterosexual men. Compared with heterosexual white counterparts, increased encoded ad exposures were reported by heterosexual black women (cigarette and cigar ads), black heterosexual men (cigar ads) and bisexual black women (cigarette and cigar ads). Compared with heterosexual non- Hispanic counterparts, increased encoded ad exposures were reported by bisexual Hispanic women (cigarette, e-cigarette and cigar ads) and heterosexual Hispanic men (cigarettes and cigar ads).

CONCLUSION

Sexual minority women of colour and black heterosexual women and men have increased encoded exposure to certain forms of tobacco ads. Further research is needed to address the impact of tobacco ads among multiple minority individuals based on sex, sexual orientation, race and ethnicity.

Changes in Recall to E-Cigarette Advertisement Exposure among Florida Youth, 2016-2019

The Centers for Disease Control and Prevention reported increases in exposure to e-cigarette ads among US middle and high school students from 2014-2016. This study examines changes in exposure to e-cigarette ads by source among youth in Florida. Methods: We analyzed Florida Youth Tobacco Survey (FYTS) data from 2016-2019 (n = 149,407). We calculated the weighted prevalence of exposure to ads by source (on radio, TV, internet, billboards/outdoor signs, or magazines/newspapers) across years and tested differences in prevalence from 2016-2019. We used logistic regression to examine the changes from 2016-2019 and further conducted multivariable logistic regression to examine the likelihood of past-30-day e-cigarette ad recall as a function of sociodemographics, tobacco use among family members, and current use of tobacco products. Results: Exposure to any type of e-cigarette ads decreased significantly from 2016 (weighted, 55.4%, 95% CI = 54.7, 56.1) to 2018 (47.3%, 95% CI = 46.6, 48.1), but rebounded in 2019 (57.0%, 95% CI = 55.7, 58.4). In multivariable logistic models, the following correlates were consistently associated with higher past-30-day exposure to any source of e-cigarette ads: survey year of 2019 (vs. 2016), being a high school (vs. middle school) student, female (vs. male), current use of e-cigarettes, current other tobacco use, and having a family member who uses tobacco. Conclusion: These findings suggest the need for continued surveillance of e-cigarette marketing practices and policies to prevent youth exposure to e-cigarette ads.

We are in This Together: Promoting Health Equity, Diversity, and Inclusion in Tobacco Research for Sexual and Gender Minority Populations

INTRODUCTION

Sexual and gender minority (SGM) individuals have higher tobacco use prevalence and consequently higher burden of tobacco-caused diseases, including cancer and cardiovascular disease compared with their heterosexual or cisgender counterparts. Yet, there is a critical gap in research focused on measuring SGM tobacco-related health disparities and addressing unmet needs of SGM individuals in the context of nicotine and tobacco research.

AIMS AND METHODS

In this commentary, we summarize recommendations discussed during a pre-conference workshop focused on challenges and opportunities in conducting SGM tobacco control research at the 2019 Society for Research on Nicotine and Tobacco Annual Meeting.

RESULTS

Specifically, we recommend defining and measuring SGM identity in all nicotine and tobacco research routinely, using novel methods to engage a demographically diverse sample of the SGM population, and eliciting SGM community voices in tobacco control research.

CONCLUSIONS

Addressing these critical research gaps will enable the scientific community to generate the data to fully understand and support SGM individuals in tobacco use prevention and cessation.

IMPLICATIONS

Tobacco use and its consequences have become increasingly concentrated in disadvantaged groups, including sexual and gender minority (SGM) populations. Through concrete recommendations in this commentary, we aimed to promote health equity, diversity, and inclusion in tobacco research for SGM populations by urging the scientific community to consider expanding efforts to monitor and address tobacco-related health disparities of SGM populations within their respective research programs.

Tobacco-Related Counseling and Documentation in Adolescent Primary Care Practice: Challenges and Opportunities

INTRODUCTION

Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to (1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and (2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices.

METHODS

Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently.

RESULTS

In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include noncigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes.

CONCLUSIONS

Tobacco use status prompts should be revised for clarity and include noncigarette tobacco products and TSE. Provider education on noncigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers.

IMPLICATIONS

Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to noncigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population.

Effects of Current and Enhanced Tobacco Corrective Messages on Smokers' Intention to Quit Smoking and Intention to Purchase Cigarettes

INTRODUCTION

A federal court has ordered tobacco companies to issue corrective messages to address tobacco-related misperceptions. This study examined the effects of viewing current versus two enhanced versions of tobacco corrective messages on smokers' intention to quit smoking and intention to purchase cigarettes.

