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Introduction Flavors with names describing blended tastes/sensations or with ambiguous terminology (“concept flavors”) are available on the e-cigarette market. Aims and Methods This study investigates adolescent and young adult use and sensory perceptions of blended and concept flavors. Current e-cigarette users aged 15–24 years (N = 2281) completed an online convenience sample survey (October 20–November 23, 2020) and rated the sensory attributes (fruity, cooling, sweet, and minty) of their current flavor(s) using nine-point scales. T-tests compared mean sensory perception scores within and between flavors. To compare concept flavors to blends, reference categories used the average of blends with relevant descriptors: fruit (Banana Ice, Iced Mango, Melon Ice, Cool Cucumber); cooling (Banana Ice, Iced Mango, Melon Ice, Blue B Ice, Cool Cucumber, Lush Ice, and Menthol Purple); sweet (Vivid Vanilla) and mint (Mint-sation). Results Most respondents had used at least one product with blended descriptors (74.8%) or concept flavor (57.9%) in the past 30 days. All flavors had high perceived strength for at least two sensory attributes. Mint taste was not perceived to be a strong sensory characteristic for all but two flavors (Mint-sation and Winter) in the study. The most commonly used flavors used blended descriptors (Iced Mango was used by 30.2% of the sample; Banana Ice: 26.2%; Lush Ice: 23.8%; Melon Ice: 22.9%). Some concept flavors did not significantly differ from flavor blend reference categories for strength of: fruit taste (Bahama Mama and Tropic); cooling sensation (Marigold, Island Breeze, Winter); sweet taste (Bahama Mama, Honeymoon, Island Breeze, Island Cream, Meteor Milk, OMG, Royal Dagger and Tropic); and mint taste (Winter). Conclusions Blended and concept flavors are used by most young e-cigarette users, who describe these products as fruity, sweet, and cooling. A variety of flavored products with high youth appeal are available in the U.S. market. Implications This study of adolescent and young adult e-cigarette users finds evidence of the popularity of e-cigarette flavors combining a cooling sensation with fruity and sweet flavorings. Some products with this flavor profile do not use characterizing descriptors. Findings inform public health interventions intended to reduce e-cigarette use in young people.

(1) Background: This study aims to describe the primary sources of e-cigarettes among young people and to explore how these sources may differ by individual-level characteristics. (2) Methods: Data were obtained from a cross-sectional, continuous tracking survey of participants. The analytic sample includes current e-cigarette users (aged 15–20 years) surveyed from January to August 2022 (N = 1296). Respondents provided information on e-cigarette source of acquisition, device type, and flavors used, as well as sociodemographic and residential characteristics. Chi-square tests were used to determine differences in source of acquisition by age, gender, race/ethnicity, United States (US) census region, urban-rural classification, flavors used, and device type. (3) Results: Although most current e-cigarette users obtained their devices through a social source (56.9%), a considerable proportion obtained e-cigarettes from a retail source (43.1%). The primary retail sources of e-cigarette acquisition were vape shops (22.0%) and gas station/convenience stores (15.9%). Source of e-cigarette acquisition differed by age, gender, US census region, flavors used, and device type, such that a lower proportion of those who were younger, female, residing in the West, and used vape pens had reported obtaining e-cigarettes via retail sources. (4) Conclusions: Results indicate that a significant proportion of youth report obtaining e-cigarettes from retail sources, despite the federal, state, and local policies that prohibit the sale of any tobacco products to those under the age of 21. Comprehensive retail regulations to help restrict tobacco product access are needed to reduce e-cigarette use among young people.

BACKGROUND The COVID-19 pandemic had wide-ranging systemic impacts, with implications for social and behavioral factors in human health. These impacts may act as confounders in population-level research studies. OBJECTIVE We sought to identify and validate an affordable, flexible measure to serve as a covariate in research spanning the COVID-19 pandemic period. METHODS Transportation Security Administration (TSA) checkpoint travel numbers were used to calculate a weekly sum of daily passengers and validated against a self-reported item on social distancing practices drawn from a continuous tracking survey among a national sample of youth and young adults (15-24 years) in the United States (N=45,080). An aggregated week-level variable was calculated as the proportion of respondents who did not practice social distancing that week (January 1, 2019 – May 31, 2022). Spearman’s rank correlation coefficients were calculated for the two measures. RESULTS TSA data ranged from 668,719 travelers the week of April 8, 2020 to nearly 15.5 million travelers the week of May 18, 2022. The weekly proportion of survey respondents who did not practice social distancing ranged from 18.1% (week of April 15, 2020) to 70.9% (week of May 25, 2022). The measures were strongly correlated from January 2019 to May 2022 (ρ=.90, p CONCLUSIONS The TSA’s travel checkpoint data provide a publicly available, flexible metric to control for time-varying pandemic impacts at a national level.

The US opioid epidemic is a serious public health problem. Rates of opioid misuse and dependence are highest for young adults ages 18–25. Prevention strategies that reduce prescription opioid misuse while decreasing stigma around dependence and treatment are critical components of addressing the epidemic. The Truth About Opioids, a mass media public education campaign, was designed to prevent opioid misuse and dependence among young adults. This study examined the intervention’s effectiveness to shift opioid-related knowledge, attitudes, and beliefs within targeted designated market areas (DMAs) over time. A sample of young adults (N = 1434) in DMAs with varying levels of media exposure was surveyed at baseline (June–September 2019) and post-intervention (July–August 2020). Logistic regression assessed associations between campaign awareness and campaign-targeted knowledge and attitudes, controlling for baseline variables. Those with any awareness had significantly higher odds of campaign-targeted opioid-related knowledge (versus no awareness) (low awareness OR = 1.52 (95% CI: 1.04, 2.24); high awareness OR = 2.47 (95% CI: 1.58, 3.87)). Those with campaign awareness were also more likely to report lower levels of opioid-related stigma and higher intentions to share information and talk to a friend about the epidemic. Mass media public education campaigns can help influence young adults’ opioid-related knowledge and attitudes.

