Effects of a Social Media Intervention on Vaping Intentions: Randomized Dose-Response Experiment

BACKGROUND

e-Cigarette use, especially by young adults, is at unacceptably high levels and represents a public health risk factor. Digital media are increasingly being used to deliver antivaping campaigns, but little is known about their effectiveness or the dose-response effects of content delivery.

OBJECTIVE

The objectives of this study were to evaluate (1) the effectiveness of a 60-day antivaping social media intervention in changing vaping use intentions and beliefs related to the stimulus content and (2) the dose-response effects of varying levels of exposure to the intervention on vaping outcomes, including anti-industry beliefs, vaping intentions, and other attitudes and beliefs related to vaping.

METHODS

Participants were adults aged 18 to 24 years in the United States. They were recruited into the study through Facebook (Meta Platforms) and Instagram (Meta Platforms), completed a baseline survey, and then randomized to 1 of the 5 conditions: 0 (control), 4, 8, 16, and 32 exposures over a 15-day period between each survey wave. Follow-up data were collected 30 and 60 days after randomization. We conducted stratified analyses of the full sample and in subsamples defined by the baseline vaping status (never, former, and current). Stimulus was delivered through Facebook and Instagram in four 15-second social media videos focused on anti-industry beliefs about vaping. The main outcome measures reported in this study were self-reported exposure to social media intervention content, attitudes and beliefs about vaping, and vaping intentions. We estimated a series of multivariate linear regressions in Stata 17 (StataCorp). To capture the dose-response effect, we assigned each study arm a numerical value corresponding to the number of advertisements (exposures) delivered to participants in each arm and used this number as our focal independent variable. In each model, the predictor was the treatment arm to which each participant was assigned.

RESULTS

The baseline sample consisted of 1491 participants, and the final analysis sample consisted of 57.28% (854/1491) of the participants retained at the 60-day follow-up. We compared the retained participants with those lost to follow-up and found no statistically significant differences across demographic variables. We found a significant effect of the social media treatment on vaping intentions (β=-0.138, 95% CI -0.266 to -0.010; P=.04) and anti-industry beliefs (β=-0.122, 95% CI 0.008-0.237; P=.04) targeted by the intervention content among current vapers but not among the full sample or other strata. We found no significant effects of self-reported exposure to the stimulus.

CONCLUSIONS

Social media interventions are a promising approach to preventing vaping among young adults. More research is needed on how to optimize the dosage of such interventions and the extent to which long-term exposure may affect vaping use over time.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04867668; https://clinicaltrials.gov/study/NCT04867668.

Longitudinal association between e-cigarette use and respiratory symptoms among US adults: Findings from the Population Assessment of Tobacco and Health Study Waves 4-5

BACKGROUND

We assessed longitudinal effects of e-cigarette use on respiratory symptoms in a nationally representative sample of US adults by combustible tobacco smoking status.

METHODS

We analyzed Waves 4-5 public-use data from the Population Assessment of Tobacco and Health Study. Study sample included adult respondents who reported no diagnosis of respiratory diseases at Wave 4, and completed Waves 4-5 surveys with no missing data on analytic variables (N = 15,291). Outcome was a validated index of functionally important respiratory symptoms based on 7 wheezing/cough questions (range 0-9). An index score of ≥2 was defined as having important respiratory symptoms. Weighted lagged logistic regression models were performed to examine the association between e-cigarette use status at Wave 4 (former/current vs. never use) and important respiratory symptoms at Wave 5 by combustible tobacco smoking status (i.e., never/former/current smokers), adjusting for Wave 4 respiratory symptom index, sociodemographic characteristics, secondhand smoke exposure, body mass index, and chronic disease.

RESULTS

Among current combustible tobacco smokers, e-cigarette use was associated with increased odds of reporting important respiratory symptoms (former e-cigarette use: adjusted odds ratio [AOR] = 1.39, 95% confidence interval [CI]: 1.07-1.81; current e-cigarette use: AOR = 1.55, 95% CI: 1.17-2.06). Among former combustible tobacco smokers, former e-cigarette use (AOR = 1.51, 95% CI: 1.06-2.15)-but not current e-cigarette use (AOR = 1.59, 95% CI: 0.91-2.78)-was associated with increased odds of important respiratory symptoms. Among never combustible tobacco smokers, no significant association was detected between e-cigarette use and important respiratory symptoms (former e-cigarette use: AOR = 1.62, 95% CI: 0.76-3.46; current e-cigarette use: AOR = 0.82, 95% CI: 0.27-2.56).

CONCLUSIONS

The association between e-cigarette use and respiratory symptoms varied by combustible tobacco smoking status. Current combustible tobacco smokers who use e-cigarettes have an elevated risk of respiratory impairments.

Perceptions of and Experiences With Cigarette and E-Cigarette Use Among a Diverse Population of US Latino Adolescents and Young Adults

PURPOSE

To determine potential unique factors influencing cigarette and e-cigarette use in US Latino youth.

APPROACH

We conducted a qualitative study assessing cigarette and e-cigarette perceptions and experiences, including experiences with/perceptions of the products, cultural influences and influences of friends and family.

SETTING

Four online discussion boards, conducted in October 2020.

PARTICIPANTS

92 Latino youth aged 15-21 years living in the US.

METHOD

Data from the discussion groups were coded and analyzed by three trained coders using a thematic analysis approach.

RESULTS

Stress relief emerged as the dominant theme connected with both cigarettes and e-cigarettes. Apart from stress, perceptions of and experiences with the products differed. E-cigarettes were commonly viewed as trendy and cool and participants often reported using them due to curiosity and popularity. Participants commonly compared e-cigarettes to cigarettes, noting benefits of e-cigarettes. Participants also noted more negative short and long-term health effects of cigarette use, and discussed generational differences between the two products.

CONCLUSION

Findings from this study help address a dearth of research examining tobacco use among diverse groups of Latino youth. Findings indicate that despite differences in country of heritage, Latino youth are united by similar opinions about cigarettes and e-cigarettes. Additionally, they share cultural values and experiences which could be leveraged for tobacco control communications that cut across populations of Latino youth.

Evaluation of response to incentive recruitment strategies in a social media-based survey

Objective

This study aimed to examine varying incentives on acceptance to participate in an online survey on social media and to identify related demographic factors.

Methods

The study used Facebook and targeted its users aged 18 to 24 years in the United States. During recruitment, participants were randomized to one of the three types of incentives for survey completion, (1) a $5 gift card, (2) a lottery for a $200 gift card, and (3) a $5 gift card plus a lottery for a $200 gift card. Acceptance rates for survey participation were compared across three incentives using percentages, 95% logit-transformed confidence intervals, and Pearson's chi-squared tests. The survey asked about cognition and behaviors around smoking and vaping.

Results

The ads had 1,782,931 impressions, 1,104,139 reaches, and 11,878 clicks. The average ad frequency was 1.615, and the click-through rate was 0.67%. Males clicked less than females when seeing the ads. The acceptance rates for the three incentives were 63.7%, 37.2%, and 64.6%, respectively. A Chi-square test confirmed that the lottery-only group had a lower acceptance rate compared to those guaranteed an incentive, including the gift card group and the gift card and lottery group. Further analyses indicated that males did not opt into the survey as often as females when given the lottery-only incentive option, and those who did not meet their financial expenses opted into the survey more often than those who had more money than their expenses when given the lottery-only incentive option.

