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Older adults who smoke are half as likely to make a quit attempt, but more likely to maintain abstinence using evidence-based treatments. Awareness of the increased risk of dementia among people who currently smoke may motivate cessation in this population, but messages have not been tested. 820 adults who smoke, ages 50-80, with no history of dementia completed an online survey examining one of three randomly assigned messages (Control N = 266, Fear N = 274, Hope N = 280) on motivation and intentions to quit. Fear and Hope messages were based on the link between smoking and dementia. Fear increased motivation to quit [t(813) = 2.818, p = 0.005] more than Control. Hope did not differ from Control [t(813) = 1.908, p = 0.057] or Fear [t(813) = 0.937, p = 0.349] in change in motivation to quit. There were no differences between messages in change in intention to quit, F(2, 817) = 0.825, p = 0.439. Future work should examine feasibility and acceptability of fear-based motivational messages on quitting success., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: To reduce smoking and the harms it causes, countries, including the USA, are considering policies to reduce nicotine in combustible tobacco to minimally addictive levels. Effective messages about very low nicotine cigarettes (VLNCs) and this policy are crucial in combating misperceptions threatening the policy's effectiveness., Data and Methods: A discrete choice experiment assessed messages about VLNCs. Participants were 590 adults who smoked exclusively, 379 adults who both smoked and used e-cigarettes, 443 adults who formerly smoked and 351 young adults who never smoked (total n=1763). Seven message attributes were varied systematically (source, harm, chemicals, nicotine, satisfaction, addictiveness and quitting efficacy). Outcomes were selection of messages that generated the most positive attitude towards reduced nicotine policy, the greatest perceived harmfulness of VLNCs, and most strongly motivated quitting and initiating behaviour for VLNCs., Results: Information about specific harms and chemicals of VLNCs had the largest effects on selection of messages as eliciting more negative attitudes towards VLNCs policy, increasing perceived VLNC harmfulness, increasing motivation to quit VLNCs and decreasing motivation to try VLNCs. Messages with information about quitting efficacy were selected as more motivating to quit among those who smoke, but also more motivating to try VLNCs among those who do not smoke., Conclusion: Harm and chemical information can be prioritised to ensure VLNCs are not misperceived as less harmful than regular cigarettes. Messages about increased quitting efficacy and reduced addictiveness associated with VLNCs may backfire if presented to those who do not smoke., Competing Interests: Competing interests: No, there are no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

How people make perceived message effectiveness (PME) judgments remains mostly unexplored. This study assessed whether people need to spontaneously think about message effectiveness to report the message as effective on rating scales and investigated emotions as precursors to PME. After viewing one of four e-cigarette prevention messages, 1,968 adult current and former smokers and nonsmokers freely expressed thoughts about the messages in an open-ended question and answered close-ended PME items. Four expressed PME variables (positive message perceptions, negative message perceptions, positive effect perceptions, and negative effect perceptions) were coded (1 = present , 0 = absent ) in the open-ended responses, and all were significantly associated with measured PME. Positive and negative emotions predicted both expressed and measured PME. Negative message perceptions was the only expressed PME construct that mediated the relationships between emotions and measured PME and outcomes (perceived risk and behavioral intentions). This suggests that messages may not need to induce effectiveness thoughts to be reported as effective, but thoughts of message ineffectiveness are a useful indicator deserving further research.

Growing evidence indicates that communicating the combined risk of smoking and COVID-19 encourages smoking cessation. Guided by the Extended Parallel Process Model (EPPM), we examined how perceived threats of smoking and COVID-19 independently and interactively predicted danger control responses (i.e., quit intentions and COVID-19-protective behavioral intentions) and fear control responses (i.e., fear and fatalism). We also explored the direct and interactive impacts of perceived efficacy of quitting smoking and COVID-protective behaviors on message outcomes. Structural equation modeling results ( N = 747 U.S. adults who smoke) indicated that the perceived efficacy of COVID-protective behaviors positively predicted quit intentions. Higher perceived threat of COVID-19 and greater quitting efficacy predicted higher quit intentions directly and indirectly via fear. As perceived COVID-protective efficacy increased, the positive association between perceived quitting efficacy and quit intentions also increased. Smoking-related threat and efficacy perceptions did not predict COVID-protective behavioral intentions. This study added to EPPM by considering how threat and efficacy perceptions deriving from two different yet closely related risks affect protective behaviors. Thus, combining multiple threats in a single message might be a promising strategy to motivate smoking cessation amid the pandemic.