ObjectiveTo determine whether awareness of emerging vaping-attributable health conditions influences vaping-related risk perceptions and behaviours among young people.DesignRespondents aged 15–24 years (n=3536) were drawn from a repeated cross-sectional online panel survey (222 participants/week) during an e-cigarette/vaping-associated lung injury (EVALI) outbreak in the USA (September 2019–January 2020). Logistic regression models tested for associations between EVALI awareness and perceived lung injury risk and product harm, stratified by e-cigarette/vape use and controlling for awareness of other e-cigarette/vaping news stories, demographic characteristics and outbreak week. Other models measured the association between perceived risk of lung injury and intentions to use (non-users) or intentions to quit (current users) e-cigarettes/vape products. Changes in national retail e-cigarette sales data were examined during national EVALI outbreak reporting.ResultsEVALI awareness was associated with: perceived risk of lung injury (current users OR 1.59, p=0.004; non-users OR 2.11, pConclusionsNews of vaping-attributable health conditions may prevent e-cigarette/vape use and encourage cessation among young people. Tobacco control campaigns should address uncertain health effects of e-cigarettes or vape products and align with risk communication by public health agencies during outbreaks.

BACKGROUND Mass media campaigns are effective in influencing a broad range of health behaviors. Prior to launching a campaign, developers often conduct ad testing to help identify strengths and weaknesses of the message executions among the campaign’s target audience. Endorsement of a six-item perceived message effectiveness (PME) measure is one approach commonly used for message selection; however, this scale often does not produce enough specificity to make important decisions on ad optimization and is typically used with adult populations for smoking cessation messages. OBJECTIVE This study includes the development of the Message Assessment Scale, a new tobacco prevention message testing scale for youth and young adults. METHODS Data were derived from numerous cross-sectional surveys designed to test the relevance and potential efficacy of anti-tobacco truth® campaign ads. Participants aged 15-24 (N=6,108) responded to a set of 12 core attitudinal items including relevance (both personal and cultural) as well as comprehension of the ad’s main message. RESULTS Data analysis included factor analyses which resulted in four scales. The four scales were significantly correlated with fact recall and vape intentions. CONCLUSIONS This set of items expands the portfolio of ad testing measures for ads focused on tobacco use prevention. Findings can inform how best to optimize ad executions and message delivery for health behavior campaigns, particularly those focused on tobacco use prevention among youth and young adult populations.

Background Mass media campaigns for preventive health messaging have been shown to be effective through years of research. However, few studies have assessed the effectiveness of campaigns on digital media, which is currently how youths and young adults are primarily consuming media. In particular, a platform that can accurately assess exposure to digital messaging in a real-life setting has yet to be developed. Objective This study examines the feasibility of a unique survey platform, Virtual Lab, to conduct a study on exposure to a media campaign within Facebook using a chatbot-style survey administration technique. Methods Virtual Lab is a survey platform that was used to recruit and survey participants within Facebook and Facebook Messenger, respectively. We created a Facebook business account with 2 Facebook pages: one for recruitment and disseminating the survey and the other one for serving the target advertisements. Pre- and postexposure surveys were administered via Facebook Messenger using a chatbot-style questionnaire 1 week apart. During this time, the target advertisements were shown to participants who completed the pre-exposure survey. The total time from recruitment to completion of the postexposure survey was 13 days, and incentive costs were US $10 per participant. Survey data were compared between those who completed both pre- and postexposure surveys and those who only completed the pre-exposure survey; that is, those who were lost to follow-up. The demographics of the complete cases were also compared to the US census data. Results A total of 375 Facebook users aged between 18 and 24 years met eligibility requirements and consented to the study, which consisted of complete cases (n=234) and participants lost to follow-up (n=141). A few differences between complete cases and participants lost to follow-up were observed. Regarding gender, complete cases comprised 40.2% males and 59.4% females, and among participants lost to follow-up, 44.0% were male and 50.4% were female (P=.003). Differences were also observed for e-cigarette use status, where a greater number of current users and fewer past and never users were lost to follow-up than complete cases (P=.01). Conclusions The use of Virtual Lab yielded a diverse sample quickly and cost-effectively. Demographic characteristics of participants who completed the study and those who were lost to follow-up were similar, indicating that no biases were caused by the platform during recruitment or testing. This study suggests the feasibility of the Virtual Lab survey platform for studies of media campaign exposure within Facebook. This platform can advance health campaign research by providing more accurate data to inform digital messaging.

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. Ethn Dis. 2020;30(3):479-488; doi:10.18865/ed.30.3.479

Mass media campaigns are one of the most effective population-level interventions for the prevention of tobacco use. However, accurately evaluating the effectiveness of these campaigns presents several challenges, particularly as campaign delivery becomes increasingly fractured across media platforms. There are a number of weaknesses associated with traditional, individual-level measures of campaign exposure in an increasingly socially networked, digital media ecosystem. This study evaluated the national truth® campaign using a novel method to measure campaign exposure through an aggregate weekly exogenous measure of awareness. We generated this exogenous measure from a continuous, cross-sectional tracking survey to predict intentions to smoke and current tobacco use among youth in the United States. Results from multi-level models indicated that weeks with aggregate campaign awareness greater than 65% were associated with lower odds of current tobacco use. We conclude with a discussion of implications and practical considerations for using this method for media campaign evaluation.