Conclusions

This study suggests that incentives guaranteed to all participants, even if the incentive's value is small, may lead to higher acceptance rates compared to a lottery for a greater incentive in social media-based surveys.

Cigar Use Progression Among New Cigar Initiators: A Two-Part Growth Curve Analysis Among a Youth and Young Adult Cohort

INTRODUCTION

Youth and young adults (YYAs) are at high risk of cigar use. This study's objective was to examine progression and sociodemographic differences in current cigar use and frequency among new cigar initiators.

AIMS AND METHODS

We conducted a two-part latent growth model among a nationally representative cohort of cigar initiators (aged 15-25) to examine 24-month trajectories of current cigar use and frequency (n = 1483). The cohort was recruited via address-based sampling with online data collection from 2014 to 2019 and surveyed approximately every 6 months.

RESULTS

The unconditional odds of current cigar use (ie, past 30-day use) within 6 months of initiation was 0.72 (95% confidence interval: 0.63, 0.82), corresponding to a probability of 42%. The odds of current use among recent cigar initiates declined 6 months after initiation and was followed by a stabilization in use over time. Among continued users, frequency (# days used in past 30 days) increased linearly over time but remained low (3.47 days/months at 24 months). Younger individuals, non-Hispanic African Americans, those with lower subjective financial status, and current users of cigarettes, other tobacco products and/or marijuana were at highest risk within 6 months of initiation. Males, younger users, and current cigarette smokers had the highest risk for cigar progression over time.

CONCLUSIONS

This study is the first to examine longitudinal cigar use patterns among YYA cigar initiators. Findings emphasize the need for research across the cigar use spectrum and the importance of interventions targeted by age, stage of use, cigarette, other tobacco, and marijuana use and key sociodemographics to interrupt use pathways.

IMPLICATIONS

This study is the first to examine progression of cigar use among YYAs who have newly initiated cigars. Results show a high probability of current cigar use within 6 months of initiation followed by a rapid decline and stabilization over time. Frequency increases among those who continue using cigars. Males, younger users, and current cigarette smokers had the highest risk for cigar progression over time. Findings emphasize the need for targeting interventions by age, stage of use, cigarette, other tobacco, and marijuana use and key sociodemographics to interrupt use pathways.

Assessing digital advertising exposure using a virtual experimental protocol

Introduction

The rapid increase in online public education campaigns underscores the need for a better understanding of the effects of exposure to digital advertising and targeted individual-level outcomes. The goal of this study is to develop a virtual experimental protocol to evaluate the dose-response effects of individual-level exposure to digital video ads on campaign outcomes in a naturalistic online browsing context.

Methods

Young adults aged 18–24 years (n = 221) completed three 5 min viewing sessions on a realistic mock-up of the YouTube mobile app over a period of 2 weeks, followed by a 10-min survey after the third session. Participants were randomized to view between 0 and 6 exposures of ads from an e-cigarette prevention campaign; respondents viewed a total of 2 ads per session, with 0 to 2 of those ads being non-skippable digital video ads from the campaign and/or a dummy ad. The video ads played prior to short YouTube videos. Outcomes measured were self-reported ad recognition, frequency of ad exposure, and main message knowledge.

Results

This study demonstrates a rapidly accessible virtual experimental protocol for evaluating the dose-response effects of digital advertising and individual-level outcomes. Five digital exposures of non-skippable video ads delivered via this platform over a 2-week period generated the highest ad recognition when there were up to six exposures. Higher exposure levels may be needed for message knowledge and ad-content-related effects.

Conclusion

This protocol can be extended to investigate dose-response effects and mechanisms of action of individual-level exposure to digital advertising for multiple campaign outcomes, including changes in knowledge, attitudes, and beliefs. Findings can inform evidence for adequate levels of digital exposure in public education campaigns.

Patterns of E-cigarette Use and Subsequent Cigarette Smoking Cessation Over 2 Years (2013/2014-2015/2016) in the Population Assessment of Tobacco and Health Study

INTRODUCTION

Understanding the population impact of e-cigarettes requires determining their effect on cigarette smoking cessation.

METHODS

Using the US Population Assessment of Tobacco and Health cohort, we examined smoking cessation among adult current cigarette smokers at Wave 1 with follow-up data at Waves 2 and 3 (n = 9724).

RESULTS

By Wave 3 (2015/2016), 17.3% of smokers had quit smoking. Smokers using e-cigarettes daily or who increased to daily use over the three waves were two to four times more likely to have quit in the short term (<1 year) and long term (1+ years) compared with never e-cigarette users (p < .001). E-cigarette use in the last quit attempt was associated with a higher likelihood of short-term (<1 year) quitting at Wave 3 (adjusted relative risk ratio: 1.33; 95% confidence interval: 1.04, 1.71) compared with smokers who did not use an e-cigarette in their last quit attempt. Noncurrent (no use in any wave) e-cigarette users and users who were unstable in use frequency were 33% and 47% less likely to quit in the short-term, respectively (p < .001). Flavored (vs nonflavored) and using a rechargeable (vs disposable) e-cigarette device was associated with an increased likelihood of both short- and long-term quitting.

CONCLUSION

Smoking cessation was more likely among frequent e-cigarette users, users of e-cigarettes in last quit attempt, and users of flavored and rechargeable devices. Less frequent, unstable, past, or never e-cigarette users were less likely to quit smoking. Monitoring the relationship between patterns of e-cigarette and cigarette use is complex but critical for gauging the potential of e-cigarettes as a harm reduction tool.

IMPLICATIONS

This study suggests that consistent and frequent e-cigarette use over time is associated with cigarette smoking cessation among adults in the United States. In addition, findings suggest that flavored e-cigarette use and use of rechargeable e-cigarette devices can facilitate smoking cessation. These results underscore the importance of carefully defining and characterizing e-cigarette exposure patterns, potential confounders, and use of e-cigarettes to quit smoking, as well as variations in length of the smoking cessation.

History and Current Trends in the Electronic Cigarette Retail Marketplace in the United States: 2010-2016

INTRODUCTION

The US market for electronic nicotine delivery systems (ENDS) has grown rapidly in the last decade. There is limited published evidence examining changes in the ENDS marketplace prior to the US Food and Drug Administration's (FDA) deeming rule in 2016. This study describes US ENDS retail market trends from 2010 to 2016.

METHODS

National data were obtained from Nielsen retail scanners for five product types: (1) disposables, (2) rechargeables, (3) cartridge replacements, (4) e-liquid bottle refills, and (5) specialty vapor products. We examined dollar sales, volume, price, brand, and flavor.

RESULTS

Adjusted national sales increased from $11.6 million in 2010 to $751.2 million in 2016. The annual rate of sales growth rapidly increased before slowing through 2015. The rate of growth spiked in 2016. Market share for menthol products and other assorted flavors increased from 20% in 2010 to 52.1% by 2016. NJOY's early market dominance shifted as tobacco industry brands entered the market and eventually captured 87.8% of share by 2016. Rechargeables and accompanying products comprised an increased proportion of total volume sold over time while disposable volume declined. Specialty vapor products appeared at retail in 2015.