Background: To better understand the various influences of COVID-19 on tobacco use, we examined three different tobacco user groups using qualitative methods., Methods: Ten online focus groups with 61 adults from the Atlanta, GA area were held in October-November 2020: four with exclusive smokers (n = 16), three with Electronic Nicotine Delivery System (ENDS) users (dual and exclusive, n = 22), and three with transitioning (recently quit or currently quitting) smokers and/or ENDS users (n = 23)., Results: Exclusive smokers reported smoking more frequently, driven by COVID-19-related stress, time at home, and boredom. They were not motivated to quit during the pandemic, and some considered smoking to be protective against COVID-19. ENDS users reported vaping less, with dual users often increasing their smoking; many were concerned about health effects of smoking and ENDS use during the pandemic. Transitioning smokers/ENDS users worried about their health and wanted to quit, but many found the stress of COVID-19 unbearable without tobacco use., Conclusions: There were some similarities among the groups, but also pronounced differences. Educational campaigns should capitalize on the teachable moment of COVID-19 to increase perceived risk of smoking. Smokers need access to more adaptive ways to deal with stress (such as mindfulness training) in lieu of smoking and systems-level approaches should address structural determinants of health that cause high levels of stress. The proposed policy to lower nicotine in combusted tobacco products might help smokers choose other means of coping instead of cigarettes by reducing the stress-relieving properties of smoking particularly salient during the pandemic., Implications: Smokers believe that cigarettes help them deal with the stresses and challenges of the COVID-19 pandemic. This needs to be counteracted by educational campaigns to increase perceived harm of smoking, alternative stress-relief strategies, and mandated changes to the combusted tobacco products to make them less appealing., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: In 2017, the US Food and Drug Administration (FDA) announced a proposed regulation to lower nicotine in cigarettes to minimally addictive levels to help smokers quit. We sought to explore effective message strategies communicating about nicotine reduction in cigarettes across the different key audiences that the regulation is most likely to influence., Methods: We designed four types of messages: efficacy messages, risk messages, a message about alternative sources of nicotine and a compensation message. Sixteen virtual focus groups were conducted in Atlanta and San Francisco in April-May 2020. Data were analysed in NVivo 12.0 using a thematic analysis approach., Findings: Exclusive smokers were receptive to both efficacy messages and risk messages. Dual users were the only group that was open to resorting to alternative sources of nicotine. Former smokers were critical of these messages as promoting the new kinds of cigarettes and potentially encouraging initiation and relapse of smoking. Non-smokers felt that efficacy messages downplayed the risks of smoking and did not scare people away from smoking. Presenting information that very low nicotine cigarettes (VLNCs) still contain harmful chemicals made smokers question continued smoking in the absence of nicotine and view VLNCs as harmful., Conclusions: Messages communicating about nicotine reduction in cigarettes might help to motivate smokers to quit and can correct the misperceptions that VLNCs are less harmful. The FDA should consider specific target audiences and use different messages that complement each other in communicating about this regulation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Several countries are considering a reduced nicotine policy that would make cigarettes minimally or nonaddictive. This qualitative study documents reactions to the policy that should be addressed by future communication efforts., Methods: In 2020, we recruited participants in Atlanta, GA and San Francisco, CA (27 people who exclusively smoke, 25 who dual use cigarettes and e-cigarettes, 32 who formerly smoked, and 31 young adults who do not smoke). We held 16 focus groups: 2 focus groups for each smoking status in each city. Participants viewed messages about very low nicotine content cigarettes (VLNCs) and were asked about their reactions to each message and their overall response to the reduced nicotine policy., Results: While responses to the policy were predominantly positive, focus group discussion also revealed concerns, questions, and misunderstandings (referred to here collectively as "perceptions") that may need to be addressed if a reduced nicotine policy is enacted. Participants expressed perceptions related to the policy intent, including that the FDA has ulterior motives, adoption/ implementation, including that nicotine would have to be replaced with other chemicals if removed or that the policy would be unfeasible to implement, and effectiveness, including concern that VLNCs would still be addictive or the policy would backfire., Conclusions: Addressing perceptions about reduced nicotine policy intent, adoption/implementation, and effectiveness could be key in creating public support and political motivation to move forward with such a policy. Countries contemplating adopting such a policy should consider pairing it with communications that address these perceptions., Implications: This study is one of very few to use qualitative methods to explore potentially problematic perceptions about nicotine reduction policy among US adults. Results illuminated new policy-specific concerns, questions, and misunderstandings about the reduced nicotine policy intent, adoption/implementation, and effectiveness. Identifying, studying, and addressing relevant perceptions may play a key role in generating support in countries contemplating such a policy., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

