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Exposure to cigarette advertising can increase the likelihood of youth smoking initiation and may encourage people who already smoke to continue. Requiring prominent, graphic warning labels could reduce these effects. We test whether graphic versus text-only warning labels in cigarette advertisements influence cognitive and emotional factors associated with youth susceptibility to smoking and adult intentions to quit. We conducted two randomized, between-subjects experiments with middle-school youth (n = 474) and adult smokers (n = 451). Both studies employed a two (graphic or text-only warnings) by two (advertisements with social cues or brand imagery) factorial design with a fifth, offset control group (social cue advertisements with the current US Surgeon General's Warning). Graphic warnings outperformed text-only warnings in reducing visual attention to the advertisement, generating visual attention to the warning and arousing more negative affect. Graphic warnings also reduced the appeal of cigarette brands among youth relative to social cue advertisements with the Surgeon General's warnings. None of the warnings (graphic or textual) influenced health risk beliefs. Graphic warning labels on cigarette advertisements appear to have effects similar to those observed on cigarette packs in previous work, with an added benefit of reducing cigarette brand appeal among youth.

This study used structural equation modeling to test a theory-based model of the pathways by which exposure to the 'truth' counterindustry media campaign influenced beliefs, attitudes, and smoking behavior in national random-digit-dial telephone surveys of 16,000 12- to 17-year-olds before, 8 months after, and 15 months after campaign launch. Consistent with concepts from the theory of reasoned action, youth in markets with higher levels of campaign exposure had more negative beliefs about tobacco industry practices and more negative attitudes toward the tobacco industry. Models also provided support for a social inoculation effect, because negative industry attitudes were associated with lower receptivity to protobacco advertising and with less progression along a continuum of smoking intentions and behavior. ((c) 2005 APA, all rights reserved). [ABSTRACT FROM AUTHOR]

This study provides additional evidence that Florida's 'truth' tobacco countermarketing campaign was successful in reducing smoking among Florida teens. Smoking rates were substantially lower among Florida teens between fall 2001 and spring 2002, whereas previous studies found that smoking rates were comparable before the launch of 'truth.' Florida teens had higher levels of 'truth' campaign awareness and were more likely to agree with campaign-targeted beliefs; 2 of these beliefs were the only items associated with current smoking. [ABSTRACT FROM AUTHOR]

Introduction: Little experimental research has evaluated whether the effects of cigarette package inserts with efficacy messages and/or pictorial health warning labels (PHWLs) differ across key subgroups of adults who smoke., Aims and Methods: Adults who reported currently smoking (n = 367) were randomly assigned to one of four groups: Small text-only HWLs on pack sides (control); inserts with efficacy messages and small HWLs (inserts-only); PHWLs showing harms of smoking (PHWLs-only); both (inserts + PHWLs). Participants received a 14-day supply of cigarettes labeled to reflect their group. Every evening over 2 weeks, participants reported forgoing and stubbing out cigarettes before they finished smoking over the prior 24 hours, combined into a binary indicator of either behavior (eg, forgoing/stubbing). Separate mixed-effects logistic models were estimated to evaluate moderation of labeling group contrasts (ie, PHWLs vs not; inserts vs. not; inserts-only vs. inserts + PHWLs; PHWLs-only vs. inserts + PHWLs) by baseline covariates (self-efficacy to quit, intention to quit, education, health literacy, and time discounting), predicting day-level forgoing/stubbing., Results: Education moderated PHWL effects, with PHWLs predicting more forgoing/stubbing only among those with low education (OR = 4.68, p < .001). Time discounting moderated insert effects, with inserts promoting forgoing/stubbing only among those with low time discounting (ie, lower impulsivity; OR = 4.35, p < .001)., Conclusions: Inserts with efficacy messages appear effective mostly among people with low time discounting, whereas PHWLs appear most effective among those with low education, suggesting their potential to address education-related disparities. Labeling strategies appeared equally effective across subgroups defined by self-efficacy to quit, quit intention, and health literacy. Combining inserts with PHWLs did not appear to mitigate moderation effects., Implications: This randomized trial with adults who smoke suggests that cigarette packs with inserts describing cessation benefits and tips can promote cessation-related behaviors (ie, forgoing or stubbing out cigarettes) among those with low-time discounting (ie, low impulsivity). Alternative interventions may be needed for people with high-time discounting, as found in cessation trials. PHWLs appear most effective among those with low education, potentially addressing education-related disparities. No differential effects were found for those with different levels of self-efficacy to quit, quit intentions, or health literacy. Combining inserts and PHWLs may not be more effective than either alone., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Hepatitis C (HCV) is a curable chronic infection, but lack of treatment uptake contributes to ongoing morbidity and mortality. State and national strategies for HCV elimination emphasize the pressing need for people with HCV to receive treatment., Objective: To identify provider-perceived barriers that hinder the initiation of curative HCV treatment and elimination of HCV in the USA., Approach: Qualitative semi-structured interviews with 36 healthcare providers who have evaluated patients with HCV in New York City, Western/Central New York, and Alabama. Interviews, conducted between 9/2021 and 9/2022, explored providers' experiences, perceptions, and approaches to HCV treatment initiation. Transcripts were analyzed using hybrid inductive and deductive thematic analysis informed by established health services and implementation frameworks., Key Results: We revealed four major themes: (1) Providers encounter professional challenges with treatment provision, including limited experience with treatment and perceptions that it is beyond their scope, but are also motivated to learn to provide treatment; (2) providers work toward building streamlined and inclusive practice settings-leveraging partnerships with experts, optimizing efficiency through increased access, adopting inclusive cultures, and advocating for integrated care; (3) although at times overwhelmed by patients facing socioeconomic adversity, increases in public awareness and improvements in treatment policies create a favorable context for providers to treat; and (4) providers are familiar with the relative advantages of improved HCV treatments, but the reputation of past treatments continues to deter elimination., Conclusions: To address the remaining barriers and facilitators providers experience in initiating HCV treatment, strategies will need to expand educational initiatives for primary care providers, further support local infrastructures and integrated care systems, promote public awareness campaigns, remove prior authorization requirements and treatment limitations, and address the negative reputation of outdated HCV treatments. Addressing these issues should be considered priorities for HCV elimination approaches at the state and national levels., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