Background Pervasive misperceptions about nicotine may influence uptake of quit smoking aids and the impact of policies addressing nicotine as a tobacco product constituent. Methods Latent class analyses were conducted using four items on nicotine beliefs asked of 4037 adults aged 18–40 in wave 9 (February–March 2016) of the Truth Initiative Young Adult Cohort Study. Confirmatory factor analyses identified three factors from 12 items: nicotine susceptibility (NSUS), nicotine severity (NSEV), and tobacco severity (TSEV). Analyses assessed correlations between latent classes, sociodemographics, and nicotine/tobacco factor scores. Results A four-class model of nicotine beliefs was the best fit, with the largest class believing that nicotine plays a major part in smoking risks (class 1, n = 2070; 52%). Class 2 shared that belief but also responded “Don’t know” to addiction questions (class 2, n = 382; 11%). Fewer belonged in class 3, who reported that nicotine plays a small part in health risks (n = 1277; 30%), and class 4, who perceived nicotine as not cancer causing (n = 308; 7%). Latent class membership was correlated with sociodemographics, peer smoking, and past 30-day tobacco use. Classes 1 and 2 had similar NSUS scores and classes 3 and 4 had similar NSEV and TSEV scores. Discussion Differences in the perceptions of nicotine and tobacco-related harms can be partially explained by clustering of underlying nicotine beliefs. These classes of beliefs are correlated with sociodemographic predictors of smoking. These findings may help to identify specific beliefs or groups to be targeted by public education efforts on nicotine. Implications The current study supports that underlying nicotine beliefs are associated with perceived harms of specific nicotine and tobacco products (relative to cigarettes), with greater false beliefs about nicotine correlated with greater perceived susceptibility to nicotine addiction. Two important inferences emerge from this study: first, that education to address nicotine beliefs may also reframe perceptions of the harms of nicotine and tobacco products; and second, that this type of education may differentially impact perceptions of the harms of nicotine products (e.g., nicotine replacement therapy and e-cigarettes) and tobacco products (e.g., cigars, smokeless, and hookah).

BackgroundE-cigarette promotion on social media coincided with the rapid growth of e-cigarette use among American youth, particularly with the increased JUUL pod vaporiser use. We examined commercial JUUL-related messages on Instagram to identify marketing appeals used to target users along the continuum of e-cigarette use; we mapped the appeals to existing theoretical marketing frameworks to better understand industry strategies.MethodsHashtag-based keyword rules were used to collect JUUL-related posts from the Instagram application programming interface, 1 March–13 November 2018. Posts were classified as commercial or non-commercial. A combination of machine learning methods, keyword algorithms and human coding were used to characterise message themes in commercial posts.ResultsKeyword filters captured 50 817 relevant posts and 41% were commercial. Among commercial posts, 91% contained recruitment/trial-based appeals (eg, combustible tobacco cessation; product sampling; giveaways) and 71% featured reinforcement/addiction-related appeals (eg, loyalty programmes). None of the commercial messages contained e-cigarette cessation-related appeals and less than 25% mentioned quitting combustible tobacco as a recruitment appeal.ConclusionsInstagram posts featuring e-cigarette related marketing can increase exposure to persuasive messages encouraging e-cigarette trial and use particularly among susceptible youth. Stronger regulations are needed to prevent exposure to social media marketing among young social media users.

Objectives. To determine whether the COVID-19 pandemic affected e-cigarette use among young people in the United States. Methods. Data came from a weekly cross-sectional online survey of youths and young adults (aged 15–24 years). Logistic regression analyses measured odds of past-30-day e-cigarette use (n = 5752) following widespread stay-at-home directives (March 14–June 29, 2020), compared with the pre‒COVID-19 period (January 1–March 13, 2020). Logistic regression among a subsample of current e-cigarette users (n = 779) examined factors associated with reduced use following stay-at-home orders. Results. Odds of current e-cigarette use were significantly lower during the COVID-19 pandemic compared with the pre‒COVID-19 period among youths aged 15 to 17 years (odds ratio [OR] = 0.72; 95% confidence interval [CI] = 0.54, 0.96) and young adults aged 18 to 20 years (OR = 0.65; 95% CI = 0.52, 0.81). E-cigarette users with reduced access to retail environments had higher odds of reporting reduced e-cigarette use (OR = 1.51; 95% CI = 1.07, 2.14). Conclusions. COVID-19 stay-at-home directives present barriers to e-cigarette access and are associated with a decline in e-cigarette use among young people. Public Health Implications. Findings support the urgent implementation of interventions that reduce underage access to e-cigarettes to accelerate a downward trajectory of youth and young adult e-cigarette use.

Introduction The purpose of this study is to examine awareness, attitudes, and related knowledge of e-cigarettes, and JUUL specifically, among parents of middle and high school students. Methods Data were collected in October–November 2018 from a nationally representative sample of U.S. parents of middle and high school students aged 11–18 years (n=2,885) to examine e-cigarette and JUUL awareness, concern about e-cigarette use, and school communication regarding e-cigarettes. Weighted frequencies and percentages are reported; Rao–Scott chi-square tests examined differences by school level. Data were analyzed in 2019. Results Although most parents (96.2%) had seen or heard of e-cigarettes, only 55.9% had seen or heard of JUUL, and only 44.2% accurately identified an image of JUUL as a vaping device. Many parents reported concern about adolescent e-cigarette use (60.6%), but fewer reported concern about their own child's use (32.9%). Most parents (73.5%) reported receiving no communication from their child's school about e-cigarettes or JUUL. Conclusions There are notable gaps in parents’ awareness of JUUL. School-to-parent communication efforts are necessary to build parents’ knowledge of e-cigarettes like JUUL to prevent the growing youth uptake of these novel and addictive products.