COVID-19 has increased the rates of serious psychological distress (SPD) among the general population. However, the SPD among smokers during the pandemic remains understudied. In a parent study, 1,004 U.S. adult smokers with and without SPD were randomized to view messages about COVID-19 risk, smoking risk, combined COVID-19 and smoking risk, or control. Outcomes were smoking quit intentions and COVID-19 protective behavior intentions. We analyzed the prevalence of SPD among current smokers; the associations between SPD, personal characteristics, and smoking and COVID-19 protective behavioral intentions; and whether SPD moderated the effect of messages about risks of smoking and COVID-19.Thirty-six percent of smokers met the criteria for SPD. Odds of having SPD were higher for older, everyday smokers, who had COVID-19, had poor health and conservative ideology. Smokers with SPD were significantly more likely to report intentions to quit smoking and seek counseling than smokers without SPD, controlling for demographics, readiness to quit, and message condition. SPD was not significantly related to COVID-19 protective intentions. The interactions between SPD and messages were nonsignificant. During the pandemic, smokers with SPD may be motivated to quit smoking, which provides an opportunity for targeted interventions to increase quit attempts.

Background: Smoking cigarettes worsens COVID-19 outcomes, and news media and health agencies have been communicating about that. However, few studies have examined how these messages affect attitudes, beliefs, and behavioral intentions of people who smoke. These are critical variables that can inform public health campaigns to motivate quitting smoking during the COVID-19 crisis., Methods: In August 2020, we conducted an online experiment in the U.S. with 1,004 adults who smoke. Participants were randomized to one of four message conditions: COVID-19 risk, smoking risk, combined risk of smoking for COVID-19 severity, or a non-risk control. Outcomes were message reactions (emotions and reactance), attitudes and beliefs (severity, susceptibility, self-efficacy, response efficacy for smoking and COVID-19, and conspiracy beliefs), and behavioral intentions (smoking intentions, COVID-protective intentions, and information-seeking)., Results: Multivariate analysis of covariance (MANCOVA) showed that combined risk messages elicited higher perceived severity of smoking-related disease than control messages. Similarly, the combined risk condition resulted in greater intentions to quit smoking in the next month (vs. COVID-19 risk condition) and intentions to reduce smoking in the next 6 months (vs. smoking risk and control; ps < .05). Multivariate logistic regression found that exposure to the combined risk messages (vs. control as referent) was associated with higher odds of mask-wearing intentions in the next 2 weeks (AOR = 1.97)., Conclusions: Health agencies can possibly use messages that communicate about the combined risk of smoking and COVID-19 as a novel strategy to motivate people who smoke to quit and take protective action for COVID-19., Competing Interests: Declarations of Interest None declared., (Copyright © 2022. Published by Elsevier B.V.)

Background: Cigarette pictorial warning labels (PWLs) could produce stronger quit intentions than text-only warning labels (TWLs) due to greater emotional arousal. Yet, it remains unclear whether PWLs that elicit different levels of emotions produce different outcomes. To better understand the role of negative emotions in the effects of PWLs, this study developed two sets of PWLs arousing different emotional levels (high vs low) but equally high on informativeness and compared them to each other and to the current TWLs., Methods: Adult US smokers (n=1503) were randomised to view nine high-emotion-arousing or low-emotion-arousing PWLs or TWLs. After each label, participants reported the negative emotions they felt while looking at the label. After seeing all the labels, participants reported their intentions to quit smoking. Mediation analyses tested whether message condition influenced quit intentions indirectly through negative emotions., Results: Compared with TWLs, PWLs produced higher levels of negative emotions (b=0.27, SE=0.04, p<0.001). Compared with low-emotion arousing PWLs, high-emotion-arousing PWLs produced higher levels of negative emotions (b = 0.24, SE=0.07, p<0.001). Higher negative emotions predicted stronger quit intentions (b=0.20, SE=0.03, p<0.001). Negative emotions mediated the effects of PWLs versus TWLs and high-emotion-arousing versus low- emotion-arousing PWLs on quit intentions., Conclusions: The results provide additional evidence for negative emotions as the mechanism through which PWLs motivate smokers to consider quitting. The findings call on the Food and Drug Administration to design and implement high-emotion-arousing cigarette warning labels., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Conversations about pictorial cigarette health warning labels (HWLs) encourage quit attempts, and prior research suggests prevalence of these conversations varies by ethnicity. We assessed the frequency of conversations about text-only HWLs among Latino and non-Latino white smokers and the relationship between conversations and subsequent quit attempts. Methods: Latino and non-Latino white adult smokers in the United States (N = 4403) were surveyed every 4 months over 2 years. Surveys queried smoking behaviors, recent quit attempts, HWL responses, including HWL conversations, and socio-demographic variables. Negative binomial generalized estimating equation (GEE) models regressed the frequency of HWL conversations on study variables. Logistic GEE models regressed quit attempts at follow-up surveys on responses from the prior wave, including frequency of HWL conversations and their interaction with ethnicity. Results: Spanish preference Latinos reported the most HWL conversations (85%), followed by English preference Latinos (59%), and non-Latino Whites (35%). More frequent HWL conversations predicted subsequent quit attempts (AOR = 1.74, 95% CI = 1.32, 2.30), but ethnicity did not moderate this effect. Conclusions: Latinos appear to talk more frequently about HWLs than non-Latino Whites but are no more likely to quit as a result. Cessation campaigns should use messages that encourage conversations about quitting.