CONCLUSIONS

Findings show strong early growth in the ENDS retail market followed by considerable slowing over time, despite a slight uptick in 2016. Trends reflect shifts to flavored products, newer generation "open-system" devices, lower prices, and tobacco industry brands. This study provides a baseline against which to compare the impact of FDA's 2016 deeming rule and future actions on the ENDS marketplace.

IMPLICATIONS

This study uses market scanner data from US retail outlets to describe trends in the ENDS retail market from 2010 to 2016, providing a baseline against which to compare the impact of FDA's 2016 deeming rule and future actions on the ENDS marketplace. Understanding historical market trends is valuable in assessing how future regulatory efforts and advances in ENDS technology may impact industry response and consumer uptake and use.

The Effectiveness of Online Messages for Promoting Smoking Cessation Resources: Predicting Nationwide Campaign Effects From Neural Responses in the EX Campaign

What are the key ingredients that make some persuasive messages resonate with audiences and elicit action, while others fail? Billions of dollars per year are put towards changing human behavior, but it is difficult to know which messages will be the most persuasive in the field. By combining novel neuroimaging techniques and large-scale online data, we examine the role of key health communication variables relevant to motivating action at scale. We exposed a sample of smokers to anti-smoking web-banner messages from a real-world campaign while measuring message-evoked brain response patterns via fMRI, and we also obtained subjective evaluations of each banner. Neural indices were derived based on: (i) message-evoked activity in specific brain regions; and (ii) spatially distributed response patterns, both selected based on prior research and theoretical considerations. Next, we connected the neural and subjective data with an independent, objective outcome of message success, which is the per-banner click-through rate in the real-world campaign. Results show that messages evoking brain responses more similar to signatures of negative emotion and vividness had lower online click-through-rates. This strategy helps to connect and integrate the rapidly growing body of knowledge about brain function with formative research and outcome evaluation of health campaigns, and could ultimately further disease prevention efforts.

Sociodemographic Disparities in the Tobacco Retail Environment in Washington, DC: A Spatial Perspective

Objective

Studies assessing sociodemographic disparities in the tobacco retail environment have relied heavily on non-spatial analytical techniques, resulting in potentially misleading conclusions. We utilized a spatial analytical framework to evaluate neighborhood sociodemographic disparities in the tobacco retail environment in Washington, DC (DC) and the DC metropolitan statistical area (DC MSA).

Methods

Retail tobacco availability for DC (n=177) and DC MSA (n=1,428) census tract was assessed using adaptive-bandwidth kernel density estimation. Density surfaces were constructed from DC (n=743) and DC MSA (n=4,539) geocoded tobacco retailers. Sociodemographics were obtained from the 2011-2015 American Community Survey. Spearman's correlations between sociodemographics and retail density were computed to account for spatial autocorrelation. Bivariate and multivariate spatial lag models were fit to predict retail density.

Results

DC and DC MSA neighborhoods with a higher percentage of Hispanics were positively correlated with retail density (rho = .3392, P = .0001 and rho = .1191, P = .0000, respectively). DC neighborhoods with a higher percentage of African Americans were negatively correlated with retail density (rho = -.3774, P = .0000). This pattern was not significant in DC MSA neighborhoods. Bivariate and multivariate spatial lag models found a significant inverse relationship between the percentage of African Americans and retail density (Beta = -.0133, P = .0181 and Beta = -.0165, P = .0307, respectively).

Conclusions

Associations between neighborhood sociodemographics and retail density were significant, although findings regarding African Americans are inconsistent with previous findings. Future studies should analyze other geographic areas, and account for spatial autocorrelation within their analytic framework.

Patterns of E-Cigarette Use Among Youth and Young Adults: Review of the Impact of E-Cigarettes on Cigarette Smoking

There is concern that e-cigarette use among youth and young adults (YAs) may lead to future cigarette or other combustible tobacco product use. A synthesis of the literature on this topic is needed because existing longitudinal studies are limited in number and not consistent in their conclusions. We conducted a search in PubMed through December 31, 2017 for peer-reviewed studies related to e-cigarette patterns of use. Of 588 relevant studies, 26 had a youth or YA sample, were longitudinal in design, and assessed e-cigarette use at baseline and cigarette smoking at follow-up. Most studies followed a sample over time and compared cigarette smoking at follow-up between baseline e-cigarette users and nonusers. Other studies examined the difference at follow-up in cigarette smoking status among smokers according to e-cigarette use at baseline. Results suggest that, among never smokers, e-cigarette use is associated with the future (6 months to 2.5 years) cigarette trial; however, firm conclusions cannot be drawn because of limitations including small sample size, measurement of experimental use (ie, ever use, past 30-day use) rather than established use, and inadequate controls for potentially confounding variables. Conclusions also cannot be drawn from studies examining the impact of e-cigarette use among smokers due to the limited number of studies and additional limitations. A comprehensive understanding of this literature is needed to inform policy makers and consumers for evidence-based decision-making and to guide future research on e-cigarette use among youth and young adults.

IMPLICATIONS

The present article provides a review of the impact of e-cigarette use on subsequent cigarette smoking among youth and YAs. Studies presented here suggest that e-cigarette use among nonsmokers is associated with subsequent cigarette smoking, but study designs are subject to numerous limitations. Future research should focus on addressing the characteristics that put youth and YAs at the risk of using either product and how appeal and accessibility of these products are related to product use in order to inform future policy-making.

Impact of e-cigarette and cigarette prices on youth and young adult e-cigarette and cigarette behaviour: evidence from a national longitudinal cohort

INTRODUCTION

Understanding the impact of prices for tobacco and nicotine products is critical for creating policies to prevent use among young people. This study examines the impact of electronic cigarette (e-cigarette) and cigarette prices on current e-cigarette and cigarette use among youth and young adults.

METHODS

Data were from a national probability-based sample aged 15-21 collected in 2014 and followed every 6 months for 2.5 years through 2016. We conducted separate conditional likelihood logistic regression models with past 30-day e-cigarette use and past 30-day cigarette use outcomes on the sample of individuals who participated in at least two survey waves (n=11 578) with linked Nielsen market-level price data for rechargeable e-cigarettes and cigarettes. Models controlled for time-varying variables at the individual and state policy levels, and fixed effects at the individual, wave and market levels.

RESULTS

Higher cigarette prices were associated with increased past 30-day e-cigarette use, indicating e-cigarettes may serve as a substitute for cigarettes. We did not find a statistically significant relationship between rechargeable e-cigarette prices and past 30-day e-cigarette use; neither did we find a significant relationship between rechargeable e-cigarette prices and past 30-day cigarette smoking.

CONCLUSION

This is the first study to examine e-cigarette and cigarette prices on e-cigarette and cigarette behaviour longitudinally among young people. Findings suggest the need for better measuring the costs associated with e-cigarette use among this population, as well as a careful assessment of price and tax policies that takes into account cross-product impact to sufficiently discourage e-cigarette and cigarette use among young people.

