Sherry Emery

Appraisal of anti-smoking advertising by youth at risk for regular smoking: a comparative study in the United States, Australia, and Britain

Objective: To compare the similarity in how youth in the United States, Australia, and Britain appraise anti-smoking advertisements with different characteristics. Design: Each participant viewed and evaluated a set of 10 anti-smoking adverts (from an overall total of 50 adverts) in a controlled experimental context using an audience response methodology. A structured telephone interview was completed one week after viewing the adverts, in which recall and engagement with the adverts by participants was evaluated. Subjects: 615 youths who were experimenting with smoking or were susceptible nonsmokers. Main outcome measures: Measures of advert appraisal and engagement. Results: Youth in the United States, Australia, and Britain responded in very similar ways to the same anti-smoking advertisements. In full multivariate models, the target audience of the advert and the advert theme were not related to the main outcome measures employed in this study. However, adverts with visceral negative or personal testimonial executional characteristics were appraised more positively by youths and were more likely to be recalled, thought about, and discussed at follow up one week later. Conclusions: Youths in three different countries responded to anti-smoking advertisements in very similar ways, suggesting that such adverts might be more actively shared among nations. The appraisal of, and engagement with, the anti-smoking adverts, however, varied substantially depending on executional characteristics. In the design of effective anti-smoking adverts, due attention needs to be paid to those characteristics that appear to most engage youth across different social and cultural environments.

Association Between Direct-to-Consumer Advertising and Testosterone Testing and Initiation in the United States, 2009-2013

Importance Testosterone initiation increased substantially in the United States from 2000 to 2013, especially among men without clear indications. Direct-to-consumer advertising (DTCA) also increased during this time. Objective To investigate associations between televised DTCA and testosterone testing and initiation in the United States. Design, Setting, and Population Ecologic study conducted in designated market areas (DMAs) in the United States. Monthly testosterone advertising ratings were linked to DMA-level testosterone use data from 2009-2013 derived from commercial insurance claims. Associations between DTCA and testosterone testing, initiation, and initiation without recent baseline tests were estimated using Poisson generalized estimating equations. Exposures Monthly Nielsen ratings for testosterone DTCA in the 75 largest DMAs. Main Outcomes and Measures (1) Rates of new serum testosterone testing; (2) rates of testosterone initiation (in-office injection, surgical implant, or pharmacy dispensing) for all testosterone products combined and for specific brands; and (3) rates of testosterone initiation without recent serum testosterone testing. Results Of 17 228 599 commercially insured men in the 75 DMAs, 1 007 990 (mean age, 49.6 [SD, 11.5] years) had new serum testosterone tests and 283 317 (mean age, 51.8 [SD, 11.3] years) initiated testosterone treatment. Advertising intensity varied by geographic region and time, with the highest intensity seen in the southeastern United States and with months ranging from no ad exposures to a mean of 13.6 exposures per household. Nonbranded advertisements were common prior to 2012, with branded advertisements becoming more common during and after 2012. Each household advertisement exposure was associated with a monthly increase in rates of new testosterone testing (rate ratio [RR], 1.006; 95% CI, 1.004-1.008), initiation (RR, 1.007; 95% CI, 1.004-1.010), and initiation without a recent test (RR, 1.008; 95% CI, 1.002-1.013). Mean absolute rate increases were 0.14 tests (95% CI, 0.09-0.19), 0.05 new initiations (95% CI, 0.03-0.08), and 0.02 initiations without a recent test (95% CI, 0.01-0.03) per 10 000 men for each monthly ad exposure over the entire period. Conclusions and Relevance Among US men residing in the 75 designated market areas, regional exposure to televised direct-to-consumer advertising was associated with greater testosterone testing, new initiation, and initiation without recent testing.

Transgender Use of Cigarettes, Cigars, and E-Cigarettes in a National Study

INTRODUCTION Tobacco use among transgender adults continues to be an area of research with few reported findings. The limited literature indicates higher cigarette use among transgender adults, compared with the general population. This national study is the first to report on cigarettes, cigars, and e-cigarettes by examining differences in transgender tobacco use independent of sexual orientation. METHODS Data were collected in 2013 using a nationally cross-sectional online survey of U.S. adults (cisgender, n=17,164; transgender, n=168) and analyzed in 2015. Past 30-day tobacco use point estimates and adjusted logistic regression while controlling for false discovery rate were reported for transgender and cisgender respondents. RESULTS Transgender adults reported higher past 30-day use of any cigarette/cigar/e-cigarette product (39.7% vs 25.1%) and current use of cigarettes (35.5% vs 20.7%), cigars (26.8% vs 9.3%), and e-cigarettes (21.3% vs 5.0%) compared with cisgender adults (all p-values ≤0.003). Transgender respondents had significantly higher odds of past 30-day tobacco product use for any cigarette/cigar/e-cigarette product (OR=1.97, 95% CI=1.25, 3.1), e-cigarettes (OR=5.15, 95% CI=3.36, 7.88), cigars (OR=3.56, 95% CI=2.27, 5.59), and cigarettes (OR=2.10, 95% CI=1.35, 3.28) versus cisgender respondents (all p-values ≤0.0035). CONCLUSIONS Transgender adults are at higher risk for tobacco use than cisgender adults and risk of specific product use varies by gender. This is the first U.S. national study to assess differences in use of various tobacco products using questions that specifically ask for gender identity separately from sexual orientation. This study provides data that can inform targeted interventions to promote transgender health.