Objective: Proposed regulation may establish nicotine standards in cigarettes to sub-addictive levels. In this study, we explore the association between nicotine perceptions and responses to a reduced nicotine policy scenario among current smokers. Methods: Data from a nationally representative sample of 18-54-year-old current tobacco users were collected in March-April 2018 (N = 1746). Current smokers (N = 854) were asked about nicotine-related health beliefs and nicotine addiction. Time to first cigarette (TTFC) was used to examine nicotine dependence. Adjusted and weighted logistic regression models examined these nicotine-related factors in association to support for a proposed government policy and related behavioral intentions. Results: Although 63% of survey participants accurately identified nicotine alone as the addiction cause, 49% incorrectly indicated that cancer and 56% indicated that increased health risk caused by cigarette smoking comes from nicotine. Smokers showed high support (72%) for a proposed low-nicotine policy. Greater misperception about nicotine harm was associated with greater odds (aOR = 1.66, p < .05) of policy support. Shorter TTFC was associated with greater intent to smoke low-nicotine cigarettes but was not associated with policy support. Conclusion: Evidence could inform health message development to address knowledge and misperceptions around nicotine when garnering public support for a low-nicotine policy.

Introduction Considerable declines in cigarette smoking have occurred in the U.S. over the past half century. Yet emerging tobacco products, including e-cigarettes, have increased in popularity among U.S. youth and adults in recent years. Nicotine content is an important factor in weighing the potential benefits and risks of e-cigarettes on individual and population level health. This study examined how nicotine concentrations of e-cigarette products sold have changed from 2013 to 2018. Methods E-cigarette sales data aggregated in 4-week periods from March 2, 2013 to September 8, 2018 (66 months total) from convenience store and mass market channels were obtained from Nielsen. Internet and vape shop sales were not available. Internet searches were used to supplement information for nicotine concentration and flavor. Products were categorized by nicotine concentration, flavor, type (disposable or rechargeable), and brand. Dollar sales, unit sales, and average nicotine concentration were assessed. Results During 2013–2018, the average nicotine concentration in e-cigarettes sold increased overall, for all flavor categories, and for rechargeable e-cigarettes. The proportion of total dollar sales comprised of higher nicotine concentration e-cigarettes (>4% mg/mL) increased from 12.3% to 74.7% during 2013–2018, with a similar increase in unit share. Zero-nicotine products accounted for less than 1% of dollar market share across all years analyzed. Conclusions E-cigarettes with higher nicotine concentrations comprise a substantial and increasing portion of U.S. e-cigarette sales. Higher nicotine concentrations may influence patterns of e-cigarette use, including harms from e-cigarette initiation among youth and potential health benefits for adult smokers switching completely to e-cigarettes.

Purpose: Examine association between emotional valence and intensity prompted by anti-tobacco advertising messages and perceived ad effectiveness among youth/young adults. Design: Online forced-exposure survey data from a nationally weighted, cross-sectional sample of youth/young adults, collected periodically over a 4-year period. Setting: National. Participants: Thirty-seven cross-sectional surveys conducted online from June 2015 to January 2018; total N = 9534. All participants, aged 15 to 21, were in the intervention; no control group. Intervention: Individuals participating in premarket testing of truth ads were forced exposed to one of 37 anti-tobacco ads. Measures: Emotional response, emotional intensity, and perceived ad effectiveness. Emotional response has been previously studied and measured. Including the discrete measure of “concerned” in positive emotions is unique to our study. It patterned with the other positive emotions when each ad was examined by each emotion. Intensity as measured in this study through the 5-point scale (“how much does this ad make you feel”) is unique in the anti-tobacco ad literature. Although several past studies ranked the degree of emotion elicited by ads, they have not incorporated the intensity of emotion as reported by the participant themselves. The scale was used to determine whether perceived ad effectiveness is similar to those used in previous studies. Analysis: Linear regressions were estimated to assess type of emotional sentiment and level of intensity in relation to perceived effectiveness of the message. Results: All 9534 participants were exposed; no control group. The βs indicate how strongly the emotion variable influences the study outcome of perceived ad effectiveness. Positive emotions (β = .76) were more highly associated with perceived ad effectiveness (β = .06). Higher intensity with positive emotional sentiment and high-intensity negative produced the highest scores for perceived ad effectiveness (β = .30). Conclusion: Eliciting a positive, high-impact emotional response from viewers can help improve perceived effectiveness, and in turn, overall ad effectiveness.

Introduction Tobacco companies continue to reach youth through direct-to-consumer marketing, which has been associated with overall tobacco use. We examine how exposure to these marketing activities influences product-specific use behaviors. Methods We analyzed data from 10 081 youth (aged 12–18 years) who participated in Waves 1 and 2 (2013–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Participants reported past 6-month tobacco coupon receipt and online tobacco marketing engagement, and susceptibility to ever and current use of cigarette, e-cigarettes, cigars, smokeless tobacco, and hookah. Weighted multivariable logistic regression examined Wave 1 predictors of coupon receipt at Wave 2, and associations between coupon receipt, online engagement, and past 30-day use of different tobacco products. Results Youth received tobacco coupons at one (9.7%) or both waves (1.2%) and 11.1% engaged with online tobacco marketing. Coupon receipt and online marketing engagement at Wave 1 predicted Wave 2 coupon receipt among susceptible-never, ever-but-not-current, and current tobacco users (p < .05). Coupon receipt and online engagement at Wave 1 was positively associated with past 30-day use of cigarettes, e-cigarettes, cigars, smokeless tobacco, and hookah at Wave 2 (p < .05). The relationships were stronger for those who received coupons at both waves or engaged with more sources of online marketing. Conclusions Tobacco direct-to-consumer marketing is reaching youth. Repeated exposure to these marketing activities within and across media is associated with use of different tobacco products. New policies and strong enforcement of existing regulations prohibiting these illegal marketing tactics are critical to protect youth from future tobacco use. Implications Tobacco companies utilize coupons and online engagement activities to increase brand awareness, knowledge, and sales of their products. These kinds of marketing activities can be influential among youth at a time when they may develop tobacco use behaviors. Our findings suggest that tobacco companies may be targeting at-risk youth through cross-media marketing activities. The findings also indicate that exposure to these marketing activities predicts subsequent use of different tobacco products, with suggestive dose–response relationships. Increased regulations are needed to protect youth from these marketing activities.