A multidisciplinary approach to health campaign effectiveness

Campaign costs are rising, making ad execution testing more critical to determine effectiveness prior to media spending. Premarket testing occurs prior to messages' airing while in-market testing examines message attributes when messages are aired within a real-world setting, where context plays an important role in determining audience response. These types of ad testing provide critical feedback to help develop and deploy campaigns. Due to recent changes in media delivery platforms and audience tobacco use behavior, this study analyzes two nationally representative youth samples, aged 15-21, to examine if pre-market ad testing is an indicator of in-market ad performance for public health campaigns, which rely on persuasive messages to promote or reduce health behaviors rather than selling a product. Using data from the Truth^® campaign, a national tobacco use prevention campaign targeted to youth and young adults, findings indicate strong associations between pre-market scores and in-market ad performance metrics.

Estimating the Pathways of an Antitobacco Campaign

PURPOSE

This study examined mechanisms through which the truth campaign, a national mass media antismoking campaign, influences smoking-related attitudes, and progression of tobacco use over time in youth and young adults.

METHODS

Structural equation modeling tested causal pathways derived from formative research and behavioral theory with a nationally representative longitudinal sample of 15-21-year-olds (n = 8747) over 24 months. Data were collected from 2014 to 2016, and analyses were conducted in 2017.

RESULTS

Greater ad awareness predicted strengthening of attitudes targeted by the campaign (i.e., feelings of independence from tobacco, antitobacco industry sentiment, decreasing acceptance of social smoking, and decreasing acceptance of smoking imagery), and attitude changes were significantly associated with greater support for an antitobacco social movement (e.g., agreement to the item "I would be part of a movement to end smoking"). Greater social movement support predicted a slower rate of progression on smoking intensity after two years of the campaign.

CONCLUSIONS

Findings suggest that engaging youth and young adults in a cause-based social movement for promoting health can be a powerful strategy to drive positive behavior change. Messages targeting attitudes that resonate with values important to this age group, including independence and connectedness, are particularly effective. Investments in national antitobacco public education campaigns are key policy interventions which continue to help prevent tobacco use among youth and young adults.

Patterns in first and daily cigarette initiation among youth and young adults from 2002 to 2015

This study’s objective was to describe long-term trends and patterns in first cigarette use (cigarette initiation) and daily cigarette use (daily initiation) among youth and young adults in the U.S. We used cross-sectional survey data from the National Survey on Drug Use and Health, 2002–2015, to estimate annual incidence of first cigarette use (N = 270,556) and first daily cigarette use (N = 373,464) for each year by age groups, race/ethnicity and gender, examining trends over time and the average annual change in initiation for each group. Several clear patterns emerged: 1) cigarette initiation and daily initiation significantly decreased over time among those aged 12–14 and 15–17 and these trends were consistent among nearly all racial/ethnic and gender subgroups; 2) among 18–21 year olds, cigarette initiation sharply increased through 2009, surpassing rates among 15–17 year olds, and sharply declined through 2015 while remaining higher than rates among the younger group, and this trend was consistent for almost all racial/ethnic subgroups; 3) daily initiation for those aged 18–21 significantly declined, and this was significant among most subgroups 4) there was no change in cigarette initiation and daily initiation for 22–25 year olds overall and most subgroups; 5) there was a significant increase in cigarette initiation for 22–25 year old Hispanics males and daily initiation for 22–25 year old males. This study provides a comprehensive look at trends in cigarette and daily initiation among U.S. youth and young adults. Despite notable declines in smoking initiation among youth and young adult populations over the last two decades, targeted prevention and policy efforts are needed for subgroups at higher risk, including young adults and Hispanic males.

Examining perceptions about IQOS heated tobacco product: consumer studies in Japan and Switzerland

OBJECTIVE

To examine consumer perceptions, attitudes and behaviours regarding the heated tobacco product, IQOS, as well as to document the product's marketing strategies to determine its potential for appealing to youth and young adults.

METHOD

Truth Initiative, in collaboration with Flamingo, collected qualitative data via: (1) expert interviews, (2) semiotic analysis of IQOS packing and marketing materials, and (3) 12 focus groups with adults in Switzerland (ages 19-44 years; June 6-9, 2016) and Japan (ages 20-39 years; June 22-24, 2016) (n=68 for both groups).

RESULTS

Expert interviews and IQOS packing and marketing analyses revealed the product is being marketed as a clean, chic and pure product, which resonated very well in Japan given the strong cultural values of order, cleanliness, quality and respect for others. Focus groups results indicated Japanese IQOS users used the product for socialising with non-smokers. Focus group participants in both Japan and Switzerland reported lower levels of satisfaction with the product relative to combustible cigarettes, although many found the product packaging to be appealing. While participants identified several benefits and barriers related to IQOS, few reported any potential health benefits of use compared with combustible tobacco products.

CONCLUSION

IQOS was marketed as a sophisticated, high tech and aspirational product. Because youth and young adults are more interested in such product positioning, this approach raises some concern about youth appeal. This research shows cultural factors appeared to affect the appeal of this messaging, indicating that prevalence and uptake data will likely not be similar from country to country.

The Effect of Branding to Promote Healthy Behavior: Reducing Tobacco Use among Youth and Young Adults

Policy interventions such as public health mass media campaigns disseminate messages in order to improve health-related knowledge, attitudes, beliefs and behaviors at the population level. Only more recently have campaigns that promote health-related behaviors adopted branding, a well-established marketing strategy, to influence how consumers think and feel about a message. This study examines whether positive brand equity for the national truth® campaign is associated with lower likelihood of cigarette use over time using the nationally representative Truth Longitudinal Cohort of youth and young adults, aged 15-21. Logistic regression models were used to examine the relationship between brand equity and the likelihood of reporting past 30-day smoking over a 12-month period. Respondents who reported positive brand equity were significantly less likely to report past 30-day smoking 12 months later (OR = 0.66, p < 0.05), controlling for covariates known to influence tobacco use behavior. Findings also translate the effect size difference to a population estimate of more than 300,000 youth and young adults having been prevented from current smoking over the course of a year. Building brand equity is a strategic process for health promotion campaigns, not only to improve message recall and salience but also to influence behavioral outcomes.

Effects of the truth FinishIt brand on tobacco outcomes

Since 2000, the truth campaign has grown as a social marketing brand. Back then, truth employed branding to compete directly with the tobacco industry. In 2014, the launch of truth FinishIt reflected changes in the brand's strategy, the tobacco control environment, and youth/young adult behavior.

Building on a previous validation study, the current study examined brand equity in truth FinishIt, as measured by validated multi-dimensional scales, and tobacco related attitudes, beliefs, and behavior based on two waves of the Truth Longitudinal Cohort data from 2015 and 2016. A fixed effects logistic regression was used to estimate the change in brand equity between panel survey waves 3 and 4 on past 30-day smoking among ever and current smokers. Additional models determined the effects of brand equity predicting tobacco attitudes/use at follow up among the full sample. All analyses controlled for demographic factors.

A one-point increase in the brand equity scale between the two waves was associated with a 66% greater chance of not smoking among ever smokers (OR 1.66, CI 1.11–2.48, p < 0.05) and an 80% greater chance of not smoking among current smokers (OR 1.80, CI 1.05–3.10, p < 0.05). Higher overall truth brand equity at wave 3 predicted less smoking at wave 4 and more positive anti-tobacco attitudes. Being male, younger, and non-white predicted some of the tobacco related attitudes.