‘Sweeter Than a Swisher’: amount and themes of little cigar and cigarillo content on Twitter

Objective Despite recent increases in little cigar and cigarillo (LCC) use—particularly among urban youth, African-Americans and Latinos—research on targeted strategies for marketing these products is sparse. Little is known about the amount or content of LCC messages users see or share on social media, a popular communication medium among youth and communities of colour. Methods Keyword rules were used to collect tweets related to LCCs from the Twitter Firehose posted in October 2014 and March–April 2015. Tweets were coded for promotional content, brand references, co-use with marijuana and subculture references (eg, rap/hip-hop, celebrity endorsements) and were classified as commercial and ‘organic’/non-commercial using a combination of machine learning methods, keyword algorithms and human coding. Metadata associated with each tweet were used to categorise users as influencers (1000 and more followers) and regular users (under 1000 followers). Results Keyword filters captured over 4 372 293 LCC tweets. Analyses revealed that 17% of account users posting about LCCs were influencers and 1% of accounts were overtly commercial. Influencers were more likely to mention LCC brands and post promotional messages. Approximately 83% of LCC tweets contained references to marijuana and 29% of tweets were memes. Tweets also contained references to rap/hip-hop lyrics and urban subculture. Conclusions Twitter is a major information-sharing and marketing platform for LCCs. Co-use of tobacco and marijuana is common and normalised on Twitter. The presence and broad reach of LCC messages on social media warrants urgent need for surveillance and serious attention from public health professionals and policymakers. Future tobacco use prevention initiatives should be adapted to ensure that they are inclusive of LCC use.

Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market

Background While national surveys showed declines in e-cigarette use in the USA between 2015 and 2016, recent reports indicate that JUUL, a sleekly designed e-cigarette that looks like a USB drive, is increasingly being used by youth and young adults. However, the extent of JUUL’s growth and its marketing strategy have not been systematically examined. Methods A variety of data sources were used to examine JUUL retail sales in the USA and its marketing and promotion. Retail store scanner data were used to capture the retail sales of JUUL and other major e-cigarette brands for the period 2011–2017. A list of JUUL-related keywords was used to identify JUUL-related tweets on Twitter; to identify JUUL-related posts, hashtags and accounts on Instagram and to identify JUUL-related videos on YouTube. Results In the short 3-year period 2015–2017, JUUL has transformed from a little-known brand with minimum sales into the largest retail e-cigarette brand in the USA, lifting sales of the entire e-cigarette category. Its US

The impact of flavour, device type and warning messages on youth preferences for electronic nicotine delivery systems: evidence from an online discrete choice experiment

150 million retail sales in the last quarter of 2017 accounted for about 40% of e-cigarette retail market share. While marketing expenditures for JUUL were moderate, the sales growth of JUUL was accompanied by a variety of innovative, engaging and wide-reaching campaigns on Twitter, Instagram and YouTube, conducted by JUUL and its affiliated marketers. Conclusions The discrepancies between e-cigarette sales data and the prevalence of e-cigarette use from surveys highlight the challenges in tracking and understanding the use of new and emerging tobacco products. In a rapidly changing media environment, where successful and influential marketing campaigns can be conducted on social media at little cost, marketing expenditures alone may not fully capture the influence, reach and engagement of tobacco marketing.

Inferring Social Influence of anti-Tobacco mass media campaigns

Objective To examine the impact of flavour, device type and health warning messages on youth preference for electronic nicotine delivery systems (ENDS), and to provide evidence and data to inform the Food and Drug Administration’s potential regulatory actions on ENDS. Design An online discrete choice experiment was conducted in September 2015. Each participant was given nine choice sets and asked to choose one out of two alternative ENDS products, with varying characteristics in three attributes (flavour, device type and warning message). The impact of the attributes on the probability of choosing ENDS was analysed using conditional and nested logit regressions, controlling for individual sociodemographic characteristics and current smoking status. Setting and participants A general population sample of 515 participants (50 ever-users and 465 never-users of ENDS) aged 14–17 years were recruited to complete the experiment using an online panel. Results Fruit/sweets/beverage flavours significantly increase the probability of choosing ENDS among youth (p<0.01 for never-users and <0.1 for ever-users) and flavour has the most pronounced impact among three attributes. Among never-users, menthol flavour also increases (p<0.05) the probability of choosing ENDS compared with tobacco flavour. Vaping devices that are modifiable, compared with cigarette-like e-cigarettes, increase (p<0.05) the probability of choosing ENDS among adolescent never-users. Warning messages reduce (p<0.01) the probability of choosing ENDS among never-users. Conclusions and relevance Restricting fruit/sweets/beverage flavours in ENDS, regulating modifiable vaping devices and adopting strong health warning messages may reduce the uptake of ENDS among youth.

