Laura A. Gibson

Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis

Importance The public health implications of e-cigarettes depend, in part, on whether e-cigarette use affects the risk of cigarette smoking. Objective To perform a systematic review and meta-analysis of longitudinal studies that assessed initial use of e-cigarettes and subsequent cigarette smoking. Data Sources PubMed, EMBASE, Cochrane Library, Web of Science, the 2016 Society for Research on Nicotine and Tobacco 22nd Annual Meeting abstracts, the 2016 Society of Behavioral Medicine 37th Annual Meeting & Scientific Sessions abstracts, and the 2016 National Institutes of Health Tobacco Regulatory Science Program Conference were searched between February 7 and February 17, 2017. The search included indexed terms and text words to capture concepts associated with e-cigarettes and traditional cigarettes in articles published from database inception to the date of the search. Study Selection Longitudinal studies reporting odds ratios for cigarette smoking initiation associated with ever use of e-cigarettes or past 30-day cigarette smoking associated with past 30-day e-cigarette use. Searches yielded 6959 unique studies, of which 9 met inclusion criteria (comprising 17 389 adolescents and young adults). Data Extraction and Synthesis Study quality and risk of bias were assessed using the Newcastle-Ottawa Scale and the Risk of Bias in Non-randomized Studies of Interventions tool, respectively. Data and estimates were pooled using random-effects meta-analysis. Main Outcomes and Measures Among baseline never cigarette smokers, cigarette smoking initiation between baseline and follow-up. Among baseline non–past 30-day cigarette smokers who were past 30-day e-cigarette users, past 30-day cigarette smoking at follow-up. Results Among 17 389 adolescents and young adults, the ages ranged between 14 and 30 years at baseline, and 56.0% were female. The pooled probabilities of cigarette smoking initiation were 30.4% for baseline ever e-cigarette users and 7.9% for baseline never e-cigarette users. The pooled probabilities of past 30-day cigarette smoking at follow-up were 21.5% for baseline past 30-day e-cigarette users and 4.6% for baseline non–past 30-day e-cigarette users. Adjusting for known demographic, psychosocial, and behavioral risk factors for cigarette smoking, the pooled odds ratio for subsequent cigarette smoking initiation was 3.62 (95% CI, 2.42-5.41) for ever vs never e-cigarette users, and the pooled odds ratio for past 30-day cigarette smoking at follow-up was 4.28 (95% CI, 2.52-7.27) for past 30-day e-cigarette vs non–past 30-day e-cigarette users at baseline. A moderate level of heterogeneity was observed among studies (I2 = 60.1%). Conclusions and Relevance e-Cigarette use was associated with greater risk for subsequent cigarette smoking initiation and past 30-day cigarette smoking. Strong e-cigarette regulation could potentially curb use among youth and possibly limit the future population-level burden of cigarette smoking.

Assessing the Consequences of Implementing Graphic Warning Labels on Cigarette Packs for Tobacco-Related Health Disparities

INTRODUCTION Population-level communication interventions, such as graphic warning labels (GWLs) on cigarette packs, have the potential to reduce or exacerbate tobacco-related health disparities depending on their effectiveness among disadvantaged sub-populations. This study evaluated the likely impact of nine GWLs proposed by the US Food and Drug Administration on (1) African American and (2) Hispanic smokers, who disproportionately bear the burden of tobacco-related illness, and (3) low education smokers, who have higher smoking rates. METHODS Data were collected online from current smokers randomly assigned to see GWLs (treatment) or the current text-only warning labels (control). Participants were stratified by age (18-25; 26+) in each of four groups: general population (n = 1246), African Americans (n = 1200), Hispanics (n = 1200), and low education (n = 1790). We tested the effectiveness of GWLs compared to text-only warning labels using eight outcomes that are predictive of quitting intentions or behaviors including negative emotion, intentions to hold back from smoking, intentions to engage in avoidance behaviors, and intentions to quit. RESULTS Across all outcomes, GWLs were significantly more effective than text-only warning labels more often than expected by chance. Results suggested that African Americans, Hispanics and smokers with low education did not differ from the general population of smokers in their reactions to any of the nine individual GWLs. CONCLUSIONS The nine GWLs were similarly effective for disadvantaged sub-populations and the general population of smokers. Implementation of GWLs is therefore unlikely to reduce or exacerbate existing tobacco-related health disparities, but will most likely uniformly increase intentions and behaviors predictive of smoking cessation.