Future research should examine long-term effects of brand equity on tobacco use and how tobacco control can optimize the use of branding in campaigns.

•

The truth FinishIt brand reflects changes in the tobacco control environment.

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Brand equity mediates FinishIt exposure and tobacco use outcomes.

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An increase in brand equity over 6 months was associated with lower smoking.

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Higher brand equity at an earlier time predicted less smoking after 6 months.

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Branding is an effective strategy in tobacco control and should be optimized.

Progression to established patterns of cigarette smoking among young adults

BACKGROUND

As tobacco control policies have been implemented across the U.S. over the past decade, patterns of smoking cigarettes have significantly changed, particularly among young adults. For many users, the typical daily use pattern of smoking several packs of cigarettes per day has been supplanted by a variety of use patterns, often referred to as light, intermittent, and occasional smoking.

METHODS

The aim of this study was to examine progression to established smoking patterns among a nationally representative, longitudinal sample of young adults (n=9791). Using repeated measures latent class techniques (RMLCA), we modeled the distribution of cigarette smoking intensity over time and latent class categories.

RESULTS

Findings demonstrate that young adults fall into three discrete classes that reflect probabilities for never to low use, daily use, and variable cigarette use for progression to established use of cigarettes: 79.3% fall into the class of "never or ever users" of cigarettes (no current use of cigarettes), 11.3% fall into the class of "rapid escalators" or daily users of cigarettes, and 9.4% fall into the "dabbler" class. Smoking patterns were found to be stable by the age of 21.

CONCLUSIONS

Intervening prior to age 21 has the potential to disrupt progression to established smoking and reduce the long-term health consequences of smoking in this age group.

Harnessing Youth and Young Adult Culture: Improving the Reach and Engagement of the truth® Campaign

The national youth and young adult tobacco prevention mass media campaign, truth®, relaunched in 2014 with the goal of creating "the generation that ends smoking." The objective of this study was to assess whether the strategy of airing truth ads during popular, culturally relevant televised events was associated with higher ad and brand awareness and increases in social media engagement. Awareness of six truth advertisements that aired during popular television events and self-reported social media engagement were assessed via cross-sectional online surveys of youth and young adults aged 15-21 years. Social engagement was also measured using separate Twitter and YouTube metrics. Logistic regression models predicted self-reported social engagement and any ad awareness, and a negative binomial regression predicted the total social media engagement across digital platforms. The study found that viewing a popular televised event was associated with higher odds of ad awareness and social engagement. The results also indicate that levels of social media engagement for an event period are greater than for a nonevent period. The findings demonstrate that premiering advertisements during a popular, culturally relevant televised event is associated with higher awareness of truth ads and increased social engagement related to the campaign, controlling for variables that might also influence the response to campaign messages.

Trajectories of Hookah Use: Harm Perceptions from Youth to Young Adulthood

OBJECTIVES

Hookah use has increased in United States, especially among young adults. This study investigates the role of harm perceptions of hookah use over a 2-year period in a nationally representative sample of youth and young adults as they transition to young adulthood.

METHODS

Using a probability-based, nationally representative, longitudinal cohort of youth aged 15-21, we analyzed the 7536 participants who completed all 4 waves. Ordered logit growth models examined changes over time in hookah use, and whether that relationship varies by baseline harm perceptions.

RESULTS

Results show that age, sex, parental education, race, and smoking status are significant predictors of hookah use. Additionally, those who perceive hookah as "less harmful" than cigarettes have the highest probability of current hookah use over time, compared to those with more accurate harm perceptions.

CONCLUSIONS

This study helps confirm the influence of harm perceptions of hookah tobacco on hookah use among youth and young adults. Increased public education efforts aimed at youth and young adults can help shift knowledge, attitudes and beliefs regarding the health consequences of hookah use.

Recruiting and retaining youth and young adults: challenges and opportunities in survey research for tobacco control

INTRODUCTION

Evaluation studies of population-based tobacco control interventions often rely on large-scale survey data from numerous respondents across many geographic areas to provide evidence of their effectiveness. Significant challenges for survey research have emerged with the evolving communications landscape, particularly for surveying hard-to-reach populations such as youth and young adults. This study combines the comprehensive coverage of an address-based sampling (ABS) frame with the timeliness of online data collection to develop a nationally representative longitudinal cohort of young people aged 15-21.

METHODS

We constructed an ABS frame, partially supplemented with auxiliary data, to recruit this hard-to-reach sample. Branded and tested mail-based recruitment materials were designed to bring respondents online for screening, consent and surveying. Once enrolled, respondents completed online surveys every 6 months via computer, tablet or smartphone. Numerous strategies were utilized to enhance retention and representativeness RESULTS: Results detail sample performance, representativeness and retention rates as well as device utilization trends for survey completion among youth and young adult respondents. Panel development efforts resulted in a large, nationally representative sample with high retention rates.

CONCLUSIONS

This study is among the first to employ this hybrid ABS-to-online methodology to recruit and retain youth and young adults in a probability-based online cohort panel. The approach is particularly valuable for conducting research among younger populations as it capitalizes on their increasing access to and comfort with digital communication. We discuss challenges and opportunities of panel recruitment and retention methods in an effort to provide valuable information for tobacco control researchers seeking to obtain representative, population-based samples of youth and young adults in the U.S. as well as across the globe.

The Relationship Between Advertising-Induced Anger and Self-efficacy on Persuasive Outcomes: A Test of the Anger Activism Model Using the Truth Campaign

Turner's Anger Activism Model (AAM) contends anger and efficacy interact in a unique way to determine message responses to campaign materials. This study tested the AAM using responses to 2 truth antismoking advertisements collected in August-October 2014 via an online, cross-sectional survey of 15- to 21-year-olds. Those aware of each of the truth advertisements (n = 319 for each) were organized into 4 anger/efficacy groups. Analysis of variance and regressions were conducted to understand group differences in message-related cognitions (persuasiveness, receptivity, conversation). Message cognitions were highest among the high anger/high efficacy group and lowest among the low anger/low efficacy group.

Young Adult Utilization of a Smoking Cessation Website: An Observational Study Comparing Young and Older Adult Patterns of Use

Background

There is little research on how young adults or young adult subgroups utilize and engage with Web-based cessation interventions when trying to quit smoking. Addressing this knowledge gap is important to identify opportunities to optimize the effectiveness of online cessation programs across diverse young adult users.

Objective

This study examines utilization of the BecomeAnEX.org smoking cessation website among young adults and young adult subgroups compared with older adults to identify patterns of use by age, gender, and race/ethnicity.

Methods

Study participants were 5983 new registered users on a free smoking cessation website who were aged 18 to 70 years. Website utilization was tracked for 6 months; metrics of use included website visits, pages per visit, length of visit, and interaction with specific website features. Differences in website use by age were examined via bivariate analyses and multivariate logistic regression adjusted for age, gender, and race/ethnicity. Interactions were examined to determine differences by gender and race/ethnicity within young (18- to 24-year-olds and 25- to 34-year-olds) and older (35 years and older) adult segments.