METHODS

US adult smokers (N = 803) were randomly assigned to view (1) two current tobacco corrective messages (Current), (2) two corrective messages that include an industry deception statement (Industry Deception), or (3) two corrective messages with an industry deception statement and testimonials of people harmed by smoking (Industry Deception + Testimonial). Outcomes were pretest-posttest change in intentions to quit smoking and posttest intention to purchase cigarette measures.

RESULTS

Intention to quit smoking increased significantly after viewing the Current corrective messages versus baseline. In addition, viewing the Industry Deception + Testimonial messages increased intention to quit smoking compared with the Current corrective condition and the Industry Deception condition. Hispanic smokers had increased intention to quit smoking and decreased intention to purchase cigarettes to a greater degree than non-Hispanic smokers in response to Industry Deception + Testimonial messages. There was no significant difference in intention to purchase cigarettes across conditions.

CONCLUSIONS

Enhancing the current corrective statements by including an industry deception statement and testimonials may strengthen effects and contribute to remedying the effects of tobacco misinformation.

IMPLICATIONS

Previous research has found that draft or proposed versions of tobacco industry corrective messages are effective in correcting beliefs and knowledge. However, studies have not examined how the current court-ordered corrective messages could change intention to quit smoking and intention to purchase cigarettes nor whether enhanced messages could perform better. Study findings suggest that the current corrective messages can increase smokers' intention to quit smoking beyond their baseline intention. More importantly, enhancing corrective messages by including an industry deception statement and testimonial was found to be more effective than current corrective messages. Findings can inform future iterations of tobacco correctives and strategies to reverse the effects of tobacco misinformation.

Sources of awareness, perceptions, and use of JUUL e-cigarettes among adult cigarette smokers

Introduction

Given JUUL e-cigarettes’ potential for smoking cessation and its drastically increased sales in the U.S., more evidence is needed to understand the antecedents of JUUL use among adult cigarette smokers. This study assessed the relationships between awareness sources, perceptions about using JUUL, and JUUL use behavior.

Methods

In an online study with adult smokers who were aware of JUUL e-cigarettes (n = 341), respondents reported their sources for learning about JUUL, perceptions of using JUUL versus Vuse (a competitor brand), and ever and past-30-day (current) JUUL use. Multivariable logistic regressions were used to examine the associations between awareness sources, perceptions, and JUUL use, adjusting for covariates.

Results

Learning about JUUL through internet ads was associated with positive perceptions about JUUL compared to Vuse, including JUUL was more fun to use (AOR = 2.04, 95% CI = 1.21, 3.42) and tastier (AOR = 1.96, 95% CI = 1.19, 3.22). Perceiving JUUL as being tastier (AOR = 2.07, 95% CI = 1.23, 3.49), more helpful for quitting smoking (AOR = 2.07, 95% CI = 1.22, 3.53), and cooler (AOR = 2.07, 95% CI = 1.21, 3.56) than Vuse was associated with ever using JUUL. Only perceiving JUUL as being tastier (AOR = 1.98, 95% CI = 1.10, 3.59) than Vuse was associated with current use of JUUL.

Discussion

Adult smokers may be more likely to focus on the sensory and social experience of using JUUL rather than JUUL’s smoking cessation benefits. These positive perceptions are likely to be influenced by internet ads in general instead of JUUL’s official marketing outlets. They are also more likely to sustain JUUL use than JUUL’s perceived smoking cessation benefits.

Longitudinal Associations Between Income Changes and Incident Cardiovascular Disease: The Atherosclerosis Risk in Communities Study

Importance

Higher income is associated with lower incident cardiovascular disease (CVD). However, there is limited research on the association between changes in income and incident CVD.

Objective

To examine the association between change in household income and subsequent risk of CVD.

Design, Setting, and Participants

The Atherosclerosis Risk In Communities (ARIC) study is an ongoing, prospective cohort of 15 792 community-dwelling men and women, of mostly black or white race, from 4 centers in the United States (Jackson, Mississippi; Washington County, Maryland; suburbs of Minneapolis, Minnesota; and Forsyth County, North Carolina), beginning in 1987. For our analysis, participants were followed up until December 31, 2016.

Exposures

Participants were categorized based on whether their household income dropped by more than 50% (income drop), remained unchanged/changed less than 50% (income unchanged), or increased by more than 50% (income rise) over a mean (SD) period of approximately 6 (0.3) years between ARIC visit 1 (1987-1989) and visit 3 (1993-1995).

Main Outcomes and Measures

Our primary outcome was incidence of CVD after ARIC visit 3, including myocardial infarction (MI), fatal coronary heart disease, heart failure (HF), or stroke during a mean (SD) of 17 (7) years. Analyses were adjusted for sociodemographic variables, health behaviors, and CVD biomarkers.

