Kristen Jarman

Eye Tracking Outcomes in Tobacco Control Regulation and Communication: A Systematic Review.

OBJECTIVE In this paper we synthesize the evidence from eye tracking research in tobacco control to inform tobacco regulatory strategies and tobacco communication campaigns. METHODS We systematically searched 11 databases for studies that reported eye tracking outcomes in regards to tobacco regulation and communication. Two coders independently reviewed studies for inclusion and abstracted study characteristics and findings. RESULTS Eighteen studies met full criteria for inclusion. Eye tracking studies on health warnings consistently showed these warnings often were ignored, though eye tracking demonstrated that novel warnings, graphic warnings, and plain packaging can increase attention toward warnings. Eye tracking also revealed that greater visual attention to warnings on advertisements and packages consistently was associated with cognitive processing as measured by warning recall. CONCLUSIONS Eye tracking is a valid indicator of attention, cognitive processing, and memory. The use of this technology in tobacco control research complements existing methods in tobacco regulatory and communication science; it also can be used to examine the effects of health warnings and other tobacco product communications on consumer behavior in experimental settings prior to the implementation of novel health communication policies. However, the utility of eye tracking will be enhanced by the standardization of methodology and reporting metrics.

Raising the Legal Age of Tobacco Sales: Policy Support and Trust in Government, 2014-2015, U.S.

INTRODUCTION The National Academy of Medicine has called for an increase in the minimum age of tobacco product sales. It is not clear what age increase would garner the greatest public support, or whether trust in the U.S. government predicts policy support. METHODS The data for these analyses are from a nationally representative telephone sample of U.S. adults (N=4,880) conducted from September 2014 to May 2015. The authors assessed whether support varied by the proposed minimum age of tobacco sales using a survey experiment (i.e., random assignment to the 19-, 20-, or 21-year age minimum condition) and, in cross-sectional analyses, whether smoking status, individual demographics, state-level politics, and general trust in the government predicted policy support. Analyses were conducted from May to December 2015. RESULTS Odds of support for raising the minimum sales age to 21 years trended higher than support for raising to age 20 or 19 years (AOR=1.22, 95% CI=0.97, 1.53, p=0.09). There was majority support for raising the age of sales for cigarettes in all regions of the U.S. (66.3%, 95% CI=64.0, 68.6). Race, age, and trust in government were significant predictors of support. CONCLUSIONS Raising the age of tobacco sales is broadly supported by the public. An age 21 years tobacco sales policy trends toward garnering more support than a policy at age 19 or 20 years. Trust in government may be an important consideration in understanding policy support beyond demographics.

Believability of Cigarette Warnings About Addiction: National Experiments of Adolescents and Adults

Introduction We conducted two experiments to examine the believability of three addiction-focused cigarette warnings and the influence of message source on believability among adolescents and adults in the United States. Methods Experimental data were collected using national phone surveys of adolescents (age 13-17; n = 1125; response rate, 66%) and adults (age 18+; n = 5014; response rate, 42%). We assessed the believability of three cigarette warnings about addiction attributed to four message sources (Food and Drug Administration [FDA], Surgeon General, Centers for Disease Control and Prevention [CDC], no source). Results The majority of adolescents and adults reported the three cigarette warnings were very believable (49%-81% for adolescents; 47%-76% for adults). We found four to five times higher odds of adolescents believing a warning that cigarettes are addictive (warning 1) or that nicotine was an addictive chemical (warning 2) compared to a warning that differentiated the addictive risks of menthol versus traditional cigarettes (warning 3), warning 1 adjusted odds ratio (aOR): 4.53, 95% confidence interval (CI): 3.10, 6.63; warning 2 aOR: 3.87, 95% CI: 2.70, 5.50. Similarly, we found three to five times higher odds of adults (including current smokers) believing the same warnings, warning 1 aOR: 3.74, 95% CI: 2.82, 4.95; warning 2 aOR: 3.24, 95% CI: 2.45, 4.28. Message source had no overall impact on the believability of warnings for either population. Conclusions Our findings support the implementation of FDAs required warnings that cigarettes are addictive and that nicotine is an addictive chemical. These believable warnings may deter adolescents from initiating smoking and encourage adults to quit smoking. Implications This article describes, for the first time, the believability of different cigarette warnings about addiction. We now know that the majority of adolescents and adults believe cigarette warnings that highlight cigarettes as addictive and that nicotine is an addictive chemical in tobacco. However, a warning that highlighted the relative risk of addiction for menthol cigarettes compared to traditional cigarettes was not as believable among either population. Our findings support the implementation of FDAs required warnings that cigarettes are addictive and that nicotine is an addictive chemical that may deter adolescents from initiating smoking and encourage adults to quit smoking.