Introduction: In 2017, the US Food and Drug Administration (FDA) proposed lowering the amount of nicotine in combusted cigarettes to minimally addictive levels. If used, to encourage cessation and maximize the benefits of this action, the FDA needs to determine the most effective way to communicate to the public the practical impact of this nicotine tobacco product standard., Methods: Data were collected in 2018 from a nationally representative, online probability sample of 1198 adult smokers (aged ≥18 years old) in the United States. Smokers were randomly assigned one of five versions of the question regarding what they would most likely do if nicotine in cigarettes was reduced (nicotine levels were reduced by 95%; the government reduced nicotine levels by 95%; cigarettes were no longer addictive; cigarettes no longer relieved cravings; cigarettes were changed so that you would be able to quit more easily). Effects of framing on anticipated tobacco use intentions and perceived risk of very low nicotine cigarettes (VLNCs) were evaluated with multinomial logistic regressions., Results: Framing the nicotine tobacco product standard as cigarettes no longer relieved cravings resulted in the highest proportion of smokers reporting they intend to quit in response to this standard (43.9%), lowest proportions reporting anticipated intentions to continue using combusted tobacco products (45.3%), and lowest proportion believing that VLNCs are less harmful than regular cigarettes (26%)., Conclusions: Different frames of nicotine reduction in cigarettes differentially affected smokers' anticipated tobacco use intentions and perceived risk of VLNCs. Presenting reduction as making cigarettes unable to relieve cravings might be particularly effective at motivating cessation., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: Health agencies are grappling with communicating risks of electronic cigarettes (e-cigarettes) compared with combusted cigarettes. This study examined smokers' responses to two types of comparative risk messages with one type incorporating more negative antismoking elements in the design., Methods: In an online experiment, 1400 US adult (18+ years) current smokers and recent quitters were randomised to view one of three comparative risk messages about e-cigarettes (CR messages), one of three comparative risk messages that included more negative antismoking elements in the design (CR- messages) or a control message. Selection of outcomes was guided by the antismoking message impact framework. Multivariate analyses of covariance and logistic regression models analysed effects of messages on message evaluations, e-cigarette-related and cigarette-related beliefs and behavioural intentions., Results: Both CR and CR- messages decreased smokers' intentions to smoke cigarettes, increased intentions to switch to e-cigarettes completely and increased perceptions that e-cigarettes are less harmful than combusted cigarettes. Neither message type increased dual use intentions relative to exclusive e-cigarettes use or smoking cessation. CR messages decreased perceived absolute risks of e-cigarettes and self-exempting beliefs about smoking, whereas CR- versus CR messages produced higher self-efficacy to quit smoking., Conclusion: Comparative risk communication might encourage smokers to switch to lower-harm tobacco products. Comparative risk messages with more negative antismoking elements in the design might be particularly effective, because they led to higher self-efficacy to quit smoking. Regulatory agencies may consider using comparative risk messages with more negative antismoking elements to educate the public about lower risk of e-cigarettes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Emotions are important in smoking-related communications, but the role of discrete positive and negative emotions in comparative risk messages about combusted and electronic cigarettes (e-cigarettes) is unclear., Method: In an online experiment, 1,202 U.S. adult current smokers or recent quitters were randomized to view one of six messages about comparative risk of e-cigarettes and cigarettes. Participants reported their feelings of hope, happiness, fear, guilt, disgust, and anger and risk perceptions and behavioral intentions about e-cigarettes and cigarettes., Results: Hope was associated with higher perceived absolute cigarette risk, lower perceived absolute and comparative e-cigarette risk, and stronger intentions to quit smoking, seek quit help, use nicotine replacement therapy (NRT), switch to e-cigarettes, and use e-cigarettes exclusively versus dual use. Happiness was related to stronger intentions to seek quit help, use NRT, and switch to e-cigarettes but higher perceived comparative risk of e-cigarettes. Fear was associated with stronger intentions to quit smoking, seek quit help, use NRT, and switch to e-cigarettes. Guilt was related to higher perceived absolute cigarette risk, lower perceived comparative e-cigarette risk, and stronger intentions to use NRT. Disgust was associated with higher absolute and comparative e-cigarette risk and stronger intentions to quit smoking, seek quit help, and use e-cigarettes exclusively versus dual use. Anger was related to lower perceived absolute cigarette risk, higher perceived comparative e-cigarette risk, and weaker intentions to quit smoking., Conclusion: Comparative risk messages about e-cigarettes that arouse hope, fear, and guilt and avoid anger might be particularly likely to have positive impact on smokers.