Results

A greater percentage of young adults aged 18 to 34 years visited the site only once compared with older adults aged 35 years and older (72.05% vs 56.59%, respectively; P<.001). Young adults also spent less time on the site and viewed fewer pages than older adults. In adjusted analyses, young adults were significantly less likely than older adults to visit the site more than once (18-24 years: adjusted odds ratio [AOR] 0.58, 95% CI 0.49-0.68, P<.001; 25-34 years: AOR 0.56, 95% CI 0.50-0.64, P<.001), spend more than 3 minutes on the site (18-24 years: AOR 0.67, 95% CI 0.57-0.79, P<.001; 25-34 years: AOR 0.56, 95% CI 0.49-0.64, P<.001), view 12 or more pages (18-24 years: AOR 0.72, 95% CI 0.61-0.83; P<.001; 25-34 years: AOR 0.67, 95% CI 0.59-0.76, P<.001), utilize the BecomeAnEX.org community (18-24 years: AOR 0.61, 95% CI 0.48-0.79, P<.001; 25-34 years: AOR 0.73, 95% CI 0.60-0.88, P<.001), or utilize Separation Exercises (18-24 years: AOR 0.68, 95% CI 0.51-0.89, P<.01; 25-34 years: AOR 0.77, 95% CI 0.63-0.94, P<.01). Gender differences in utilization were more pronounced among young adults compared with older adults, with lower levels of utilization among young men than young women. For all age groups, utilization was higher among whites and African Americans than among Hispanics and other racial minorities, with one exception—BecomeAnEX.org community utilization was significantly higher among Hispanic young adults compared with white and African American young adults.

Conclusions

Results point to important areas of inquiry for future research and development efforts. Research should focus on enhancing demand and increasing engagement among younger adults and men, examining strategies for capitalizing on young adult developmental needs, and increasing utilization of effective site features among diverse young adult users.

Design and Feasibility Testing of the truth FinishIt Tobacco Countermarketing Brand Equity Scale

The original truth campaign was a branded, national smoking prevention mass media effort focused on at-risk youth ages 12-17. Today the truth brand focuses on the goal of finishing tobacco (truth FinishIt). There have been significant changes in the tobacco control landscape, leading FinishIt to focus on 15- to 21-year-olds. The present article reports on formative research and media monitoring data collected to pilot test a new truth FinishIt brand equity scale. The goals of this study were to (a) content analyze truth FinishIt mass media ads, (b) assess truth's social media and followers' perceptions of truth's digital brand identity, and (c) develop and feasibility test a new version of the truth FinishIt brand equity scale using data from an existing Truth Initiative media monitoring study. Through factor analysis, we identified a brand equity scale, as in previous research, consisting of 4 main constructs: brand loyalty, leadership/satisfaction, personality, and awareness. Targeted truth attitudes and beliefs about social perceptions, acceptability, and industry-related beliefs were regressed on the higher order factor and each of the 4 individual brand equity factors. Ordinary least squares regression models generally showed associations in the expected directions (positive for anti-tobacco and negative for pro-tobacco) between targeted attitudes/beliefs and truth FinishIt brand equity. This study succeeded in developing and validating a new truth FinishIt brand equity scale. The scale may be a valuable metric for future campaign evaluation. Future studies should examine the effects of truth FinishIt brand equity on tobacco use behavioral outcomes over time.

Contextual Influences and Campaign Awareness Among Young Adults: Evidence from the National truth® Campaign

Mass media campaigns have been found to shape the public's knowledge, attitudes, beliefs, and behavior around tobacco. This study examines the influence of contextual factors with respect to awareness of the national truth® campaign, a mass media, branded tobacco use prevention campaign, among a sample of young adults (n = 2,804) aged 24-34 years old; these respondents were within the age range for both the primary and secondary targets of the campaign during the period (2000-2007) when the campaign was airing television advertising at consistently high levels. Mulitvariable models reveal lower educational attainment and Hispanic ethnicity as significant contextual factors predictive of lower campaign awareness, controlling for media use. In contrast, gender, state tobacco control policy, sensation-seeking, current smoking status, and community-level SES variables were not significantly associated with campaign awareness. Further research is needed to identify the mechanisms through which public education campaigns operate, particularly among disadvantaged communities.

American Spirit Pack Descriptors and Perceptions of Harm: A Crowdsourced Comparison of Modified Packs

INTRODUCTION

In 2015, the Food and Drug Administration issued warnings to three tobacco manufacturers who label their cigarettes as "additive-free" and/or "natural" on the grounds that they make unauthorized reduced risk claims. The goal of this study was to examine US adults' perceptions of three American Spirit (AS) pack descriptors ("Made with Organic Tobacco," "100% Additive-Free," and "100% US Grown Tobacco") to assess if they communicate reduced risk.

METHODS

In September 2012, three cross-sectional surveys were posted on Amazon Mechanical Turk. Adult participants evaluated the relative harm of a Marlboro Red pack versus three different AS packs with the descriptors "Made with Organic Tobacco," "100% Additive-Free," or "100% US Grown Tobacco" (Survey 1; n = 461); a Marlboro Red pack versus these AS packs modified to exclude descriptors (Survey 2; n = 857); and unmodified versus modified AS pack images (Survey 3; n = 1001).

RESULTS

The majority of Survey 1 participants rated the unmodified AS packs as less harmful than the Marlboro Red pack; 35.4%-58.8% of Survey 2 participants also rated the modified (no claims) packs as less harmful than Marlboro Red. In these surveys, prior use of AS cigarettes was associated with reduced perceptions of risk (adjusted odds ratio [AOR] 1.59-2.40). "Made with Organic Tobacco" and "100% Additive-Free" were associated with reduced perceptions of risk when comparing the modified versus the unmodified AS packs (Survey 3).

CONCLUSIONS

Data suggest that these AS pack descriptors communicate reduced harm messages to consumers. Findings have implications for regulatory actions related to product labeling and packaging.

IMPLICATIONS

These findings provide additional evidence that the "Made with Organic Tobacco," "100% Additive-Free," and "100% US Grown" descriptors, as well as other aspects of the AS pack design, communicate reduced harm to non-, current, and former smokers. Additionally, they provide support for the importance of FDA's 2015 warning to Santa Fe Natural Tobacco Company on "100% Additive Free" as an unauthorized modified risk claim.

Implementation of a Multimodal Mobile System for Point-of-Sale Surveillance: Lessons Learned From Case Studies in Washington, DC, and New York City

Background

In tobacco control and other fields, point-of-sale surveillance of the retail environment is critical for understanding industry marketing of products and informing public health practice. Innovations in mobile technology can improve existing, paper-based surveillance methods, yet few studies describe in detail how to operationalize the use of technology in public health surveillance.

Objective

The aims of this paper are to share implementation strategies and lessons learned from 2 tobacco, point-of-sale surveillance projects to inform and prepare public health researchers and practitioners to implement new mobile technologies in retail point-of-sale surveillance systems.