Believability of new diseases reported in the 2014 Surgeon General's Report on smoking: Experimental results from a national survey of US adults

BACKGROUND Tobacco use is the leading cause of preventable disease and death globally. The 2014 Surgeon Generals Report included new diseases linked to smoking, including liver and colon cancer, diabetes and tuberculosis. As more diseases are linked to smoking, which diseases should we communicate to the public and what message source has the most impact? METHODS Data were collected through a nationally representative phone survey of US adults (N=5014), conducted from September 2014 through May 2015. We experimentally randomized participants to a 2 (new smoking disease messages - liver and colon cancers compared to diabetes and tuberculosis) by 4 (message sources - CDC, FDA, Surgeon General, and none) experiment. The outcome was message believability. RESULTS About half the sample was female (51.5%) and 17.8% were a current smoker. Overall, 56% of participants said the messages were very believable. Cancer messages (liver and colon cancer) were significantly more believable than messages about chronic disease (tuberculosis and diabetes), 61% vs. 52%. Smokers were less likely to report both sets of new disease messages as very believable compared to non-smokers. Significantly more smokers intending to quit (44.5%) found the messages to be very believable compared to smokers not intending to quit (22.6%). Believability did not differ by message source. CONCLUSION Important differences exist in believability of disease messages about new tobacco-related information. Messages emphasizing the causal link between smoking and new diseases should be considered for use in mass media campaigns.

Factors Influencing Trust in Agencies That Disseminate Tobacco Prevention Information

Several health-related agencies administer national and targeted public education campaigns to provide health information and change health-related behaviors. The trust the public has in these agencies as the source of the message impacts the effectiveness of their communication campaigns. In this study, we explore the perceived trust of agencies that communicate health messages in the tobacco control field. As part of a larger tobacco regulatory science study, we conducted six 90-min focus groups comprising 41 participants. Five main themes emerged pertinent to the agency: (1) its integrity, (2) its competence, (3) its motives, (4) how it is portrayed in the media, and (5) skepticism and mistrust about it. Given the significant resources spent on health messaging to the public and potential benefits offered by this communication, an understanding of public trust in the agencies as the source of health messages is important. Findings suggest health information may be ignored or discounted when there is mistrust in the agency sending those messages.

Public Knowledge and Credibility Perceptions of the FDA as a Tobacco Regulator

Introduction Since the U.S. Food and Drug Administration (FDA) was granted regulatory authority over tobacco products in 2009, few studies have examined perceived credibility of the FDA in this role. The current study assessed knowledge and credibility of the FDA as a regulator of tobacco products. Methods In a nationally representative survey of U.S. adults (N = 4758), we assessed knowledge that the FDA regulates the manufacture, distribution, and marketing of cigarettes, and credibility of the FDA as a tobacco regulator. We examined demographic differences in knowledge and credibility, and associations of knowledge and trust in government with credibility perceptions. Results Less than half of respondents reported knowing the FDA regulates how cigarettes are sold (46.8%) and advertised (49.7%), and only 36.0% knew the FDA regulates how cigarettes are made, with few demographic differences. Respondents reported that the FDA was moderately credible in regulating tobacco. Knowledge of the FDA as a tobacco regulator and trust in government were the strongest predictors of credibility. Being of younger age, being White (compared to African American), and being male were associated with higher credibility ratings of the FDA. Conclusions Much of the public still does not know that the FDA regulates tobacco products, and credibility perceptions are moderate. Greater knowledge of the FDAs regulatory role was associated with higher credibility; efforts that increase the publics understanding of the FDAs role as a tobacco regulator may positively impact views of the agencys credibility. This may in turn improve public reception to the FDAs messages and regulations. Implications This study is the first to show nationally representative estimates of both knowledge and credibility of the FDA as a tobacco regulator. Our research shows further that knowledge of the FDAs tobacco regulatory roles is likely to be an important factor related to perceived credibility of the FDA. Increasing the publics knowledge of the FDAs roles may enhance the agencys credibility, which can improve public reception to messages and regulations.

Cigarette Constituent Health Communications for Smokers: Impact of Chemical, Imagery, and Source

INTRODUCTION Communication campaigns are incorporating tobacco constituent messaging to reach smokers, yet there is a dearth of research on how such messages should be constructed or will be received by smokers. METHODS In a 2 × 2 × 2 experiment, we manipulated three cigarette constituent message components: (1) the toxic constituent of tobacco (arsenic vs. lead) with a corresponding health effect, (2) the presence or absence of an evocative image, and (3) the source of the message (FDA vs. no source). We recruited smokers (N = 1669, 55.4% women) via an online platform and randomized them to one of the eight message conditions. Participants viewed the message and rated its believability and perceived effectiveness, the credibility of the message source, and action expectancies (ie, likelihood of seeking additional information and help with quitting as a result of seeing the message). RESULTS We found significant main effects of image, constituent, and source on outcomes. The use of arsenic as the constituent, the presence of an evocative image, and the FDA as the source increased the believability, source credibility, and perceived effectiveness of the tobacco constituent health message. CONCLUSIONS Multiple elements of a constituent message, including type of constituent, imagery, and message source, impact their reception among smokers. Specifically, communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes that are associated with subsequent attitude and behavioral changes. IMPLICATIONS This article describes how components of communication campaigns about cigarette constituents are perceived. Multiple elements of a tobacco constituent message, including type of constituent, image, and message source may influence the reception of messages among current smokers. Communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes among smokers. The effects of such campaigns should be examined, as well as the mechanisms through which such campaigns affect change.