Background: This study used an audience segmentation and message targeting approach to identify three distinct smoker groups-Older Freedom Smokers (OFS), Reluctant Smokers (RS), and Young Enthusiasts (YE)-and examined whether an electronic nicotine delivery systems (ENDS) message targeting each smoker group (targeted message) was associated with more health-enhancing outcomes than messages targeting other groups (nontargeted messages). Methods: An online experiment was conducted among 580 adult smokers with 180 OFS, 200 RS, and 200 YE. Each smoker group viewed a targeted message and two nontargeted messages in a random order. Following the presentation of each message, participants reported their perceived message effectiveness, message reactions, ENDS- and cigarette-related beliefs, and behavioral intentions. Results: The targeted vs. nontargeted messages mostly did not produce more health-enhancing outcomes on perceptions of absolute and comparative risks of ENDS and cigarettes, response efficacy of ENDS, and self-efficacy as well as intentions to quit smoking. Conclusions: Our targeted messages did not appear to be a better choice over nontargeted messages to communicate about ENDS to smokers. Given the increasing call to accurately inform the public of the risk differences among various tobacco products, future studies should continue to explore whether targeted messages could be employed to communicate about the comparative risks of ENDS.

This study assessed smokers' responses to different smoking cessation topics and imagery for cigarette package inserts. Adult smokers from Canada ( n = 1000) participated in three discrete choice experiments (DCEs): DCE 1 assessed five cessation benefit topics and five imagery types; DCE 2 assessed five messages with tips to improve cessation success and five imagery types; DCE 3 assessed four reproductive health benefits of cessation topics and four imagery types. In each DCE, participants evaluated four or five sets of four inserts, selecting the most and least motivating (DCEs 1 & 3) or helpful (DCE 2) for quitting. Linear mixed models regressed choices on insert and smoker characteristics. For DCE 1, the most motivating messages involved novel disease topics and imagery of younger women. For DCE 2, topics of social support, stress reduction and nicotine replacement therapy were selected as most helpful, with no differences by imagery type. For DCE 3, imagery influenced choices more than topic, with imagery of a family or a mom and baby selected as most motivating. Statistically significant interactions for all three experiments indicated that the influence of imagery type on choices depended on the message topic. Messages to promote smoking cessation through cigarette pack inserts should consider specific combinations of message topic and imagery.

Objectives: Message fatigue, a phenomenon of being tired of repeated exposure to messages promoting the same health behavior, may reduce the effectiveness of anti-tobacco messages, such as warning labels. As an initial step towards understanding the phenomenon, we examined predictors of anti-tobacco message fatigue., Methods: An online study (N = 1838) involving a non-probability sample of nonsmokers and smokers in the United States assessed anti-tobacco message fatigue and individual-level factors including demographic variables and smoking status. General linear models were used to analyze the data., Results: The multivariable results show that individuals who were younger, male, and had higher income and education reported higher levels of anti-tobacco message fatigue. African Americans reported significantly lower levels of message fatigue than other racial groups. Current smokers reported greater message fatigue than transitioning smokers and nonsmokers. Among current smokers, those with greater nicotine dependence reported higher levels of anti-tobacco message fatigue., Conclusions: These findings underscore the importance of segmenting the audience based on their levels of message fatigue and using more novel message strategies and delivery methods to influence populations with relatively higher levels of anti-tobacco message fatigue.