The U.S. Food and Drug Administration (FDA) currently requires a warning about the addictive nature of nicotine to be placed on electronic cigarette advertisements and packaging. To consider the value of additional warning messages on public health outcomes, this study examines the additive effect of new warnings that are based on recent claims from U.S. federal authorities. We conducted a secondary analysis of recent data from 1,202 U.S. youth ages 14-17 to test the impact of exposure to additional warnings placed on advertisements for vaping products on cognitive elaboration, fear, and willingness to vape and smoke. This investigation also looked closely at effects on youth who may have increased risk of future vaping due to prior vaping experiences or having friends who vape. Exposure to the alternative warnings did not amplify cognitive elaboration compared to the current FDA warning alone, but it did increase fear. Youth elaboration on both the benefits and risks of vaping was associated with willingness to both vape and smoke, but fear was not associated with either outcome. The effects of warning label exposure and cognitive elaboration varied by prior vaping experience and having at least one friend who vapes. We conclude by discussing the implications of this contingent pattern of effect and association.

Objective: Colorectal cancer (CRC) is the third leading cause of cancer death among both men and women in the United States. CRC-related events may increase media coverage and public attention, boosting awareness and prevention. This study examined associations between several types of CRC events (including unplanned celebrity cancer deaths and planned events like national CRC awareness months, celebrity screening behavior, and screening guideline changes) and news coverage, Twitter discussions, and Google search trends about CRC and CRC screening., Methods: We analyzed data from U.S. national news media outlets, posts scraped from Twitter, and Google Trends on CRC and CRC screening during a three-year period from 2020 to 2022. We used burst detection methods to identify temporal spikes in the volume of news, tweets, and search after each CRC-related event., Results: There is a high level of heterogeneity in the impact of celebrity CRC events. Celebrity CRC deaths were more likely to precede spikes in news and tweets about CRC overall than CRC screening. Celebrity screening preceded spikes in news and tweets about screening but not searches. Awareness months and screening guideline changes did precede spikes in news, tweets, and searches about screening, but these spikes were inconsistent, not simultaneous, and not as large as those events concerning most prominent public figures., Conclusions: CRC events provide opportunities to increase attention to CRC. Media and public health professionals should actively intervene during CRC events to increase emphasis on CRC screening and evidence-based recommendations., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Cigarette package inserts that describe quitting benefits and tips may promote cessation; however, research is needed to understand better their effects, including potentially enhancing the effects of pictorial health warning labels (PHWLs)., Methods: A randomized trial with a 2×2 factorial design was conducted with adult smokers (n=356) assigned to either small text-only health warning labels (HWLs; control); inserts with cessation messages, and the small text-only HWLs (inserts-only); large PHWLs (PHWLs-only); both inserts and PHWLs (inserts + PHWLs). Participants received a 14-day supply of their preferred cigarettes with packs labeled to reflect their group. Upon finishing the trial, participants reported their past 14-day frequency of noticing, reading, thinking about smoking harms and cessation benefits, talking about labels, and forgoing cigarettes because of the labels. Ordered logistic models regressed these outcomes on labeling groups, and mediation analyses assessed whether attention (i.e. noticing, reading) to labels mediated effects of labeling exposure on other outcomes (i.e. thinking about harms/benefits, talking, forgoing)., Results: The inserts + PHWLs group reported higher frequencies than the control group for all outcomes. Compared to the control group, both the inserts-only and PHWLs-only groups reported higher frequency of noticing (AOR=3.53 and 2.46, respectively) and reading labels (AOR=2.89 and 1.71), thinking about smoking risks because of the labels (AOR=1.93 and 1.82), and talking about labels (AOR=2.30 and 2.70). Participants in the inserts-only group also reported more frequent thinking about quitting benefits (AOR=1.98). Attention mediated all labeling effects except for the contrast between PHWLs only and control., Conclusions: Compared to text-only HWLS, cigarette labeling that involves inserts, PHWLs, or both appears more effective at drawing attention to warnings, which mediated the effects on cessation-related psychosocial and behavioral outcomes., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. All the authors report that since the initial planning of the work, this study was supported by the National Cancer Institute of the National Institutes of Health. J.W. Hardin reports that in the past 36 months participated on scientific review board of Celgene (Bristol Myers Squibb), which is unrelated to this manuscript. E.E. Hackworth reports that in the past 36 months received support for attending meetings and travelling from the National Institute on Drug Abuse, Society for the Study of Addiction, University of South Carolina. J.F. Thrasher reports that in the past 36 months there were grants or contracts from the UK Medical Research Council, the University of South Carolina, the Food & Drug Administration/NIH, the Canadian Institutes of Health Research, the Australian National Health and Medical Research Council and the American Cancer Society. In the past 36 months, he has also received consulting fees from the University of Stirling and has received payments for lectures/ presentations from the University of Alabama. He has also participated on the University of South Carolina Board for NIH for a funded clinical trial. Finally, J.F. Thrasher reports that in the past 36 months participated in the “Smokefree South Carolina” and the Tobacco Product Scientific Advisory Committee of the US Food and Drug Administration. J. Niederdeppe reports that in the past 36 months there were grants or contracts from the Agency for Research on Healthcare Quality (Grant to Cornell), Robert Wood Johnson Foundation (Multiple Grants to Cornell), National Institute of Diabetes and Digestive and Kidney Diseases (Grant to Cornell) and the National Science Foundation (Grant to Cornell). In the past 36 months, he has also received Payment for service on academic panel during Policy Dissemination Science workshop from New York University, Honorarium for public lecture and keynote speech + travel reimbursement from Peking University, a small payment (which is standard) for service on several grant review panels from NIH Office of the Director. He also reports that he has travelled for several workshops and consensus committee report meetings paid for by the National Academies (no honoraria or consulting fee is part of this work) from the National Academy of Medicine, and has travelled to Monterrey for a 2-day meeting to inform public health investments for the Hayward Institute (received small honorarium as well) from the Hayward Institute. In the past 36 months, he has offered service on center grant EAB, including consulting payment and travel to one meeting/year from the University of North Carolina, and has offered service on center grant EAB, including consulting payment and travel to one meeting/year from the University of Wake Forest. Finally, J. Niederdeppe reports that in the past 36 months he had an unpaid role on BOD for local non-profit that provides mental health and wellness services from Family & Childrens Service of Ithaca. M. Kim reports that in the past 36 months there were grants or contracts from the National Institute of Drug Abuse and the Food and Drug Administration., (© 2024 Lambert V.C. et al.)