Results

Of the 8989 included participants (mean [SD] age at enrollment was 53 [6] years, 1820 participants were black [20%], and 3835 participants were men [43%]), 900 participants (10%) experienced an income drop, 6284 participants (70%) had incomes that remained relatively unchanged, and 1805 participants (20%) experienced an income rise. After full adjustment, those with an income drop experienced significantly higher risk of incident CVD compared with those whose incomes remained relatively unchanged (hazard ratio, 1.17; 95% CI, 1.03-1.32). Those with an income rise experienced significantly lower risk of incident CVD compared with those whose incomes remained relatively unchanged (hazard ratio, 0.86; 95% CI, 0.77-0.96).

Conclusions and Relevance

Income drop over 6 years was associated with higher risk of subsequent incident CVD over 17 years, while income rise over 6 years was associated with lower risk of subsequent incident CVD over 17 years. Health professionals should have greater awareness of the influence of income change on the health of their patients.

Youth and Young Adult Use of Pod-Based Electronic Cigarettes From 2015 to 2019: A Systematic Review

IMPORTANCE

The use of electronic cigarettes (e-cigarettes) has rapidly increased among youth and young adults, but knowledge gaps exist on the potential health effects of using recently introduced pod-based e-cigarettes.

OBJECTIVE

To conduct a systematic review of recent peer-reviewed scientific literature on pod-based e-cigarettes.

EVIDENCE REVIEW

A search of online databases, including PubMed, Web of Science, Embase, and EBSCO HOST, was conducted to identify pod-based e-cigarette-associated articles from June 2015 (the time when JUUL [JUUL Labs] was introduced) to June 2019. We included English-language articles that presented primary data on pod-based e-cigarettes.

FINDINGS

Pod-based e-cigarettes represent a substantial evolution in design by increasing the efficient delivery of nicotine. While these products may contain less harmful constituents than other types of e-cigarettes and cigarettes, there is no evidence that the levels found are safe among youth. There is evidence for higher nicotine dependence associated with their use. Pod-based e-cigarette brands, compared with other e-cigarette brands, have targeted youth and young adults with social media marketing. There was less discussion about the use of these products as smoking cessation devices or their health risks on social media. The social acceptability and favorable perceptions of pod-based e-cigarettes may underlie the use of these products.

CONCLUSIONS AND RELEVANCE

The appeal and dependence potential of pod-based e-cigarettes for youth emphasize the need for stronger regulations on product design, social media, marketing channels, and youth access together with health communications that emphasize the risks of nicotine dependence.

Interpersonal Diffusion of Health Information: Health Information Mavenism among People Age 65 and over in Japan

Health information mavens are those who provide and share health information with others via interpersonal communication. We investigated the characteristics of health information mavens among Japanese elderly and whether those who share health information with others via interpersonal communication behave more healthily or report better health status compared to their peers. Data come from a cross-sectional analysis of 27,414 participants in the Japanese Gerontological Evaluation Study (JAGES) (mean age = 74 years). Mavenism is associated with being female, younger age, higher educational status, and perceived financial condition, as well as larger social networks, higher social support, and media exposure. A higher mavenism score was associated with healthier dietary, and exercise behaviors, but not associated with smoking or alcohol consumption. Mavens were more likely to have a disease and/or report disease symptoms. Health information mavens have the potential to facilitate word-of-mouth communication among older adults, who tend to be more disadvantaged in terms of health information access compared to younger populations.

Associations Between Exposure and Receptivity to Branded Cigarette Advertising and Subsequent Brand Preference Among US Young Adults

INTRODUCTION

Exposure and receptivity to cigarette advertising are well-established predictors of cigarette use overall. However, less is known about whether exposure and receptivity to advertising for specific brands of cigarettes (ie, Marlboro, Camel, and Newport) are longitudinally associated with any subsequent cigarette use and subsequent use of those specific brands.

METHODS

We analyzed data from a US sample of 7325 young adults aged 18-24 years who completed both Wave 1 and Wave 2 of the Population Assessment of Tobacco and Health study. Weighted logistic regression models were used to examine (1) among Wave 1 never-smokers, associations between Wave 1 exposure and receptivity to advertising for Marlboro, Camel, and Newport and subsequent overall and brand-specific smoking initiation at Wave 2, and (2) among Wave 1 ever-smokers, associations between Wave 1 exposure and receptivity to advertising for Marlboro, Camel, and Newport and subsequent preference of those brands at Wave 2.