Objectives: In this study, we investigated perceptions of prescription opioid misuse among young adults who had or had not been prescribed opioids in the past. Methods: Participants from a national online panel, age 18-34 (N = 1220), completed a survey about their medical use of opioids and their perceptions of the risks and prevalence of opioid misuse and dependence. Associations between prescription history and perceptions of opioids were tested using generalized ordered logistic models. Results:Most respondents reported receiving at least one prescription for opioids in their lifetime (68%), with 57% reporting past-year prescriptions. Re spondents with more lifetime prescriptions perceived higher rates of misuse and dependence. More lifetime prescriptions were associated with lower perceived risk of occasional prescription opioid misuse but higher perceived risk for regular misuse. Conclusions: Prior experience with receiving a prescription for opioid pain relievers is associated with young adults' perceptions of opioid misuse. Taking prescription opioids, even as directed, provides young adults with expo- sure to the drugs that may shape these perceptions both by increasing awareness of the drug and through exposure to misuse of the drug.

Background Mass media campaigns are effective for influencing a broad range of health behaviors. Prior to launching a campaign, developers often conduct ad testing to help identify the strengths and weaknesses of the message executions among the campaign’s target audience. This process allows for changes to be made to ads, making them more relevant to or better received by the target audience before they are finalized. To assess the effectiveness of an ad’s message and execution, campaign ads are often rated using a single item or multiple items on a scale, and scores are calculated. Endorsement of a 6-item perceived message effectiveness (PME) scale, defined as the practice of using a target audience’s evaluative ratings to inform message selection, is one approach commonly used to select messages for antitobacco campaigns; however, the 6-item PME scale often does not produce enough specificity to make important decisions on ad optimization. In addition, the PME scale is typically used with adult populations for smoking cessation messages. Objective This study includes the development of the Message Assessment Scale, a new tobacco prevention message testing scale for youth and young adults. Methods Data were derived from numerous cross-sectional surveys designed to test the relevance and potential efficacy of antitobacco truth campaign ads. Participants aged 15-24 years (N=6108) responded to a set of 12 core attitudinal items, including relevance (both personal and cultural) as well as comprehension of the ad’s main message. Results Analyses were completed in two phases. In phase I, mean scores were calculated for each of the 12 attitudinal items by ad type, with higher scores indicating more endorsement of the item. Next, all items were submitted to exploratory factor analysis. A four-factor model fit was revealed and verified with confirmatory factor analysis, resulting in the following constructs: personally relevant, culturally relevant, the strength of messaging, and negative attributes. In phase II, ads were categorized by performance (high/medium/low), and constructs identified in phase I were correlated with key campaign outcomes (ie, main fact agreement and likelihood to vape). Phase II confirmed that the four constructs identified in phase I were all significantly correlated with main fact agreement and vape intentions. Conclusions Findings from this study advance the field by establishing an expanded set of validated items to comprehensively assess the potential effectiveness of advertising executions. This set of items expands the portfolio of ad testing measures for ads focused on tobacco use prevention. Findings can inform how best to optimize ad executions and message delivery for health behavior campaigns, particularly those focused on tobacco use prevention among youth and young adult populations.

IntroductionYouth 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 MethodsWe 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.ResultsThe 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.ConclusionsThis 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.ImplicationsThis 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.

To examine whether youth and young adult e-cigarette use is associated with initiation of cigars, little cigars, or cigarillos (CLCCs) and current use of flavored CLCCs.The sample is drawn from the Truth Longitudinal Cohort, a probability-based longitudinal cohort of youth and young adults recruited at ages 15-21 and surveyed every six months. The sample for this study was CLCC-naïve defined as those who had never used CLCCs as of 2017 (N = 5586). The outcomes were the odds of (1) initiating any CLCC use and (2) reporting current (past 30-day) use of flavored CLCCs from 2018 to late 2019. The main predictor was use of e-cigarettes by 2018.The odds of initiating a CLCC was greater for those who had used ever used JUUL (OR: 3.30, p0.001) or were current users of another type of e-cigarette by 2018 (OR: 3.57, p0.001). Odds of CLCC initiation was also greater for those who had ever used combustible cigarettes (OR: 1.62, p0.05), were current smokers (OR: 3.12, p0.001) or had used marijuana (OR: 1.92, p0.001) by 2018. E-cigarette use that occurred by 2018 was associated with greater odds of current use of flavored CLCCs compared to non-flavored CLCCs (ever users of JUUL: OR: 2.57, p0.01; current users of some other e-cigarette: OR: 3.06, p0.05).This study raises new concerns about the effects of e-cigarette use on subsequent combustible tobacco use. Restrictions on CLCCs should be considered in conjunction with current policies designed to reduce the youth vaping epidemic.