Tobacco warning labels effectively educate consumers about the harms of tobacco and reduce smoking behavior. Lessons from tobacco warning labels can be applied to developing and implementing warning labels for sugar-sweetened beverages (SSBs). Large pictorial rotating warnings are particularly effective. Dental professionals can be an important voice in countering the industry's efforts to create controversy around the effects of SSBs and in advocating for effective warning labels based on the evidence from the tobacco warning labels. Sugar, rum and tobacco are commodities which are nowhere necessaries of life, which are become objects of almost universal consumption and which are therefore extremely proper subjects of taxation. 1 ., Competing Interests: Conflict of Interest

Introduction: Young adults in the military are aggressively targeted by tobacco companies and are at high risk of tobacco use. Existing antismoking advertisements developed for the general population might be effective in educating young adults in the military. This study evaluated the effects of different themes of existing antismoking advertisements on perceived harm and intentions to use cigarettes and other tobacco products among Air Force trainees., Methods: In a pretest-post-test experiment, 782 Airmen were randomised to view antismoking advertisements in 1 of 6 conditions: anti-industry, health effects+anti-industry, sexual health, secondhand smoke, environment+anti-industry or control. We assessed the effect of different conditions on changes in perceived harm and intentions to use cigarettes, electronic cigarettes, smokeless tobacco, hookah and cigarillos from pretest to post-test with multivariable linear regression models (perceived harm) and zero-inflated Poisson regression model (intentions)., Results: Antismoking advertisements increased perceived harm of various tobacco products and reduced intentions to use. Advertisements featuring negative effects of tobacco on health and sexual performance coupled with revealing tobacco industry manipulations had the most consistent pattern of effects on perceived harm and intentions., Conclusions: Antismoking advertisements produced for the general public might also be effective with a young adult military population and could have spillover effects on perceptions of harm and intentions to use other tobacco products besides cigarettes. Existing antismoking advertising may be a cost-effective tool to educate young adults in the military., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Introduction: Tobacco manufacturers' aggressive promotion of new smokeless tobacco products such as snus warrants a timely and effective public health response. This study tested potential countermarketing messages to discourage current and former smokers from becoming dual users of smokeless tobacco and cigarettes., Methods: In a pretest-post-test experiment, 1836 adult current and recently former smokers from a national sample were randomised to view one of six antismokeless tobacco ads followed by a snus ad, to view a control ad followed by a snus ad; or to view two control ads. Perceived effectiveness of ads and actual changes in attitudes and openness to snus were compared across groups using analyses of variance., Results: Some ads that were perceived as most effective did not change attitudes or openness to trying snus, and conversely, some ads not perceived as effective changed attitudes and openness to snus. Ads portraying the negative health effects of smokeless tobacco were perceived as most effective, but ads with antitobacco industry themes significantly decreased favourable attitudes toward snus. Responses to ads were different for smokers who had ever used smokeless tobacco: for this group health effects and humorous/testimonial ads were effective., Conclusions: Measures of perceived effectiveness of antitobacco ads need to be augmented with measures of actual effectiveness to assess countermarketing messages. Some of the developed ads, such as ads with anti-industry themes, were effective for the overall population of smokers whereas humorous/testimonial and health effects ads were particularly effective in changing attitudes of past users of smokeless tobacco., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Cigarette companies increasingly promote novel smokeless tobacco products to smokers, encouraging them to use smokeless tobacco in smoke-free environments. New messages may counteract this promotion. We developed 12 initial anti-smokeless message ideas and tested them in eight online focus groups with 75 US smokers. Those smokers who never tried smokeless tobacco were unaware of health risks of novel smokeless tobacco products, perceived scary messages as effective and acknowledged the addictive nature of nicotine. Smokers who had tried smokeless tobacco shared their personal (mainly negative) experiences with smokeless tobacco, were aware of health risks of novel smokeless tobacco products, but denied personal addiction, and misinterpreted or disregarded more threatening messages. Portraying women as smokeless tobacco users was perceived as unbelievable, and emphasizing the lack of appeal of novel smokeless tobacco products was perceived as encouraging continued smoking. Future ads should educate smokers about risks of novel smokeless tobacco products, but past users and never users may require different message strategies.