RESULTS

Among Wave 1 young-adult never-smokers, exposure to Camel advertising, but not Marlboro or Newport, was associated with smoking initiation with any brand of cigarettes at Wave 2. Among Wave 1 young-adult ever-smokers, receptivity to Marlboro, Camel, and Newport advertising was associated with subsequent preference for each brand, respectively, at Wave 2.

CONCLUSIONS

This study found evidence for the association between receptivity to branded cigarette marketing and subsequent use of that brand. These findings provide evidence regarding the pathways through which cigarette marketing attracts young adults to use cigarettes and can inform tobacco prevention and counter-marketing efforts.

IMPLICATIONS

This study extends prior work on the effects of cigarette advertising exposure and receptivity by illustrating the brand specificity of this advertising. These findings provide evidence that receptivity to branded cigarette advertising is longitudinally associated with preference for those specific cigarette brands.

Engagement With Online Tobacco Marketing Among Adolescents in the United States: 2013-2014 to 2014-2015

OBJECTIVE

To assess changes in engagement with online tobacco and electronic cigarette (e-cigarette) marketing (online tobacco marketing) among adolescents in the United States between 2013 and 2015.

METHODS

We assessed the prevalence of six forms of engagement with online tobacco marketing, both overall and by brand, among adolescents sampled in Wave 1 (2013-2014; n = 13651) and Wave 2 (2014-2015; n = 12172) of the nationally representative Population Assessment for Tobacco and Health Study. Engagement was analyzed by tobacco use status: non-susceptible never tobacco users; susceptible never tobacco users; ever tobacco users, but not within the past year; and past-year tobacco users.

RESULTS

Among all adolescents, the estimated prevalence of engagement with at least one form of online tobacco marketing increased from 8.7% in 2013-2014 to 20.9% in 2014-2015. The estimated prevalence of engagement also increased over time across all tobacco use statuses (eg, from 10.5% to 26.6% among susceptible adolescents). Brand-specific engagement increased over time for cigarette, cigar, and e-cigarette brands.

CONCLUSION

Engagement with online tobacco marketing, both for tobacco and e-cigarettes, increased almost twofold over time. This increase emphasizes the dynamic nature of online tobacco marketing and its ability to reach youth. The Food and Drug Administration, in cooperation with social networking sites, should consider new approaches to regulate this novel form of marketing.

IMPLICATIONS

This is the first study to estimate the national prevalence of engagement with online tobacco marketing among adolescents over time. The estimated prevalence of this engagement approximately doubled between 2013-2014 and 2014-2015 among all adolescents and, notably, among adolescents at relatively low risk to initiate tobacco use. This increase in engagement could represent public health harm if it results in increased initiation and use of tobacco products. Stronger federal regulation of online tobacco marketing and tighter control of access to tobacco-related content by social media sites could reduce adolescents' exposure to and engagement with online tobacco marketing.

Trends in the Prevalence of Exposure to e-Cigarette Aerosol in Public Places Among US Middle and High School Students, 2015 to 2018

This survey study examines trends in and factors associated with exposure to secondhand smoke from combusted tobacco and secondhand aerosol from electronic cigarettes (e-cigarettes) among US youth from 2015 to 2018.

Testing the Effect of Vapor in ENDS Public Service Announcements on Current Smokers and ENDS Users' Psychophysiological Responses and Smoking and Vaping Urge

Electronic nicotine delivery systems (ENDS) are increasingly popular, especially among young adults. Many ENDS advertisements and anti-ENDS public service announcements (PSAs) contain portrayals of ENDS use and visible vapor. Though it is plausible that vapor would be processed in similar ways to traditional combustible cigarette smoking cues, this has not been consistently established. In a laboratory session, we assessed cognitive and emotional processing using psychophysiological measures (e.g., facial electromyography, heart rate, and skin conductance) among young participants who were either smokers only (N = 43) or dual users of ENDS and cigarettes (N = 28) as they viewed four anti-vaping PSAs depicting either vapor or no vapor. Self-report urge to smoke traditional cigarettes and urge to vape and recognition (encoding) of information within the PSAs were measured following each PSA. Orbicularis oculi activation (positive emotion), heart rate deceleration (cognitive resource allocation), recognition (encoding), and vaping urge were greater in the vapor-present condition relative to vapor-absent condition. Hence, the presence of vapor in anti-vaping PSAs activates the approach/appetitive motivational system indicated by greater positive emotion, cognitive resource allocation, and memory, but also greater vaping urge compared to PSAs absent in vapor. Recommendations for inclusion of vapor and design of anti-vaping PSAs are discussed.