Context: Media messaging matters for public opinion and policy, and analyzing patterns of campaign strategy can provide important windows into policy priorities., Methods: The authors used content analysis supplemented with keyword-based text analysis to assess the volume, proportion, and distribution of media attention to race-related issues in comparison to gender-related issues during the general election period of the 2022 midterm campaigns for federal office in the United States., Findings: Race-related mentions in campaign advertising were overwhelmingly focused on crime and law and order, with very little attention to racism, racial injustice, and the structural barriers that lead to widespread inequities. In stark contrast to mentions of gender, racial appeals were less identity focused and were competitively contested between the parties in their messaging, but they were much more likely to be led by Republicans., Conclusions: The results suggest that discussions of race and gender were highly polarized, with consequences for public understanding of and belief in disparities and policies important to population health., (Copyright © 2024 by Duke University Press.)

There are significant racial disparities in obesity and diabetes such that prevalence rates are higher among Black Americans than White Americans. This study examined effects of communicating the prevalence of obesity/diabetes and comparing race-specific prevalence rates between White and Black Americans to highlight racial health disparities. We conducted two preregistered, between-subjects randomized online experiments with an analytic sample of 1,232 U.S. adults ( n  = 609 for the obesity study and n  = 623 for the diabetes study) stratified by race. In each experiment, we randomly assigned respondents to read an obesity/diabetes message 1) without disease prevalence information, 2) with the national obesity/diabetes prevalence rate, 3) with the race-specific obesity/diabetes prevalence rate among White Americans, 4) with the race-specific prevalence rate among Black Americans, or 5) comparing the race-specific prevalence rates between White and Black Americans, or 6) to a no-message condition. Results showed that diabetes prevalence information reduced the overestimation of race-specific diabetes prevalence. Comparing the obesity prevalence rate among White Americans to that of Black Americans increased support for policies to reduce racial health disparities, but also made Black respondents less likely to cut calories. Race-specific disease prevalence information and intergroup disease prevalence comparisons may have both positive and unintended consequences on message recipients. Health educators should be more cautious when communicating disease prevalence information.

Communicating health disparities in mass and social media has typically taken the form of comparing disease risks and outcomes between two or more social groups, a strategy known as social comparison framing. This comprehensive review examined the design and results of 17 studies from 15 peer-reviewed journal articles about the effects of social comparison framing of health disparities. Most studies focus on race-based disparities across a variety of health topics. For individual-level outcomes, social comparison tends to reduce perceived disease risks for the lower disease prevalence group while prompting negative emotions and yielding inconsistent impact on health behavioral intentions among members of the higher prevalence group. For societal-level outcomes, social comparison often has either null or polarizing effects on support for policies to address these disparities that vary by racial identity/attitudes of the respondents. Studies also find that racial comparisons trigger lower levels of support for policy remedies relative to economic, educational, or geographic comparisons. We conclude that social comparison framing of health disparities, in the absence of broader discussion of the social and structural causes of these disparities, is more likely to incur negative consequences. We propose several possible strategies to communicate health disparity information more effectively., Competing Interests: Declaration of competing interest The authors report that there are no competing interests to declare., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Underrepresentation of historically marginalized populations in clinical trials continues to threaten the validity of health intervention research. Evidence supports the merits of intercept and other proactive forms of recruitment for achieving more equitable representation. However, researchers also report lower retention and adherence to protocols among these populations, particularly in longitudinal studies. Few studies have compared recruitment methods for longitudinal randomized trials testing health interventions, with even fewer having done so for trials involving ecological momentary assessment (EMA). As intervention research integrates EMA and other data collection approaches requiring substantial participant effort, it is critical to better understand the effectiveness and implications of strategies to improve the representativeness of health research. This secondary data analysis compared outcomes of proactive and reactive recruitment strategies (mobile lab intercepts and internet/flyer advertising, respectively) in study inclusion, task completion, and retention within a 14-day randomized controlled trial that used EMA to evaluate cigarette package health messages. Proactive recruitment resulted in higher proportions of participants with low income and education, limited health literacy, and of diverse racial/ethnic makeup. However, this recruitment method also resulted in lower task completion, especially in the second week of the trial period, and lower retention, although group differences were not explained by participant sociodemographic characteristics targeted by inclusion efforts. We conclude that proactive recruitment via intercepts is an effective strategy for health intervention research that aims to include stakeholders from historically marginalized groups but that researchers and funders must recognize these methods require additional resources, considerations, and capacity to address non-trivial challenges to successful participation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Context: Current use and potential future uptake of e-cigarettes among youth remain public health concerns in the U.S., even as people who smoke combustible cigarettes could benefit from switching completely to e-cigarettes. The U.S. Food and Drug Administration (FDA) is considering alternative warning messages, but warnings that discourage youth from use may also deter people who smoke from switching. This study tests ten pre-registered hypotheses on effects of warning messages with national samples of youth overall and adults who smoke and/or vape., Methods: NORC recruited 1639 adults (ages 18+) who smoke, vape, or use both products, from their probability-sampled AmeriSpeak Panel and augmented their AmeriSpeak Teen Panel with Lucid's nonprobability opt-in panel to recruit 1217 youth (ages 14-17) to participate in a web-based survey experiment. We randomly assigned respondents to view one of five warning label conditions and respond to measures of their e-cigarette risk beliefs, willingness to use e-cigarettes, and (among people who smoke or vape) considerations to quit these products., Findings: Relative to the current FDA warning about nicotine, warning messages about the harms of e-cigarette use for youth brain development did not influence risk beliefs or reduce willingness to use these products among youth. Brain development warning messages did increase beliefs about these harms among adults but did not increase quit considerations among people who vape, relative to the FDA warning. Warning messages with information about chemical constituents of vaping products and the harm of these chemicals produced higher e-cigarette quit considerations than did the FDA warning among adults who vape., Conclusion: Potential alternative warning label messages were largely ineffective relative to the current FDA warning about nicotine, though limited evidence suggests some potential for chemical + harm messaging to encourage people who use both e-cigarettes and cigarettes to consider quitting both., Competing Interests: Declaration of competing interest Alan Mathios has received support on another project related to e-cigarettes which is funded by a grant to Cornell University from the Foundation for a Smoke Free World. No funds from this other grant were used in any way for this study. We have no additional statements of conflict of interest to disclose for any of the other co-authors., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