Talking About Quitting: Interpersonal Communication as a Mediator of Campaign Effects on Smokers’ Quit Behaviors

This study examined the role of interpersonal communication in the context of a mass media anti-smoking campaign. Specifically, it explored whether conversations about campaign ads and/or about quitting mediated campaign exposure effects on 2 quitting behaviors (sought help to quit and tried to quit smoking completely), as well as the relation between ad-related and quitting-related conversations. Data were collected before the campaign and monthly for 16 months during the campaign through cross-sectional telephone surveys among a sample of 3,277 adult Philadelphia smokers. Follow-up interviews were conducted among 877 participants 3 months after their first survey. Cross-sectional and longitudinal mediation models with bootstrap procedures assessed the indirect effects of campaign exposure on outcomes through conversations, and the indirect effects of conversations about ads on outcomes through conversations about quitting. In addition, lagged regression analyses tested the causal direction of associations between the variables of interest. The results partially support hypotheses that conversations about quitting mediate campaign effects on quitting-related behaviors and, in line with previous research, that conversations about the ads have indirect effects on quitting-related behaviors by triggering conversations about quitting. These findings demonstrate the importance of considering interpersonal communication as a route of campaign exposure effects when evaluating and designing future public health campaigns.

Are Young People’s Beliefs About Menthol Cigarettes Associated With Smoking-Related Intentions and Behaviors?

INTRODUCTION Little is known about the beliefs that youth and young adults hold about menthol cigarettes or the influence of these beliefs on tobacco use initiation. METHODS Online cross-sectional surveys with 13- to 17-year-old current nonsmokers (n = 553) and 18- to 25-year-old never (n = 586) and current tobacco users (n = 307) in the United States assessed the association between endorsing each of 9 pro-menthol beliefs and (a) intentions to smoke menthol cigarettes over the next year, (b) current use of menthol cigarettes, (c) intentions to use tobacco in general over the next year, and (d) current use of tobacco products in general. RESULTS Menthols were perceived to be less harmful and addictive than nonmenthol cigarettes by between 13% and 23% of respondents. Between 20% and 58% believed that menthols had favorable sensory properties, and 7%-25% believed that menthol smokers were more popular and attractive than nonmenthol smokers. Logistic regression analyses (adjusting for confounders) indicated that, on the whole, those who endorsed pro-menthol beliefs were more likely to intend to use, and to currently use, both menthols and tobacco products in general. For example, respondents who believed that menthol cigarettes were more refreshing in sensation (one of the most frequently endorsed beliefs) were significantly more likely to (a) intend to smoke menthol cigarettes (13- to 17-year-olds, odds ratio [OR] = 2.12, 95% confidence interval [CI] = 1.03, 4.34; 18- to 25-year olds, OR = 2.62, 95% CI = 1.04, 6.60), (b) currently use menthol cigarettes (18- to 25-year olds, OR = 3.40, 95% CI = 2.20, 5.26), (c) intend to use tobacco (13- to 17-year-olds OR = 1.74, 95% CI = 1.14, 2.65), and (d) currently use tobacco (18- to 25-year olds, OR = 2.06, 95% CI = 1.44, 2.93). CONCLUSIONS Youth and young adults who do not currently smoke and who hold favorable beliefs about menthol cigarettes are at greater risk for beginning to use tobacco products, indicating that the availability of menthol cigarettes may contribute to tobacco use initiation. These findings support recent claims that the elimination of menthol cigarettes would improve public health in the United States.

Nonmedical information seeking amid conflicting health information: negative and positive effects on prostate cancer screening

Abstract This study investigates the impact of seeking information about the prostate-specific antigen (PSA) test on men’s PSA test use during a period of conflicting recommendations. Analyses used longitudinal survey data collected in 2005 and 2006 from a nationally representative sample of U.S. males aged 40–70 years (n = 777). Cross-sectionally, nonmedical information seeking was significantly associated with increased odds of having a PSA test in the past year (Time 1 odds ratio [OR] = 9.74, p < .01, 95% confidence interval [CI] = 4.37, 21.70; Time 2 OR = 5.78, p < .01, 95% CI = 3.17, 10.55). However, lagged analyses showed that among men who had a PSA at Time 1, active seeking is associated with reduced odds of later having a PSA test (OR = 0.33, p < .05, 95% CI = 0.13, 0.85). Participants who had not had a PSA test in the past year very rarely sought information about PSA tests. Information acquisition in an environment of conflicting recommendations may influence adoption of cancer screening behaviors.

Applying Quantitative Approaches to the Formative Evaluation of Antismoking Campaign Messages

This article shares an in-depth summary of a formative evaluation that used quantitative data to inform the development and selection of promotional ads for the antismoking communication component of a social marketing campaign. A foundational survey provided cross-sectional data to identify beliefs about quitting smoking, that campaign messages should target, as well as beliefs to avoid. Pretesting draft ads against quantitative indicators of message effectiveness further facilitated the selection and rejection of final campaign ads. Finally, we consider lessons learned from the process of balancing quantitative methods and judgment to make formative decisions about more and less promising persuasive messages for campaigns.