In 2020, almost 20% of high school students reported current e-cigarette use. Mass media tobacco prevention campaigns are effective for preventing tobacco use among youth and young adults but selecting messages that will have maximum impact on the target audience is a significant challenge for campaign developers. This study describes the method for identification of potential messaging targets for a national anti-vape mass media campaign using criteria proposed by Hornik and Woolf in their health communication framework. A national sample of 15- to 24-year-olds (N = 1564) was recruited via an online panel in May 2020. Participants endorsed a series of vape-related attitudinal items. Items were considered potential message targets if they distinguished between the four vape use groups (current users, ever users, susceptible never-users, and non-susceptible never-users) and if less than 70% of respondents endorsed the anti-vape item response. The resulting items targeted five potential message themes, each forming a scale measured with three to four individual items. Message themes included social acceptability of vaping, anti-vape industry sentiment, independence from vaping, non-vaping identity, and perceived risk of harm. Findings were used to inform the development of truth® campaign messaging focused on reducing the prevalence of e-cigarette use among youth and young adults.

Although measuring exposure to public health messages is key to understanding campaign effectiveness, little is known about how exposure to and avoidance of digital ad messages may influence self-reported ad recall. A sample of 15&ndash, 24-year-olds (n = 297) received a varying number of forced-view and skippable test ads across multiple simulated YouTubeTM sessions. Each session was coded for whether the participant viewed the ad or skipped it. While a majority of participants recalled the test ad, the odds of ad recall did not vary by number of sessions (opportunities for exposure). Rather, ad recall was sensitive to the number of completed ad views such that odds of ad recall doubled for each additional time the ad was completely viewed. Findings suggest that public health digital message exposure and recall can be optimized with sufficient attention paid to the proportions of forced-view ads aired when aiming to reach younger audiences.

ObjectiveAntismoking mass media campaigns have contributed to significant declines in combustible tobacco use among young people. This study evaluates a national anti-e-cigarette campaign to determine its association with knowledge, attitudes and beliefs in the context of increasing e-cigarette use in the USA.MethodsA national sample of respondents aged 15–24 years (n=8421) was drawn from a repeated cross-sectional online panel survey (220 participants/week) (October 2018 to December 2019). Self-reported exposure to the truth anti-e-cigarette campaign was measured according to level of ad awareness. Outcomes were subjective knowledge of campaign-targeted facts about e-cigarettes and attitudinal constructs about perceived e-cigarette harm, social unacceptability and anti-industry sentiments. Covariates included respondent demographics, current e-cigarette use and cigarette use, parental smoking, sensation seeking, mental health and growth in e-cigarette sales.ResultsAd awareness was associated with knowledge that e-cigarette users are more likely to start smoking (low OR: 1.28, 95% CI 1.14 to 1.44; high OR: 1.88, 95% CI 1.66 to 2.13) and of the nicotine content of JUUL compared with cigarettes (low OR: 1.63, 95% CI 1.45 to 1.82; high OR: 2.50, 95% CI 2.21 to 2.84). High ad awareness was associated with knowledge that the long-term health effects of JUUL use are unknown (OR: 1.88, 95% CI 1.57 to 2.28). High ad awareness was associated with significantly higher perceived product harm (OR: 1.35, 95% CI 1.18 to 1.54), social unacceptability (OR: 1.32, 95% CI 1.15 to 1.53) and anti-industry attitudes (OR: 1.40, 95% CI 1.21 to 1.62), compared with respondents with no awareness.ConclusionsYoung people with awareness of anti-e-cigarette ads demonstrate higher levels of campaign-targeted knowledge, attitudes and beliefs. Future campaign evaluation priorities include measuring the campaign effects on e-cigarette use behaviours.

Mass media campaigns are an effective population-level intervention for preventing tobacco use. However, little evidence exists for whether these campaigns similarly influence demographic subgroups. This study examined the effects of the truth® campaign to reduce tobacco use among demographic subgroups. We used data from a national, continuous, cross-sectional tracking survey of 15–24-year-olds (n = 32 331). We used a measure of weekly aggregated campaign exposure to assess whether cigarette smoking intentions and current cigarette use varied by race/ethnicity, financial situation and population density subgroups, controlling for factors known to be associated with tobacco use. Examining estimates across subgroup categories in light of the overall model estimates revealed that the effects of week-level campaign exposure on cigarette smoking intentions and current cigarette use were similar across subgroups. Wald tests of equality across estimates in each subgroup suggested that the estimates did not differ from one another in any given instance. The truth campaign does not differ significantly in its capacity to prompt declines in tobacco use across a broad spectrum of US youth and young adults. Mass media tobacco prevention campaigns can be an effective and critical component of a comprehensive tobacco control program, particularly with respect to reducing tobacco-related disparities among demographic subgroups.

Public health organizations are increasingly turning to social media as a channel for health campaign dissemination, as these platforms can provide access to “hidden” or at-risk audiences such as populations of color and youth. However, few studies systematically assess the effects of such campaigns in a competitive communication environment characterized by an influx of sophisticated tobacco product marketing. The objective of the current study is to investigate how content and source features of Twitter messages about truth® campaigns influence their popularity, support, and reach. Keyword rules were used to collect tweets related to each of the six campaigns from the Twitter Firehose posted between August 2014 and June 2016. Data were analyzed using a combination of supervised and unsupervised machine learning, keyword algorithms, and human coding. Tweets were categorized by source type (direct or truth®-owned social influencer; non-influencer). Tweet content was coded and classified for valence and campaign references (branded vs. non-branded or organic content). Message reach was calculated by source type and message type. Keyword filters captured 308,216 tweets posted by 225,912 Twitter users. Findings revealed that campaigns that utilized social influencers as message sources generated more campaign-branded and sharable content (e.g., campaign hashtags) and greater volume of tweets per day and reach per day. Influential users posted fewer organic messages and more branded/sharable content, generating greater reach compared to non-influencers. Oppositional messages decreased over time. Harnessing cultural elements endemic to social media, such as popular content creators (influencers) and messages (memes), is a promising strategy for improving health campaign interest and engagement.