E-cigarette use among youth presents a public health risk. Yet, cigarette smokers who substantially reduce their smoking or switch completely from traditional combustible cigarettes could benefit. As science about e-cigarettes is continually emerging, any potential warnings are likely to contain uncertain language. Hedged verbiage may impact decision making. To assess reactions, we conducted 16 online focus groups; 8 with youth ( n  = 32, grouped by gender and by vaping experience) and 8 with adult tobacco users ( n  = 37, grouped by smokers, dual users of e-cigarettes and cigarettes, and former smokers who switched to e-cigarettes). Each focus group viewed and discussed 8 potential warnings messages. We conducted an inductive thematic analysis of the reactions to warning messages that contain uncertain language. Respondents' reactions were often negative, but varied based on specific usages of uncertainty, existing beliefs about uncertainty in law and science, and smoking/vaping use patterns that supported the use of uncertainty related to e-cigarettes. Many youth (and some adults) believed that uncertain language enabled audiences to minimize the likelihood of harm or interpreted it as meaning there are both healthy and unhealthy e-cigarettes. This qualitative study provides evidence that the use of types of uncertain language, the frequency of that use, and/or the selection of particular words in warnings, might not achieve the intended public health aims of increasing understanding of risk, deterring youth uptake, and/or facilitating a substantial switch from cigarettes. The use of certain types of uncertain language appears to have significant potential to bring unintended consequences. Suggestions for research and policy are included.

Background: Cigarette pack inserts with messages on cessation benefits and advice are a promising labeling policy that may help promote smoking cessation., Purpose: To assess insert effects, with and without accompanying pictorial health warning labels(HWLs), on hypothesized psychosocial and behavioral outcomes., Methods: We conducted a 2 × 2 between-subject randomized trial (inserts with efficacy messages vs. no inserts; large pictorial HWLs vs. small text HWLs), with 367 adults who smoked at least 10 cigarettes a day. Participants received a 14-day supply of their preferred cigarettes with packs modified to reflect their experimental condition. Over 2 weeks, we surveyed participants approximately 4-5 times a day during their smoking sessions, querying feelings about smoking, level of worry about harms from smoking, self-efficacy to cut down on cigarettes, self-efficacy to quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported their perceived susceptibility to smoking harms and, for the last 24 hr, their frequency of thinking about smoking harms and cessation benefits, conversations about smoking cessation or harms, and foregoing or stubbing out cigarettes before they finished smoking. Mixed-effects ordinal and logistic models were estimated to evaluate differences between groups., Results: Participants whose packs included inserts were more likely than those whose packs did not include inserts to report foregoing or stubbing out of cigarettes (OR = 2.39, 95% CI = 1.36, 4.20). Otherwise, no statistically significant associations were found between labeling conditions and outcomes., Conclusions: This study provides some evidence, albeit limited, that pack inserts with efficacy messages can promote behaviors that predict smoking cessation attempts., (© Society of Behavioral Medicine 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Young adults new to tobacco (including e-cigarettes) are at an increased risk of e-cigarette use after e-cigarette exposure. This study examined the association between noticing e-cigarette advertising features and perceived product appeal among non-tobacco-using young adults., Methods: A sample of non-tobacco-using young adults (ages 18-29 years; n=1993) completed an online survey in 2021. We content analysed visible features from 12 e-cigarette ads that represented commonly used e-cigarette brands. Participants viewed the ads and clicked on the areas of the ads that drew their attention. Participants reported e-cigarette product appeal for each ad, including ad liking, product curiosity and use interest. We used generalised estimating equations to examine within-person associations between noticing specific ad features and reporting each and any type of product appeal, adjusting for noticing other features and participant characteristics., Results: Noticing people, discounts, non-tobacco (menthol and mint/fruit) flavours, positive experience claims or product images was positively associated with having any e-cigarette product appeal. Noticing discounts or mint/fruit flavours was also positively associated with e-cigarette use interest. In contrast, noticing nicotine warnings or smoking cessation claims was negatively associated with ad liking and product curiosity., Conclusions: Attention to several e-cigarette ad features (eg, people, discounts, non-tobacco flavours) was associated with increased e-cigarette product appeal, whereas attention to nicotine warnings and smoking cessation claims was associated with reduced appeal among non-tobacco-using young adults. Restricting appeal-promoting features while strengthening the effects of nicotine warnings and smoker-targeted claims in e-cigarette ads may potentially reduce e-cigarettes' overall appeal among this priority population., Competing Interests: Competing interests: MBM holds an Innovation in Regulatory Science Award from the Burroughs Wellcome Fund which in part supports her and RK’s effort. MBM has served as a paid expert witness in litigation sponsored by the Public Health Advocacy Institute against RJ Reynolds. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