Objectives: We investigated the frequency of alternative tobacco product use (loose leaf, moist snuff, snus, dissolvables, electronic cigarettes [e-cigarettes]) among smokers and the association with quit attempts and intentions., Methods: A nationally representative probability-based cross-sectional survey of 1836 current or recently former adult smokers was completed in November 2011. Multivariate logistic regressions evaluated associations between alternative tobacco product use and smoking cessation behaviors., Results: Of the smokers, 38% had tried an alternative tobacco product, most frequently e-cigarettes. Alternative tobacco product use was associated with having made a quit attempt, and those intending to quit were significantly more likely to have tried and to currently use the products than were smokers with no intentions to quit. Use was not associated with successful quit attempts. Interest in future use of alternative tobacco products was low, except for e-cigarettes., Conclusions: Alternative tobacco products are attractive to smokers who want to quit smoking, but these data did not indicate that alternative tobacco products promote cessation. Unsubstantiated overt and implied claims that alternative tobacco products aid smoking cessation should be prohibited.

BackgroundExposure to advertisements for tobacco products and tobacco warning labels evokes emotions. This study evaluated the association of discrete positive and negative emotions with interest in alternative tobacco products.MethodIn 2013, 1,226 U.S. adult nonsmokers and current smokers viewed advertisements for moist snuff, snus, and electronic cigarettes (e-cigarettes) with various warning labels and then indicated their emotional responses in terms of anger, anxiety, sadness, guilt, disgust, discouragement, hope, and contentment. Outcomes were openness to using moist snuff, snus, and e-cigarettes in the future and interest in a free sample of each product. Data were analyzed in 2016.ResultsHope was positively associated with openness and interest across all alternative tobacco products as was contentment for moist snuff and snus. Anger was negatively associated with openness to moist snuff and e-cigarettes, disgust negatively to moist snuff and snus, and anxiety negatively to e-cigarettes. Being a current smoker, ever trying a corresponding product, being male, and younger age were associated with greater openness to and interest in moist snuff and snus. For e-cigarettes, being a current smoker, ever trying e-cigarettes, and being female were associated with greater openness, and being a current smoker was associated with greater odds of selecting a free sample.ConclusionsPositive emotions, particularly hope, were consistently positively associated with interest in alternative tobacco products. Hope is widely used by tobacco and e-cigarette companies to advertise their products. Antitobacco messages should aim to lower hope associated with tobacco products but increase hope for cessation or life without tobacco.

Research suggests that smoking may compound the risk of serious health problems to smokers who contract COVID-19. This study examines whether and how exposure to news stories reporting the severe COVID-19 risk to smokers may influence smokers' emotional responses (fear, anxiety, and sadness) and intentions to take measures to quit smoking. Current smokers in the US participated in an online experiment (N = 495) and were randomized to read smoking risk news stories or news stories reporting the combined risk of smoking and COVID-19. We found that combined risk news stories lead to participants feeling more fearful and sadder than when they viewed smoking risk news stories (M = 5.74; SD = 2.57 vs. M = 5.20; SD = 2.74; p <.05). Fear fully mediated the effect of news exposure on intentions to take measures to quit smoking (ß =.09; SE = 05; 95% CI [.010,.200]). Moreover, moderated-mediation analyses revealed that the mediating effect of fear was conditioned on the levels of comparative optimism, such that the association between fear and intentions to take measures to quit smoking was only significant among smokers whose comparative optimism was at the mean score (ß =.16; SE = 05; 95% CI [.071,.250]), and for those whose comparative optimism was high (ß =.27; SE =.06; 95% CI [.146,.395]). These results suggest that fear of the pandemic and optimism might play important roles in predicting and explaining the association between exposure to news stories and intentions to take measures to quit smoking. Messages about heightened risk of COVID-19 complications for smokers that increase fear might be an effective strategy to motivate smokers to quit. Such messages should be used to turn the adversity of COVID-19 pandemic into an intervention opportunity to reduce tobacco-related disease. [ABSTRACT FROM AUTHOR]