CONTEXT The opioid crisis poses a significant burden at a national level, and certain states have seen particularly high rates of misuse, addiction, and overdose. In 2017, Rhode Island reported opioid-related deaths nearly twice the national average. OBJECTIVE To test message efficacy and evaluate the effectiveness of campaign messaging to shift attitudes/beliefs related to opioid misuse in Rhode Island. DESIGN In phase 1, near-final versions of 6 advertisements were shown to a sample of the target audience via an online survey portal to assess responses to the messages (N = 1210). Phase 2 of the study employed a pre/posttest design whereby 2 cross-sectional surveys were conducted, first prior to the campaign launch (N = 456) and another survey 6 months later in Rhode Island (N = 433). SETTING Phase 1 was conducted online using a nationally representative panel, and phase 2 included a convenience sample of participants in Rhode Island recruited to undergo an online survey. PARTICIPANTS Eighteen- to 29-year-old members of a nationally representative online panel (phase 1) and 15- to 34-year-olds living in the state of Rhode Island during data collection periods. MAIN OUTCOME MEASURE(S) Empathy and destigmatization ("someone like me could become addicted..." and "those who are dependent on prescription opioids are victims") and perceived risk of developing dependence on opioids. RESULTS In both phases, there was an increase in empathy ("someone") (phase 1: pretest [31%], posttest [42%; z = 5.5, P < .0001] and phase 2 [34% baseline vs 41% follow-up; z = 2.0, P = .04]) and destigmatization ("victims") (phase 1: pretest [54%], posttest [58%; z = 2.2, P = .01] and phase 2 [46% baseline vs 54% follow-up; z = 2.2, P = .03]). There was also an increase in perceived risk: phase 1 (pretest [65%], posttest [75%; z = 5.4, P < .0001]) and phase 2 (66% baseline vs 74% follow-up; z = 2.5, P = .01). CONCLUSIONS This study demonstrated the potential efficacy of a media campaign to shift young adults' opioid-related attitudes.

Despite declines in overall cigarette smoking in the United States, menthol cigarette smoking prevalence has increased among young adults (18-25 years) and remains constant among older adults (26 years and older). Disparities in menthol cigarette use exist, with higher prevalence among younger adult smokers and among racial/ethnic minority populations. Menthol in cigarettes has been shown to play a role in increasing smoking initiation and making it more difficult to quit smoking. Little research focuses on perceptions of the addictive potential and health consequences of menthol cigarette use. This analysis uses data from a national panel of U.S. adults ( n = 1,303) surveyed in 2016. Participants were asked to what extent they agreed with various statements regarding menthol use among demographic and tobacco use subgroups. These data reveal disparities in perceptions of the impact of menthol use, with Black, non-Hispanic, and Hispanic adults and adults with lower income and less education misperceiving the health effects and addiction potential of menthol in cigarettes. Determining how and to what extent population subgroups understand the effect of menthol cigarette use can inform public education strategies and, in turn, policy efforts to ban or restrict menthol cigarette availability.

Many mass media campaigns aimed at changing young people&rsquo, s health behavior air on digital platforms rather than on broadcast media (e.g., television), given the intended audience&rsquo, s preference for web-based communication. While research suggests self-reported ad recall correlates with exposure to television advertising, it remains unclear whether self-report measures are correlated with exposure to digital advertising. This study examined the association between an objective measure of digital ad exposure and self-reported recall of digital ads from the truth&reg, tobacco prevention campaign. Digital ad tracking methodology was employed to identify members of an online panel (ages 18&minus, 34) who had been exposed to ads during their regular web browsing. Demographics of exposed participants were used to develop a matched control group of non-exposed panel members. Members of the Exposed group (n = 458) and matched Control participants (n = 506) were surveyed on recall of truth ads, media use, and demographics. Results indicated that Exposed participants had significantly higher odds of reporting ad recall compared to Control participants. With each additional ad exposure, the odds of self-reporting higher frequency of ad exposure increased by 8% (OR = 1.08, 95% CI = 1.01&minus, 1.16). Findings suggest self-reported measures of ad recall are a valid measure of campaign exposure in a digital media environment.

ObjectiveTo examine potential changes in email and direct mail advertisements for flavoured e-cigarettes following the 2020 Food and Drug Administration (FDA) flavour guidance.MethodsDigital copies of e-cigarette advertisements were obtained from Mintel Comperemedia (November 2019–May 2020) and coded for the presence of flavours. Χ2 tests were used to determine changes in the prevalence of email and direct mail advertisements for e-cigarettes with menthol, non-menthol and no flavours.ResultsFollowing FDA guidance, the relative proportion of menthol-flavoured e-cigarette advertisements sent via email significantly increased from 22.5% to 52.2%. No changes were found for e-cigarette advertisements mentioning no flavours, nor non-menthol-flavoured e-cigarettes, sent via email or direct mail.ConclusionsThe 2020 FDA flavour guidance was followed by an increased proportion of direct-to-consumer email advertisements of menthol-flavoured e-cigarette products.

ObjectiveTo 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.MethodTruth 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).ResultsExpert 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.ConclusionIQOS 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.