While many countries require prominent pictorial health warning labels (PHWLs) on the outside of cigarette packs to communicate the harms of smoking, there is evidence that cigarette pack inserts that contain efficacy messages may enhance the effectiveness of PHWLs. The US Food and Drug Administration (FDA) has regulatory authority to communicate with smokers through inserts. While current labeling regulations do not require inclusion of inserts, the FDA could implement them in the future. This study assesses US smokers' perceptions of cigarette package inserts at the conclusion of a two-week randomized trial on cigarette labeling where half of participants were exposed to insert messages (two response-efficacy messages and two self-efficacy messages) in their packs. Participants (n = 359) completed a 30- to 60-min interview with both quantitative and qualitative assessments, including measures of recall and perceived message effectiveness (PME) for specific inserts. Correlates of recall and PME were estimated using mixed-effects regression models. Qualitative responses to PME items were analyzed using thematic analysis. Response-efficacy messages had higher PME and recall than self-efficacy messages. People had diverse responses to the inserts, including that they were positive, thought-provoking, and helpful. Reactions to and perceptions of the inserts indicate potential benefits of integrating efficacy messages into labeling policies., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Alcohol use is a major risk factor for several forms of cancer, though many people have limited knowledge of this link. Public health communicators and cancer advocates desire to increase awareness of this link with the long-term goal of reducing cancer burden. The current study is the first to examine the prevalence and content of information about alcohol use as a cancer risk on social media internationally., Methods: We used a three-phase process (hashtag search, dictionary-based auto-identification of content, and human coding of content) to identify and evaluate information from Twitter posts between January 2019 and December 2021., Results: Our hashtag search retrieved a large set of cancer-related tweets (N = 1,122,397). The automatic search process using an alcohol dictionary identified a small number of messages about cancer that also mentioned alcohol (n = 9061, 0.8%), a number that got small after adjusting for human coded estimates of the dictionary precision (n = 5927, 0.5%). When cancer-related messages also mentioned alcohol, 82% (n = 1003 of 1225 examined through human coding) indicated alcohol use as a risk factor. Coding found rare instances of problematic information (e.g., promotion of alcohol, misinformation) in messages about alcohol use and cancer., Conclusions: Few social media messages about cancer types that can be linked to alcohol mention alcohol as a cancer risk factor. If public health communicators and cancer advocates want to increase knowledge and understanding of alcohol use as a cancer risk factor, efforts will need to be made on social media and through other communication platforms to increase exposure to this information over time., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors have no conflicts of interest or financial disclosures for this submission., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aims: To test whether showing spectators counter-advertisements exposing alcohol harms alone, or exposing alcohol harms and alcohol sponsorship, before watching an alcohol-sponsored sporting event promotes less favourable post-event attitudes and intentions towards alcohol sponsor brands and alcohol in general., Design: On-line between-subjects experiment., Setting: Australia., Participants: A sample of Australian adults aged 18-49 years who planned to watch an alcohol-sponsored National Rugby League (NRL) State of Origin series game was recruited through an online panel., Interventions: Participants were randomly assigned to one of three counter-advertising conditions: control (neutral advertisement); counter-advertisement exposing alcohol harms; and counter-advertisement exposing alcohol sponsorship and harms, to view at least four times during the week before watching the alcohol-sponsored sporting event., Measurements: Participants (n = 1932) completed a pre-test questionnaire a week before the sporting event. Within 4 days of watching the sporting event, participants completed post-test measures assessing sponsor brand awareness, attitudes and preferences towards the brand, as well as knowledge, attitudes and intentions for alcohol in general (n = 1075)., Findings: Compared with the control advertisement, the counter-advertisement exposing alcohol sponsorship and harms promoted higher (6-13%) awareness of sponsor brands, less favourable attitudes towards sponsor brands and drinking beer, lower purchase intentions for sponsor brands (Cohen's d = 0.15, 0.31, 0.27, respectively) and perceived less image-based similarity and fit between the sporting event and sponsor brands (Cohen's d = 0.20 and 0.56). Both counter-advertisements promoted lower perceptions of the appropriateness of consuming alcohol while watching sport (Cohen's d = 0.22 and 0.34), higher awareness of alcohol harms (6-34%) and higher intentions (8-13%) to reduce alcohol consumption than the control advertisement., Conclusions: At alcohol-sponsored sporting events, counter-advertisements addressing alcohol harms may promote knowledge of harms and intentions to drink less. Counter-advertisements that additionally expose and critique alcohol sponsorship may detract from perceptions of sponsor brand image and intentions to purchase the sponsor's products., (© 2023 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Colorectal cancer and breast cancer are among the most common types of cancer in the United States, and cancer screening is an effective way to detect and treat these cancers early. Health news stories, medical websites, and media campaigns regularly highlight the national lifetime risks of specific cancers and their screening rates, but recent research suggests that people tend to overestimate the prevalence of health problems but underestimate the prevalence of disease prevention behaviors in the absence of numerical information. This study featured two online experiments, one focused on breast cancer (N = 632) and one focused on colorectal cancer (N = 671), to examine the effects of communicating national cancer lifetime risks and screening rates among samples of screening-eligible adults in the United States. Findings confirmed prior work in showing that people overestimated colorectal/breast cancer lifetime risks but underestimated colorectal/breast cancer screening rates. Communicating the national lifetime risk of dying from colorectal/breast cancer lowered people's national risk estimates, which in turn was associated with lower perceived cancer risks for themselves. In contrast, communicating the national colorectal/breast cancer screening rate increased people's estimates of the prevalence of cancer screening, which in turn was associated with higher perceived self-efficacy to engage in cancer screening and greater screening intentions. We conclude that efforts to promote cancer screening may benefit from messages that include data on national cancer screening rates but may not benefit from including national rates of lifetime cancer risks., (© 2023 Society for Risk Analysis.)