Effects of a risk-based online mammography intervention on accuracy of perceived risk and mammography intentions

OBJECTIVE This experiment tested the effects of an individualized risk-based online mammography decision intervention. The intervention employs exemplification theory and the Elaboration Likelihood Model of persuasion to improve the match between breast cancer risk and mammography intentions. METHODS 2918 women ages 35-49 were stratified into two levels of 10-year breast cancer risk (<1.5%; ≥1.5%) then randomly assigned to one of eight conditions: two comparison conditions and six risk-based intervention conditions that varied according to a 2 (amount of content: brief vs. extended) x 3 (format: expository vs. untailored exemplar [example case] vs. tailored exemplar) design. Outcomes included mammography intentions and accuracy of perceived breast cancer risk. RESULTS Risk-based intervention conditions improved the match between objective risk estimates and perceived risk, especially for high-numeracy women with a 10-year breast cancer risk ≤1.5%. For women with a risk≤1.5%, exemplars improved accuracy of perceived risk and all risk-based interventions increased intentions to wait until age 50 to screen. CONCLUSION A risk-based mammography intervention improved accuracy of perceived risk and the match between objective risk estimates and mammography intentions. PRACTICE IMPLICATIONS Interventions could be applied in online or clinical settings to help women understand risk and make mammography decisions.

Evaluation of a Mass Media Campaign Promoting Using Help to Quit Smoking

BACKGROUND Although there is evidence that promoting individual cessation aids increases their utilization, mass media campaigns highlighting the benefit of using help to quit have not been evaluated. PURPOSE The effects of a Philadelphia adult smoking-cessation media campaign targeting using help in ad taglines were analyzed from March to November 2012. This study distinctively analyzed the campaigns impact at both the population level (effects on the average person) and the individual level (effects among those who reported exposure). METHODS The 16-month mass media campaign aired in Philadelphia PA from December 2010 to March 2012. A representative sample of adult Philadelphia smokers was interviewed by telephone at baseline (n=491) and new samples were interviewed monthly throughout the campaign (n=2,786). In addition, a subsample of these respondents was reinterviewed 3 months later (n=877). RESULTS On average, participants reported seeing campaign ads four times per week. Among individual respondents, each additional campaign exposure per week increased the likelihood of later reporting using help (OR=1.08, p<0.01), adjusting for baseline use of help and other potential confounders. This corresponded to a 5% increase in the use of help for those with average exposure relative to those with no exposure. Cross-sectional associations between individual campaign exposure and intentions to use help were consistent with these lagged findings. However, there was no evidence of population-level campaign effects on use of help. CONCLUSIONS Although the campaign was effective at the individual level, its effects were too small to have a population-detectable impact.

Recall of “The Real Cost” Anti-Smoking Campaign Is Specifically Associated With Endorsement of Campaign-Targeted Beliefs

Though previous research suggests the FDA’s “The Real Cost” anti-smoking campaign has reduced smoking initiation, the theorized pathway of effects (through targeted beliefs) has not been evaluated. This study assesses the relationship between recall of campaign television advertisements and ad-specific anti-smoking beliefs. Respondents in a nationally representative survey of nonsmoking youths age 13–17 (n = 4,831) reported exposure to four The Real Cost advertisements and a fake ad, smoking-relevant beliefs, and nonsmoking intentions. Analyses separately predicted each targeted belief from specific ad recall, adjusting for potential confounders and survey weights. Parallel analyses with non-targeted beliefs showed smaller effects, strengthening claims of campaign effects. Recall of four campaign ads (but not the fake ad) significantly predicted endorsement of the ad-targeted belief (Mean β = .13). Two-sided sign tests indicated stronger ad recall associations with the targeted belief relative to the non-targeted belief (p < .05). Logistic regression analyses indicated that respondents who endorsed campaign-targeted beliefs were more likely to have no intention to smoke (p < .01). This study is the first to demonstrate a relationship between recall of ads from The Real Cost campaign and the theorized pathway of effects (through targeted beliefs). These analyses also provide a methodological template for showing campaign effects despite limitations of available data.

Explaining the effects of a decision intervention on mammography intentions: The roles of worry, fear and perceived susceptibility to breast cancer

Objective: This study examines the effects of a mammography decision intervention on perceived susceptibility to breast cancer (PSBC) and emotion and investigates how these outcomes predict mammography intentions. Design: Randomised between-subjects online experiment. Participants were stratified into two levels of risk. Within each stratum, conditions included a basic information condition and six decision intervention conditions that included personalised risk estimates and varied according to a 2 (amount of information: brief vs. extended) × 3 (format: expository vs. untailored exemplar vs. tailored exemplar) design. Participants included 2465 US women ages 35–49. Main Outcome Measures: PSBC as a percentage, PSBC as a frequency, worry, fear and mammography intentions. Results: The intervention resulted in significant reductions in PSBC as a percentage for women in both strata and significant increases in worry and fear for women in the upper risk stratum. Of the possible mediators examined, only PSBC as a percentage was a consistent mediator of the effect of the intervention on mammography intentions. Conclusion: The results provide insight into the mechanism of action of the intervention by showing that PSBC mediated the effects of the intervention on mammography intentions.