Lesbian, Gay, Bisexual, and Transgender (LGBT) View it Differently Than Non-LGBT: Exposure to Tobacco-related Couponing, E-cigarette Advertisements, and Anti-tobacco Messages on Social and Traditional Media

Anti-tobacco mass media campaigns are designed to influence tobacco users. It has been proved campaigns will produce their changes in awareness, knowledge, and attitudes, and also produce meaningful behavior change of audience. Anti-smoking television advertising is the most important part in the campaign. Meanwhile nowadays successful online social networks are creating new media environment, however little is known about the relation between social conversations and anti-tobacco campaigns. This paper aims to infer social influence of these campaigns, and the problem is formally referred to as the “Social Influence inference of anti-Tobacco mass mEdia campaigns” (SITE) problem. To address the SITE problem, a novel influence inference framework, “TV Advertising Social Influence Estimation” (ASIE), is proposed based on our analysis of two anti-tobacco campaigns. ASIE divides audience attitudes towards TV ads into three distinct stages: (1) Cognitive, (2) Affective and (3) Conative. Audience online reactions at each of these three stages are depicted by ASIE with specific probabilistic models based on the synergistic influences from both online social friends and offline TV ads. Extensive experiments demonstrate the effectiveness of ASIE.

Twitter analysis of California's failed campaign to raise the state's tobacco tax by popular vote in 2012

BACKGROUND LGBT populations use tobacco at disparately higher rates nationwide, compared to national averages. The tobacco industry has a history targeting LGBT with marketing efforts, likely contributing to this disparity. This study explores whether exposure to tobacco content on traditional and social media is associated with tobacco use among LGBT and non-LGBT. METHODS This study reports results from LGBT (N = 1092) and non-LGBT (N = 16430) respondents to a 2013 nationally representative cross-sectional online survey of US adults (N = 17522). Frequency and weighted prevalence were estimated and adjusted logistic regression analyses were conducted. RESULTS LGBT reported significantly higher rates of past 30-day tobacco media exposure compared to non-LGBT, this effect was strongest among LGBT who were smokers (p < .05). LGBT more frequently reported exposure to, searching for, or sharing messages related to tobacco couponing, e-cigarettes, and anti-tobacco on new or social media (eg, Twitter, Facebook, etc.) than did non-LGBT (p < .05). Non-LGBT reported more exposure from traditional media sources such as television, most notably anti-tobacco messages (p = .0088). LGBT had higher odds of past 30-day use of cigarettes, e-cigarettes, and cigars compared to non-LGBT, adjusting for past 30-day media exposure and covariates (p ≤ .0001). CONCLUSIONS LGBT (particularly LGBT smokers) are more likely to be exposed to and interact with tobacco-related messages on new and social media than their non-LGBT counterparts. Higher levels of tobacco media exposure were significantly associated with higher likelihood of tobacco use. This suggests tobacco control must work toward reaching LGBT across a variety of media platforms, particularly new and social media outlets. IMPLICATIONS This study provides important information about LGBT communities tobacco-related disparities in increased exposure to pro-tobacco messages via social media, where the tobacco industry has moved since the MSA. Further, LGBT when assessed as a single population appear to identify having decreased exposure to anti-tobacco messages via traditional media, where we know a large portion of tobacco control and prevention messages are placed. The study points to the need for targeted and tailored approaches by tobacco control to market to LGBT using on-line resources and tools in order to help reduce LGBT tobacco-related health disparities. Although there have been localized campaigns, only just recently have such LGBT-tailored national campaigns been developed by the CDC, FDA, and Legacy, assessment of the content, effectiveness, and reach of both local and national campaigns will be important next steps.

Inferring Social Influence of Anti-Tobacco Mass Media Campaign

Background The rapid diffusion of social media in the past decade has allowed community members to sway the discourse on elections. We use analyses of social media to provide insight into why the strong public support 1 year prior to the election did not result in an increased tobacco tax from the 2012 California Proposition 29 vote. Methods Using the Twitter historical Firehose, we chose all tweets on Proposition 29 posted between 1 January and 5 June 2012 differentiating between early and late campaign periods. Tweets were coded for valence, theme and source. We analysed metadata to characterise accounts. Television ratings data in 9 major California media markets were used to show the strength of the 2 campaigns. Results ‘No on 29’ launched television advertising earlier and with much higher household gross rating points (GRPs) than the ‘Yes on 29’ campaign. Among 17 099 relevant tweets from 8769 unique accounts, 53% supported Proposition 29, 27% opposed and 20% were neutral. Just under half (43%) were from accounts affiliated with the campaigns. Two-thirds of campaign messages originated outside California. The ‘Yes’ campaign focused on simple health messages, which were equally represented in both campaign periods. However, anti-tax tweets increased at relative to pro-tax tweets in the second period. Conclusions Although the Prop 29 campaigns did not effectively engage the Californian twitter communities, analysis of tweets provided an earlier indication than public polls of the loss of public supporting this election. Prospective Twitter analysis should be added to campaign evaluation strategies.