Introduction: Young adults are at risk for cigar smoking, which is associated with cancers and pulmonary and cardiovascular diseases. Little is known about young adults' beliefs about smoking cigarillos, little filtered cigars, and large cigars, and how these beliefs may vary across cigar types and by cigar susceptibility., Aims and Methods: The larger study surveyed a U.S. sample of young adults (18-30 years old) who never used tobacco products (n = 948) through Qualtrics online panel services in August 2021-January 2022. We assessed participants' susceptibility to using different cigar types. Participants were randomly assigned to open-ended questions about one of the three cigar types to elicit behavioral, normative, and control beliefs. We conducted thematic analysis to code emergent themes within each belief and examined the frequency of reported themes at the intersection of cigar type and cigar susceptibility., Results: Cigar susceptible participants reported positive behavioral beliefs (eg, anticipated relaxation, mood regulation, being cool), friends as supportive referents, and easy-to-smoke control beliefs (eg, high accessibility, low cost) more frequently than non-susceptible participants. Varied frequency by cigar type also emerged. For example, cigarillo and little filtered cigar features were mentioned more frequently as easy-to-smoke control beliefs, while low accessibility was reported more frequently as a hard-to-smoke control belief for large cigars., Conclusions: Findings identify salient beliefs about cigarillo, little filtered cigar, and large cigar smoking among young adult tobacco never-users. Future research should investigate the potential importance of these beliefs in cigar smoking susceptibility and initiation among young adults, and their potential utility in prevention research., Implications: This thematic analysis identified salient beliefs about cigarillos, little filtered cigars, and large cigars among a U.S. young adult sample, and differentiated emergent beliefs by cigar susceptibility status and by cigar type. Given the lack of cigar smoking prevention media campaigns, identifying these beliefs is the one of the first steps in developing effective cigar smoking prevention strategies. Future quantitative studies are needed to confirm the relationships between these beliefs and smoking initiation of each cigar type to further inform the types of beliefs to be targeted in strategic communication and help prevent cigar smoking initiation among susceptible young adults., (Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco 2023.)

Context: Scholars have suggested that direct-to-consumer advertising (DTCA) of prescription drugs may discourage or encourage changes in lifestyle to improve health. The current paper informs this debate by examining associations between estimated exposure to DTCA for drugs focused on heart disease/cholesterol and diabetes and self-reported exercise and consumption of a variety of unhealthy foods (candy, sugary drinks, alcohol, and fast food)., Methods: We estimated exposure to DTCA by combining data from Kantar Media Intelligence (Kantar) on televised pharmaceutical DTCA airings in the U.S. from January 2003 to August 2016 (n = 7,696,851 airings) with thirteen years of data from the Simmons National Consumer Survey (Simmons), a mailed survey on television viewing patterns. We estimated associations between exposure to advertising (both overall and for advertisements with specific content) and self-reported physical activity and dietary behavior using Simmons data from January 2004 to December 2016 (n = 288,483 respondents from n = 157,621 unique households in the U.S.). Our analysis controls for many potential confounders including respondent demographics, temporal trends, and program placement to account for purposeful ad targeting to higher-risk adults., Findings: Higher estimated exposure to DTCA for heart disease and diabetes drugs were not consistently associated with meaningful differences in the frequency of engaging in regular physical activity. Greater estimated exposure to DTCA for both diseases were, linked to small but consistently higher volume of consumption of candy, sugar-sweetened beverages, alcohol, and fast food. Specific DTCA message content about diet and exercise explained very little of the observed association between overall DTCA exposure volume and study outcomes., Conclusions: Many Americans were regularly exposed to pharmaceutical DTCA for heart disease and diabetes from 2003 to 2016. Widespread exposure to such DTCA is associated with higher levels (though small in magnitude) of consuming alcohol, fast food, candy, and sugar-sweetened beverages., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Alcohol consumption is causally linked to multiple cancers. African-Americans are at greater risk of cancer than other demographic groups and suffer more serious consequences. Awareness and knowledge of the alcohol-cancer link are low, especially among African-Americans compared to other racial/ethnic groups. This study built on the theory of identity-based motivation (TIBM) to explore how people think about alcohol consumption in relation to their social identities and beliefs about cancer., Methods: Data come from 20 in-depth interviews with current drinkers (10 White and 10 African-American adults) in a major mid-Atlantic city in the summer of 2021, using race- and gender-concordant interviewers. An abductive and iterative approach identified salient themes about how drinkers thought about alcohol, social identities, and cancer., Results: While most participants discussed alcohol use as an important part of American culture, African-American participants were more likely to discuss drinking as a way to cope with racism and other hardships. Participants also noted the need to address structural issues that would make it difficult to cut back on drinking. Both White and African-American participants talked about stressors in life that drive them to drink and make cutting back difficult, and African-American participants discussed how the location of liquor stores in their neighborhoods made alcohol too readily available., Conclusions: Insights from these interviews confirm the relevance of racial and other identities in shaping responses to alcohol-cancer messaging, and emphasize the need to consider both behavior change and policy change to create supportive environments for such changes.

Objective: Given social media's reach and potential, a systematic review is needed to assess their effectiveness in influencing alcohol consumption and related harms, attitudes, and awareness., Method: We searched 12 databases from inception to December 2022, along with reference lists of eligible studies. We included studies of any design conducted in any country, reported in English, evaluating campaigns using social media alone or in combination with other media. We assessed study quality, extracted data, and completed a narrative synthesis., Results: Eleven of 6,442 unique studies met inclusion criteria, spanning 17 countries, targeting diverse populations, and predominantly using repeated cross-sectional study designs. Most were of weak quality. Only three studies evaluated campaigns relying solely or primarily on social media. Two drink-driving campaigns had no behavioral impact, whereas two others found behavior change. Two of three studies targeting college student drinking found significant reductions in drinking after the campaign, but a third detected no differences in quality or duration of drinking. Only one study measured changes in attitudes, finding that the campaign significantly increased policy support for key alcohol policies. All studies noted awareness, but only six quantified short-term measures, showing increased campaign awareness., Conclusions: It is unclear from the peer-reviewed literature whether public health-oriented social media campaigns can influence alcohol consumption and related harms, attitudes, and/or awareness. Our review nevertheless indicates that social media campaigns offer potential in some populations to influence these outcomes. There is an urgent need for the public health field to test and rigorously evaluate social media's utility as a vehicle for influencing population-level alcohol consumption and related problems, attitudes, and awareness.