Background: The Extended Parallel Process Model (EPPM) responses that emerge from spontaneous reactions to cigarette warning labels remain understudied. We identified the EPPM responses in reactions to cigarette warning labels and evaluated their predictors and relationship with warning perceptions. Methods: U.S. adult current smokers, transitioning smokers (quit in the past two years or currently quitting) and never smokers (n = 1838) saw nine of 81 cigarette warning labels. Participants freely wrote their thoughts after viewing the first label and reported perceived informativeness, negative emotions, and denial for this label. Responses were coded for the presence of the EPPM response categories. Multivariable logistic regression models described adaptive and maladaptive respondent characteristics, and linear regression models assessed the relationship between the response categories and label perceptions. Results: Participants' responses contained adaptive (65.4%), maladaptive (16.5%), no response (14.7%), and mixed responses (both adaptive and maladaptive; 3.4%). Current smokers had decreased odds of adaptive response compared to never and transitioning smokers. Compared to text warnings, pictorial warnings were associated with increased odds of adaptive and decreased odds of maladaptive responses. Adaptive response was associated with increased odds of intentions to quit smoking. Adaptive respondents reported the highest levels of informativeness and negative emotions among the four response categories. Conclusions: The finding demonstrating predominantly adaptive (and few maladaptive) responses to warning labels supports the continued use of fear appeals in warning label design. The greater adaptive and lower maladaptive responses to pictorial warnings could serve as additional evidence for FDA to implement pictorial warning labels. [ABSTRACT FROM AUTHOR]

Objectives: Our aim was to identify message characteristics for cigarette pack inserts that aim to help smokers quit. Methods: US adult smokers from an online consumer panel (N = 665) participated in a discrete choice experiment with a 2x2x2x2x4 within-subjects balanced incomplete block design, manipulating: image (vs no image), text type (testimonial vs informational), cessation resource information (vs none), call to action (vs none), and message topic (well-being, financial benefit, cravings, social support). Participants evaluated 9 choice sets, each with 4 inserts, selecting: (1) the most and least helpful for quitting; and (2) the most and least motivating to quit. Linear models regressed choices on insert characteristics, controlling for sociodemographics and smoking-related variables. We assessed interactions between insert characteristics and smoker attributes (ie, education, quit intention, self-efficacy). Results: Inserts were most helpful and motivating when they included an image, provided cessation resource information, or referenced well-being and financial benefits. Significant interactions indicated that inserts with cessation resource information were relatively more helpful and motivating among smokers with low self-efficacy, an intention to quit, or lower education. Conclusion: Cigarette pack inserts with imagery and cessation resource information may be particularly effective in promoting smoking cessation. [ABSTRACT FROM AUTHOR]

Objectives: Message fatigue, a phenomenon of being tired of repeated exposure to messages promoting the same health behavior, may reduce the effectiveness of anti-tobacco messages, such as warning labels. As an initial step towards understanding the phenomenon, we examined predictors of anti-tobacco message fatigue. Methods: An online study (N = 1838) involving a non-probability sample of nonsmokers and smokers in the United States assessed anti-tobacco message fatigue and individual-level factors including demographic variables and smoking status. General linear models were used to analyze the data. Results: The multivariable results show that individuals who were younger, male, and had higher income and education reported higher levels of anti-tobacco message fatigue. African Americans reported significantly lower levels of message fatigue than other racial groups. Current smokers reported greater message fatigue than transitioning smokers and nonsmokers. Among current smokers, those with greater nicotine dependence reported higher levels of anti-tobacco message fatigue. Conclusions: These findings underscore the importance of segmenting the audience based on their levels of message fatigue and using more novel message strategies and delivery methods to influence populations with relatively higher levels of anti-tobacco message fatigue. [ABSTRACT FROM AUTHOR]

As governments consider policy action to reduce smoking, a key factor in creating political will is the level of public support, particularly among smokers who are most affected by the policies. The goal of this paper is to assess and compare the level of support in Canada, the United States, England, and Australia for five smoking control policies: 1) banning menthol in cigarettes, 2) banning cigarette additives, 3) reducing nicotine in cigarettes to make them less addictive, 4) raising the minimum age to purchase cigarettes to 21 years and older, and 5) requiring pictorial warning labels on cigarette packs (examined in the US only). Data for these analyses come from 8165 daily cigarette smokers who responded to the 2016 International Tobacco Control Four Country Smoking and Vaping Survey. In all countries, the highest level of support was for raising the legal age for purchase to 21 years and older (62-70%) and reducing the nicotine content of cigarettes to make them less addictive (57-70%). Smokers who were less dependent on cigarettes and those expressing interest in quitting were more likely to support all policies. When asked how they would respond to a nicotine reduction policy, the most common response given was to try the non-nicotine cigarettes to see how they liked them (42-48%), with the next most common response being to quit smoking entirely (16-24%). The high level of support for these proposed policies among daily smokers provides important evidence for policymakers to counteract claims that such policies would be unpopular. [ABSTRACT FROM AUTHOR]