Methods

From 2011 to 2013, 2 point-of-sale surveillance pilot projects were conducted in Washington, DC, and New York, New York, to capture information about the tobacco retail environment and test the feasibility of a multimodal mobile data collection system, which included capabilities for audio or video recording data, electronic photographs, electronic location data, and a centralized back-end server and dashboard. We established a preimplementation field testing process for both projects, which involved a series of rapid and iterative tests to inform decisions and establish protocols around key components of the project.

Results

Important components of field testing included choosing a mobile phone that met project criteria, establishing an efficient workflow and accessible user interfaces for each component of the system, training and providing technical support to fieldworkers, and developing processes to integrate data from multiple sources into back-end systems that can be utilized in real-time.

Conclusions

A well-planned implementation process is critical for successful use and performance of multimodal mobile surveillance systems. Guidelines for implementation include (1) the need to establish and allow time for an iterative testing framework for resolving technical and logistical challenges; (2) developing a streamlined workflow and user-friendly interfaces for data collection; (3) allowing for ongoing communication, feedback, and technology-related skill-building among all staff; and (4) supporting infrastructure for back-end data systems. Although mobile technologies are evolving rapidly, lessons learned from these case studies are essential for ensuring that the many benefits of new mobile systems for rapid point-of-sale surveillance are fully realized.

Exploring Smoking Cessation Attitudes, Beliefs, and Practices in Occupational Health Nursing

The purpose of this study was to explore occupational health nurses’ attitudes, beliefs, and practices regarding the delivery of smoking cessation services to workers. The study included 707 members of the American Association of Occupational Health Nurses (AAOHN) who completed a one-time survey during the fall of 2012. Results indicated that occupational health nurses believed that evidence-based treatments are at least somewhat effective and that they should provide smoking cessation services to their workers; however, a majority of occupational health nurses reported that they did not have appropriate smoking cessation training or guidelines in their workplaces. Occupational health nurses would benefit from training in the use of smoking cessation guidelines and evidence-based smoking cessation interventions, which could be used in their clinical practice. Employers should ensure that workplace policies, such as providing coverage for cessation services, facilitate smokers’ efforts to quit. Employers can benefit from many of these policies through cost savings via reduced health care costs and absenteeism.

National Enforcement of the FSPTCA at Point-of-Sale

Objective

To describe patterns in the enforcement of the US Food and Drug Administration's current compliance check program.

Methods

Data on retail violation rates (RVR) resulting from compliance checks were analyzed. Novel methods were developed to quantify violations and unify data on retail location and violation type.

Results

As of July 2013, 42 states and 3 US territories conducted compliance checks. Ninety-six percent of warning letters and 100% of Civil Monetary Penalties addressed sales to minors. RVRs varied significantly over time (OR = 1.15) and between states (ICC = 0.18).

Conclusions

The compliance checks database makes it possible to examine how retail enforcement is unfolding over time and place. Results reveal an emphasis on youth access violations, presenting opportunities for research on regulations designed to reduce youth access.

Patterns of combustible tobacco use in U.S. young adults and potential response to graphic cigarette health warning labels

In the evolving landscape of tobacco use, it remains unclear how tobacco control efforts should be designed and promoted for maximum impact. The current study links the identification of latent classes of young adult combustible tobacco users with anticipated responses to graphic health warning labels (HWLs). Data were collected in January 2012 using an online address-based panel as part of the Legacy Young Adult Cohort Study, and analyses were conducted in 2013. Latent class analyses identified five groups of tobacco users in a national sample of 4,236 young adults aged 18-34years: (1) little cigar/cigarillo/bidi (LCC) and hookah users (4%); (2) nonusers, open to smoking (3%); (3) daily smokers who self-identify as "smokers" (11%); (4) nondaily, light smokers who self-identify as "social or occasional smokers" (9%); and (5) nonusers closed to smoking (73%). Of the nonusers closed to smoking, 23% may be better characterized as at risk for tobacco initiation. Results indicate differences in the potential effectiveness of HWLs across classes. Compared to the daily "smokers," LCC and hookah users (RRR=2.35) and nonusers closed to smoking (RRR=2.33) were more than twice as likely to report that new graphic HWLs would make them think about not smoking. This study supports the potential of graphic HWLs to prevent young nonusers from using tobacco products. It suggests that the extension of prominent HWLs to other tobacco products, including LCCs and hookah tobacco, may also serve a prevention function.

Tobacco Retail Outlet Density and Young Adult Tobacco Initiation

BACKGROUND

A growing body of evidence indicates that the density of tobacco retail outlets around the home residence may influence tobacco use among youth and adults. The purpose of this study was to examine the impact of neighborhood tobacco retail outlet density on young adult initiation of different tobacco product types.

METHODS

Cross-sectional data from a 2013 nationally representative sample of young adults aged 18-34 was examined in relation to a 2012 geocoded listing of all outlets likely to sell tobacco in the United States. Separate multivariable logistic regression analyses examined associations between neighborhood outlet density and past 6 months first use of cigarettes, non-cigarette combustible products, and noncombustible products among adults aged 18-24 and 25-34.

RESULTS

Outlet density was significantly associated with recent initiation of cigarettes and other combustibles, but this impact varied for younger and older groups. Increased density was significantly associated with a higher likelihood of initiating cigarette use among adults aged 25-34 (OR = 3.75, 95% CI = 1.18, 11.90), and of initiating non-cigarette combustible use among 18-24 year olds (OR = 3.16, 95% CI = 1.03, 9.74). There was no impact of outlet density on recent noncombustible product initiation among either group.

CONCLUSION

This study is the first to examine the impact of tobacco outlet density on young adult initiation of cigarettes and other tobacco products. Findings demonstrate that residential neighborhood outlet density is associated with recent initiation of combustible products and this effect varies by product type and age. The tobacco outlet environment may be a critical factor in promoting young adult tobacco use initiation.

Cigarette price variation around high schools: evidence from Washington DC

This study examines lowest cigarette prices in all tobacco retail outlets in Washington D.C. (n=750) in relation to the type and number of high schools nearby, controlling for confounders. The lowest overall and Newport menthol prices were significantly lower at outlets near public non-charter and charter schools compared with outlets near private schools. Given higher smoking prevalence and more price-sensitive youth subgroups in U.S. public schools, exposure to low prices may contribute to tobacco-related health disparities in minority and low-income populations. Tobacco taxes combined with policies to minimize the increasing use of price as a marketing tool are critical.

The impact of the tobacco retail outlet environment on adult cessation and differences by neighborhood poverty

AIMS

This study examined the impact of tobacco retail outlets on cessation outcomes over time among non-treatment-seeking smokers and assessed differences by neighborhood poverty and individual factors.

DESIGN

Observational longitudinal cohort study using geospatial data. We used generalized estimating equations to examine cessation outcomes in relation to the proximity and density of tobacco retail outlets near the home.

SETTING

Eight large Designated Media Areas across the United States.

PARTICIPANTS

A total of 2377 baseline smokers followed over three waves from 2008 to 2010.

MEASUREMENTS

Outlet addresses were identified through North American Industry Classification System codes and proximity and density measures were constructed for each participant at each wave. Outcomes included past 30-day abstinence and pro-cessation attitudes.