Aims: A warning on e-cigarette packaging is one way the U.S. government can inform the public of known harms of e-cigarette use. Currently, the only required warning on these products is: "WARNING: This product contains nicotine. Nicotine is an addictive chemical." This exploratory study aims to inform potential future investigations and FDA decisions regarding alternative warnings that may generate fear in addition to being intentionally informational., Method: Data were obtained from responses by 16 online focus groups with adult (N = 47, age range = 18-64) and youth (N = 32, age range 14-16) participants with various smoking and vaping experiences. We showed each focus group a set of hypothetical e-cigarette warning labels to determine how they respond to currently existing public statements that communicate information on the toxicity of ingredients in e-cigarettes, potential health risks, addiction to nicotine, and the uncertainty of the science regarding health effects of using these products. The focus group interviews were audio recorded and transcribed. Transcripts were subjected to a multiphase coding process to identify common response themes. Codes derived from the Extended Parallel Processing Model were then applied to understand impact of potentially fear-inducing language by warning category and age group., Results: For adults, all warnings-except those about addiction-gave rise to spontaneous danger control (intended) responses, such as quit intentions. Warnings highlighting cognitive and uncertain effects may be particularly promising for adult consumers of tobacco products because both gengerated danger control and response efficacy without evidence of fear control. However, responses also suggest that warnings risk discouraging some adults who use combustible cigarettes from transitioning to e-cigarettes for harm reduction. For youth, while evidence of response efficacy and danger control emerged among youth exposed to messages in all warning categories but one-addiction-unproductive reactions indicative of fear control were also prevalent among youth respondent across most warning types. On average, youth were more skeptical than adults about the harms of using e-cigarettes., Policy Implications: Implications of study findings for the development of future effective e-cigarette warning messages are explored., Competing Interests: One of the co-authors, Alan Mathios, has received support on another project related to e-cigarettes which is funded by a grant to Cornell University from the Foundation for a Smoke Free World. No funds from this other grant were used in any way for this study. We have no additional statements of conflict of interest to disclose for any of the other co-authors. The authors have declared no other competing interests., (Copyright: © 2023 Avery et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Policy Points Many studies have explored the impact of message strategies to build support for policies that advance racial equity, but few studies examine the effects of richer stories of lived experience and detailed accounts of the ways racism is embedded in policy design and implementation. Longer messages framed to emphasize social and structural causes of racial inequity hold significant potential to enhance support for policies to advance racial equity. There is an urgent need to develop, test, and disseminate communication interventions that center perspectives from historically marginalized people and promote policy advocacy, community mobilization, and collective action to advance racial equity., Context: Long-standing racial inequities in health and well-being are shaped by racialized public policies that perpetuate disadvantage among Black, Brown, Indigenous, and people of color. Strategic messaging can accelerate public and policymaker support for public policies that advance population health. We lack a comprehensive understanding of lessons learned from work on policy messaging to advance racial equity and the gaps in knowledge it reveals., Methods: A scoping review of peer-reviewed studies from communication, psychology, political science, sociology, public health, and health policy that have tested how various message strategies influence support and mobilization for racial equity policy domains across a wide variety of social systems. We used keyword database searches, author bibliographic searches, and reviews of reference lists from relevant sources to compile 55 peer-reviewed papers with 80 studies that used experiments to test the effects of one or more message strategies in shaping support for racial equity-related policies, as well as the cognitive/emotional factors that predict their support., Findings: Most studies report on the short-term effects of very short message manipulations. Although many of these studies find evidence that reference to race or use of racial cues tend to undermine support for racial equity-related policies, the accumulated body of evidence has generally not explored the effects of richer, more nuanced stories of lived experience and/or detailed historical and contemporary accounts of the ways racism is embedded in public policy design and implementation. A few well-designed studies offer evidence that longer-form messages framed to emphasize social and structural causes of racial inequity can enhance support for policies to advance racial equity, though many questions require further research., Conclusions: We conclude by laying out a research agenda to fill numerous wide gaps in the evidentiary base related to building support for racial equity policy across sectors., (© 2023 The Authors. The Milbank Quarterly published by Wiley Periodicals LLC on behalf of The Milbank Memorial Fund.)