Purpose Young adulthood is an important period for preventing the establishment of negative health behaviors that can influence trajectories to chronic disease and early death. Given the evolving nature of educational attainment and income variation during this developmental period, identifying indicators of socioeconomic status (SES) remains a challenge. This study examines measures of subjective and objective indicators of SES to predict health risk for young adults. Methods This study uses data from the Truth Initiative Young Adult Cohort Study from respondents aged 18 to 34 years who completed 3 consecutive surveys between June 2011 and August 2012 (n = 2182). Analyses were conducted to compare a measure of subjective financial situation (SFS) to commonly used SES measures for adults and adolescents. Age-stratified, multivariable logistic regression was used to model the relationship between 5 SES indicators (SFS, household income, respondent education, parental education, and subjective childhood financial situation) and dichotomized versions of 3 health status measures (body mass index, self-reported health status, and quality of life), controlling for gender, race/ethnicity, and region. Results Findings indicate that SFS is associated with other commonly used SES measures. Prospective associations with health outcomes revealed that SFS is a stronger predictor of health outcomes among young adults aged 18 to 24 years as compared with other SES measures. Conclusion This study provides evidence that subjective financial situation may be more robust than traditional SES indicators in predicting health outcomes among young adults, particularly for 18- to 24-year-olds, and should be considered a viable candidate measure for assessing SES among this age group.

Introduction Over the past decade, public education mass media campaigns have been shown to be successful in changing tobacco-related attitudes, intentions, and behaviors among youth and young adults. In 2014, the national truth® campaign re-launched a new phase of the campaign targeted at a broad audience of youth and young adults, aged 15-21, to help end the tobacco epidemic. Methods The study sample for this analysis is drawn from the Truth Longitudinal Cohort (TLC), a probability-based, nationally representative cohort designed to evaluate the relationship between awareness of truth media messages and changes in targeted attitudes, beliefs, and behaviors over time. The sample for this study was limited to those with data at baseline and three subsequent follow-up surveys (n = 7536). Results Logistic regression models indicate that truth ad awareness is significantly associated with increases in targeted anti-tobacco attitudes as well as reduced intentions to smoke over time, holding constant baseline attitudes and intentions. Results also suggest a dose-response relationship in that higher levels of truth ad awareness were significantly associated with higher likelihood of reporting agreement across all five attitudinal constructs: anti-smoking imagery, anti-social smoking sentiment, anti-tobacco social movement, anti-tobacco industry sentiment, and independence. Conclusions Longitudinal results indicate a significant dose-response relationship between awareness of the new phase of the truth campaign and campaign-targeted attitudes and intentions not to smoke among youth and young adults. Implications Findings from this study confirm that a carefully designed anti-tobacco public education campaign aimed at youth and young adults is a key population-level intervention within the context of an expanding tobacco product landscape and a cluttered media environment. As tobacco use patterns shift and new products emerge, evidence-based public education campaigns can play a central role in helping the next generation to reject tobacco. Public education mass media campaigns are a key component to changing tobacco use attitudes and behavior, particularly among youth and young adults.

IntroductionEvaluation 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.MethodsWe 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 representativenessResultsResults 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.ConclusionsThis 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 Truth Initiative strives to protect a new generation of youths who are prime prospects for the tobacco industry, by engaging that audience and reigniting their interest. The current authors oversaw a three-phase study that included recruiting a national cohort sample—believed to be the first of its kind—of more than 10,000 members of Generation Z, ages 15 to 21 years old. The authors9 methods informed a new cross-platform campaign that fueled brand awareness and prompted changes in attitudes against smoking, while generating $88.6 million in earned media value with 78.5 million earned media impressions.

Electronic cigarette (e-cigarette) use, including JUUL, has risen to epidemic levels among high school and middle school students in the United States. Schools serve as a key environment for prevention and intervention efforts to address e-cigarette use, yet little is known about the awareness of and response to e-cigarettes in schools. This national survey of middle and high school teachers and administrators ( n = 1,420) measured JUUL awareness, e-cigarette policies, and barriers to enforcement in schools. While two thirds of respondents had heard of a product called JUUL (67.6%), less than half accurately identified a photo of a JUUL as a vaping device/e-cigarette (47.3%). Awareness of JUUL (80.9%) was higher among high school teachers (83.3%) than among middle school teachers (78.3%). A large majority of respondents reported that their school had an e-cigarette policy (82.9%), but less than half of the sample worked in a school with a policy that specifically included JUUL (43.4%). Those working in a school with an e-cigarette policy in place noted that e-cigarettes’ discreet appearance (65.6%) and difficulties in identifying origin of vapor or scent (46.1%) made the policy difficult to enforce. Efforts to increase middle and high school staff awareness of the ever-evolving e-cigarette market are essential to help prevent youth use. Adoption and enforcement of policies will be critical to ensure that schools remain tobacco-free spaces.

Objectives. To examine responses to hypothetical restrictions on menthol cigarettes among young adult menthol smokers in the United States. Methods. We surveyed Truth Initiative Young Adult Cohort respondents 18 to 34 years of age every 6 months from December 2011 through October 2016. Menthol cigarette smokers (n = 806, n = 1963 observations) indicated their response if menthol cigarettes were unavailable. Weighted analyses accounting for repeated measures were used to estimate the prevalence and correlates of responses and trends over time. Results. Overall, 23.5% of young adult menthol smokers said they would quit if menthol cigarettes were unavailable, with this response largely unchanged between 2011 and 2016. There was a significant increase in the switch to another tobacco product response (from 7.4% to 13.2%; P = .01) associated with current noncigarette use. In adjusted analyses, African Americans, women, those with less than a high school education, and those with any quit intention were more likely to say they would quit smoking. Conclusions. Increased intentions to switch products suggest the acceptability and availability of alternatives to menthol cigarette smokers. Menthol cigarette restrictions benefit vulnerable groups and those interested in quitting, but the availability of menthol in noncigarette products could limit benefits.