FINDINGS

Smokers in high poverty census tracts living between 500 m and 1.9 km from an outlet were over two times more likely to be abstinent than those living fewer than 500 m from an outlet (P < 0.05). Density within 500 m of home was associated with reduced abstinence [odds ratio (OR) = 0.94; confidence interval (CI) = 0.90, 0.98) and lower pro-cessation attitudes (Coeff = -0.07, CI = -0.10, -0.03) only in high poverty areas. In low poverty areas, density within 500 m was associated with greater pro-cessation attitudes (OR = 0.06; CI = 0.01, 0.12). Gender, education and heaviness of smoking did not moderate the impact of outlet proximity and density on cessation outcomes.

CONCLUSIONS

In the United States, density of tobacco outlets within 500 m of the home residence appears to be negatively associated with smoking abstinence and pro-cessation attitudes only in poor areas.

The role of interventional radiology in complications after paediatric liver transplantation

Liver transplantation has become an established treatment in both adults and children for end-stage liver disease, acute hepatic failure and certain liver tumours. There is a significant risk of complications after all forms of liver transplantation. The interventional radiologist plays a critical role in the diagnosis and treatment of these complications. The use of image-guided, minimally invasive procedures reduces the need for surgical revision or retransplantation and improves graft and patient survival rate. This article reviews some of the most common vascular and non-vascular complications after paediatric liver transplantation, and the interventional radiology techniques used to diagnose and treat them.

Effects of enamel fluorosis and dental caries on quality of life

The objectives of this study were to determine the impact of enamel fluorosis and dental caries on oral health-related quality of life (OHRQoL) in North Carolina schoolchildren and their families. Students (n = 7,686) enrolled in 398 classrooms in grades K-12 were recruited for a onetime survey. Parents of students in grades K-3 and 4-12 completed the Early Childhood Oral Health Impact Scale (ECOHIS) and Family Impact Scale (FIS), respectively. Students in grades 4-12 completed the Child Perceptions Questionnaire (CPQ8-10 in grades 4-5; CPQ11-14 in grades 6-12). All students were examined for fluorosis (Dean's index) and caries experience (d2-3fs or D2-3MFS indices). OHRQoL scores (sum response codes) were analyzed for their association with fluorosis categories and sum of d2-3fs and D2-3MFS according to ordinary least squares regression with SAS procedures for multiple imputation and analysis of complex survey data. Differences in OHRQoL scores were evaluated against statistical and minimal important difference (MID) thresholds. Of 5,484 examined students, 71.8% had no fluorosis; 24.4%, questionable to very mild fluorosis; and 3.7%, mild, moderate, or severe fluorosis. Caries categories were as follows: none (43.1%), low (28.6%), and moderate to high (28.2%). No associations between fluorosis and any OHRQoL scales met statistical or MID thresholds. The difference (5.8 points) in unadjusted mean ECOHIS scores for the no-caries and moderate-to-high caries groups exceeded the MID estimate (2.7 points) for that scale. The difference in mean FIS scores (1.5 points) for the no-caries and moderate-to-high groups exceeded the MID value (1.2 points). The sum of d2-3fs and D2-3MFS scores was positively associated with CPQ11-14 (B = 0.240, p < .001), ECOHIS (B = 0.252, p ≤ .001), and FIS (B = 0.096, p ≤ .01) scores in ordinary least squares regression models. A child's caries experience negatively affects OHRQoL, while fluorosis has little impact.

A multilevel analysis of gender, Latino immigrant enclaves, and tobacco use behavior

Research suggests that immigrant enclaves positively influence health behaviors such as tobacco use through supportive social networks and informal social control mechanisms that promote healthy behavioral norms. Yet, the influence of social cohesion and control on tobacco use may depend on smoking-related norms, which can vary by gender. This study examines the influence of neighborhood Latino immigrant enclave status on smoking and cessation among Hispanic men and women. Data from the Los Angeles Family and Neighborhood Survey was combined with census data to assess the relationship between immigrant enclaves, gender, and smoking using multilevel regression. The effect of the Hispanic enclave environment on smoking differed by gender. Living in an enclave had a harmful effect on tobacco use among Hispanic men, marginally increasing the likelihood of smoking and significantly reducing cessation. This effect was independent of neighborhood socioeconomic status, nativity, and other individual demographics. Neighborhood immigrant concentration was not associated with smoking or cessation for Hispanic women. Research, interventions, and policies aimed at reducing smoking among Hispanics may need to be gender responsive to ensure effectiveness as well as health and gender equity.

Cameras for Public Health Surveillance: A Methods Protocol for Crowdsourced Annotation of Point-of-Sale Photographs

Background

Photographs are an effective way to collect detailed and objective information about the environment, particularly for public health surveillance. However, accurately and reliably annotating (ie, extracting information from) photographs remains difficult, a critical bottleneck inhibiting the use of photographs for systematic surveillance. The advent of distributed human computation (ie, crowdsourcing) platforms represents a veritable breakthrough, making it possible for the first time to accurately, quickly, and repeatedly annotate photos at relatively low cost.

Objective

This paper describes a methods protocol, using photographs from point-of-sale surveillance studies in the field of tobacco control to demonstrate the development and testing of custom-built tools that can greatly enhance the quality of crowdsourced annotation.

Methods

Enhancing the quality of crowdsourced photo annotation requires a number of approaches and tools. The crowdsourced photo annotation process is greatly simplified by decomposing the overall process into smaller tasks, which improves accuracy and speed and enables adaptive processing, in which irrelevant data is filtered out and more difficult targets receive increased scrutiny. Additionally, zoom tools enable users to see details within photographs and crop tools highlight where within an image a specific object of interest is found, generating a set of photographs that answer specific questions. Beyond such tools, optimizing the number of raters (ie, crowd size) for accuracy and reliability is an important facet of crowdsourced photo annotation. This can be determined in a systematic manner based on the difficulty of the task and the desired level of accuracy, using receiver operating characteristic (ROC) analyses. Usability tests of the zoom and crop tool suggest that these tools significantly improve annotation accuracy. The tests asked raters to extract data from photographs, not for the purposes of assessing the quality of that data, but rather to assess the usefulness of the tool. The proportion of individuals accurately identifying the presence of a specific advertisement was higher when provided with pictures of the product’s logo and an example of the ad, and even higher when also provided the zoom tool (χ²₂=155.7, P<.001). Similarly, when provided cropped images, a significantly greater proportion of respondents accurately identified the presence of cigarette product ads (χ²₁=75.14, P<.001), as well as reported being able to read prices (χ²₂=227.6, P<.001). Comparing the results of crowdsourced photo-only assessments to traditional field survey data, an excellent level of correspondence was found, with area under the ROC curves produced by sensitivity analyses averaging over 0.95, requiring on average 10 to 15 crowdsourced raters to achieve values of over 0.90.

Results

Further testing and improvement of these tools and processes is currently underway. This includes conducting systematic evaluations that crowdsource photograph annotation and methodically assess the quality of raters’ work.

Conclusions

Overall, the combination of crowdsourcing technologies with tiered data flow and tools that enhance annotation quality represents a breakthrough solution to the problem of photograph annotation, vastly expanding opportunities for the use of photographs rich in public health and other data on a scale previously unimaginable.