Background: Tobacco price promotions may prompt tobacco trials among youth. We assessed whether receiving price promotions for any tobacco, cigarettes, e-cigarettes and cigars was associated with product use progression., Methods: The analysis included a nationally representative sample of youth never tobacco users (aged 12-16; n=9405) from wave 4 (2016-2018) of the Population Assessment of Tobacco and Health Study. We assessed past-year receipt of price promotions and use progression (initiation, current use and ever regular use) for any tobacco, cigarettes, e-cigarettes and cigars 1 year later at wave 4.5 (2017-2018). Multivariable logistic regressions were used to examine the associations between receiving price promotions and use progression by product type, controlling for covariates., Results: At wave 4.5, 9.4% of youth initiated any tobacco (1.8%, 7.8% and 0.9% for cigarettes, e-cigarettes and cigars), and 5.4% received any price promotions (3.8%, 3.1% and 0.9% for cigarettes, e-cigarettes and cigars). Receiving any tobacco price promotions was associated with any tobacco initiation (adjusted OR (AOR)=1.77; 95% CI 1.30 to 2.41), current use (AOR=1.54; 95% CI 1.06 to 2.23) and ever regular use (AOR=1.76; 95% CI 1.04 to 3.10). Receiving e-cigarette price promotions was associated with e-cigarette initiation (AOR=1.78; 95% CI 1.18 to 2.26), current use (AOR=1.88; 95% CI 1.17 to 3.02) and ever regular use (AOR=2.10; 95% CI 1.02 to 4.40). The associations specific to cigarettes and cigars were only found for product initiation., Discussion: Receiving price promotions for any tobacco and e-cigarettes was respectively associated with the use progression of any tobacco and e-cigarettes. Continuous monitoring of tobacco marketing activities is needed to identify youth-appealing price promotion tactics., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Exposure to alcohol advertising and sponsorship through elite sport is associated with harmful use of alcohol. Owing to strong financial and cultural ties between alcohol and sport in Australia, policy action to restrict alcohol sport sponsorship is unlikely to occur without strong public support for change. This study tested whether exposure to counter-advertising exposing industry marketing of harmful products-a technique shown to be effective in tobacco control-promotes higher support for policy change and less favourable beliefs about the alcohol industry among sport spectators., Methods: A sample of 1,075 Australian adults aged 18-49 years who planned to watch an National Rugby League (NRL) State of Origin series game, featuring prominent alcohol sponsorship, was recruited through an online panel and randomly assigned to one of three conditions: control (neutral advertisement); counter-advertisement exposing alcohol harms; counter-advertisement exposing alcohol sponsorship and harms. Participants completed a pre-test questionnaire and viewed their assigned counter-advertisement multiple times in the 5-7 days before the NRL game. Within four days of watching the game, participants completed post-test measures., Results: Compared to both the control advertisement and the counter-advertisement exposing alcohol harms, participants who viewed the counter-advertisement exposing alcohol sponsorship and harms were significantly more likely to indicate support for each of four policies aimed at restricting sports-related alcohol marketing, including the complete removal of alcohol sponsorship from sport (51% vs. 32% and 37%). They were also significantly less likely to agree with statements such as "alcohol companies should be allowed to sponsor sport since their products are legal" (39% vs. 63% and 60%) and significantly less likely to report liking alcohol companies in general (38% vs. 59% and 54%). There were no significant differences in policy support or industry beliefs between participants who saw the counter-advertisement exposing alcohol harms and those who saw the control advertisement., Conclusion: Counter-advertising employing messages that expose and critique the intent and impact of pervasive alcohol sponsorship in sport has potential to bolster public support for policies targeting alcohol sport sponsorship, diminish beliefs supportive of alcohol industry marketing strategies and enhance negative views of alcohol companies and their marketing practices., (© 2023. The Author(s).)

This study explored the effectiveness of nuanced messages, described in our study as warnings, that seek to convey the potential benefits of switching from cigarettes to e-cigarettes for adults. The messages were designed to convey the potentially complex idea that e-cigarettes are likely less harmful than combustible cigarettes but that e-cigarettes still present a risk. Eight adult focus groups (N = 37) with varying smoking profiles responded to a set of messages that are used by government agencies and non-government organizations to convey the benefits of switching and ongoing risk associated with e-cigarette use. Results indicate that a suggestion of health benefits from exclusive use of e-cigarettes was met with skepticism from users of e-cigarettes and combustible cigarettes, and generated confusion about what these benefits were. Messages suggesting that individuals who have switched to e-cigarettes should not switch back to combustible cigarettes elicited the strongest statements of doubt and mistrust among focus group participants, regardless of smoking status. Participants representing all smoking profiles agreed with the message suggesting that switching from combustible cigarettes to e-cigarettes still exposes the user to ongoing health risks. Our focus group discussions suggest that adult smokers may not interpret nuanced messages about harm reduction in a way that will encourage switching behavior., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This study was funded by a grant from the National Cancer Institute Grant No 5R01CA246605-03. “The E-Cigarette Population Paradox: Testing Effects of Youth-Targeted Population Warnings for E-Cigarettes Among Two Key Populations.” https://maps.cancer.gov/overview/DCCPSGrants/abstract.jsp?applId=10242804&term=CA246605. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. One of the co-authors, Alan Mathios, has received support on another project related to e-cigarettes which is funded by a grant to Cornell University from the Foundation for a Smoke Free World. No funds from this other grant were used in any way for this study. We have no additional statements of conflict of interest to disclose for any of the other co-authors., (© 2022 The Authors.)

Televised public service announcements were one of the ways that the U.S. federal government distributed health information about the COVID-19 pandemic to Americans in 2020. However, little is known about the reach of these campaigns or the populations who might have been exposed to the information these ads conveyed. We conducted a descriptive analysis of federally-affiliated public service announcement airings to assess where they were aired and the market-level social and demographic characteristics associated with the airings. We found no correspondence between airings and COVID-19 incidence rates from March to December 2020, but we found a positive association between airings and the Democratic vote share of the market, adjusting for other market demographic characteristics. Our results suggest that PSAs may have contributed to divergent exposure to health information among the U.S. public during the first year of the COVID-19 pandemic., Competing Interests: The authors have declared that no competing interests exist.

Obesity and diabetes are widespread health conditions with rising prevalence rates in the United States. News stories and health campaign messages frequently feature prevalence rates of obesity and diabetes, at times under the expectation that such messages will increase readers' disease awareness, health behaviors, and policy support. At the same time, American adults overestimate the prevalence of obesity and diabetes in the absence of prevalence information, raising important questions about the implications of communicating accurate prevalence information that may be lower than baseline estimates. The current study examines the effects of communicating information about the prevalence of obesity and diabetes, varying the format of this information (using qualitative terms, raw frequencies, or percentages). Results from two pre-registered, web-based randomized experiments suggest that only prevalence statistics in percentage formats shift readers' prevalence estimates, though in some percentage formats these estimates were lower than observed in a no-message control group. Prevalence estimates, in turn, were positively associated with perceived social causes of obesity/diabetes, intensions for healthy behaviors, and support for policy-level solutions. These findings offer guidance for health communication campaigns that seek to increase healthy behavior and support for policies to address health conditions.