Are Some of the Cigar Warnings Mandated in the U.S. More Believable Than Others

Background: Text warnings are mandated on cigars sold in the United States (U.S.), however little published research has examined effectiveness of cigar warnings. This is the first study examining the believability of cigar warnings among adults in the U.S. Methods: Adults in the U.S. (n = 5014) were randomized in a phone survey to receive one of three cigar-specific mandated warning messages (“Cigar smoking can cause cancers of the mouth and throat, even if you do not inhale”, “Cigar smoking can cause lung cancer and heart disease”, and “Cigars are not a safe alternative to cigarettes”) with one of four warning sources (no source, Surgeon General, CDC (Centers for Disease Control and Prevention), FDA (Food and Drug Administration)). Results: Most adults found the cigar warnings very believable (66.9%). Weighted logistic regression results indicate that the message “Cigar smoking can cause lung cancer and heart disease” was associated with higher odds of being very believable (AOR: 2.05, 95% CI: 1.55, 2.70) and the message “Cigars are not a safe alternative to cigarettes” was associated with lower odds of being very believable (AOR: 0.71, 95% CI: 0.55, 0.92) compared to the message “Cigar smoking can cause cancers of the mouth and throat, even if you do not inhale”. Warning source had no impact on believability. Conclusions: We tested three of the currently mandated cigar warnings in the U.S. and found significant differences in believability between them. Further research on cigar warnings may improve communication to the public on cigar health risks, ultimately preventing uptake of cigars and promoting cessation among cigar users.

Providing Nicotine Replacement Therapy in Focus Groups.

In many research studies, tobacco users are asked to forgo tobacco during study appointments to avoid interrupting study sessions with breaks or disrupting research flow and efficiency. Although onset of withdrawal varies according to levels of nicotine dependence, symptoms commonly begin within 30 minutes of abstinence.1 Symptoms of nicotine withdrawal include irritability, restlessness, anxiety, and difficulty concentrating.2 Nicotine cravings pose a particular problem in tobacco research, as discussion of tobacco products and tasks participants complete may act as triggers to use.3 In recent focus groups among adults that currently smoke cigarettes, we offered nicotine replacement therapy (NRT) to participants to prevent nicotine withdrawal and encourage participants to stay in the 90-minute session. To our knowledge, no previous research has undertaken this approach. This letter documents the use and perceptions of NRT in our focus groups, and makes recommendations based on our experience. NRT can reduce the desire to use cigarettes and ameliorate withdrawal symptoms experienced during quit attempts.4 While NRT is most commonly used to aid in smoking cessation, research shows that NRT is safe to use regardless of quit intentions, and that certain products can be used on demand to combat acute nicotine cravings.5 NRT is supported by the World Health Organization (WHO) Framework Convention on Tobacco Control and was added to the WHO Model List of Essential Medicines in 2009.6,7 NRT products are available in most countries, although accessibility is limited in many developing countries.8 In the United States NRT can be purchased over the counter in the form of a patch, gum or a lozenge. The nicotine lozenge is especially effective for curbing acute tobacco cravings, as it allows the user to control the timing and dosage for rapid release of nicotine. As part of a larger study on tobacco control communication, we conducted five focus groups with adults who currently smoke cigarettes. The 90-minute sessions had no planned breaks so that the flow of discussion was not interrupted. We provided 2 mg nicotine lozenges that participants could use at any time. Lozenges were placed in the middle of the table with brief instructions for use, and participants were free to utilize them at any time during the study session. Four of 51 participants utilized the nicotine lozenges, and reactions to the available NRT were overwhelmingly positive. Participants reported that the NRT provision helped avoid potential nicotine cravings and was a nice and respectful gesture. Typical comments included:

Information to Improve Public Perceptions of the Food and Drug Administration (FDA’s) Tobacco Regulatory Role

While the Food and Drug Administration (FDA) has had regulatory authority over tobacco products since 2009, public awareness of this authority remains limited. This research examines several broad types of information about FDA tobacco regulatory mission that may improve the perceptions of FDA as a tobacco regulator. Using Amazon Mechanical Turk, 1766 adults, smokers and non-smokers, were randomly assigned to view a statement about FDA regulatory authority that varied three information types in a 2 × 2 × 2 between subjects experimental design: (1) FDA’s roles in regulating tobacco (yes/no); (2) The scientific basis of regulations (yes/no); and (3) A potential protective function of regulations (yes/no). Using factorial ANOVA, we estimated the main and interactive effects of all three types of information and of smoking status on the perceptions of FDA. Participants that were exposed to information on FDA roles reported higher FDA credibility and a greater perceived knowledge of FDA than those who did not. Exposure to information about the scientific basis of regulations led to more negative views of the tobacco industry. Participants who learned of the FDA’s commitment to protecting the public reported higher FDA credibility and more positive attitudes toward regulations than those who did not learn of this commitment. We observed no significant interaction effects. The findings suggest that providing information about the regulatory roles and protective characterization of the FDA’s tobacco regulatory mission positively influence public perceptions of FDA and tobacco regulations.