Youths' Perceptions of Nicotine Harm and Associations With Product Use.

INTRODUCTION: Although nicotine is the main addictive substance in tobacco, tobacco combustion is responsible for most tobacco-related diseases. U.S. adults hold misperceptions about nicotine harm. However, little is known about youth nicotine perceptions. AIMS AND METHODS: To address this gap, we assessed U.S. youths' nicotine perceptions and how these perceptions relate to tobacco use. Participants were youth (ages 12-17) in waves 4 (w4; December 2016-January 2018; N = 14 798) and 4.5 (w4.5; December 2017-December 2018; N = 12 918) of the Population Assessment of Tobacco and Health Study, a nationally representative longitudinal cohort study. We describe beliefs about nicotine; perceptions of the nicotine harm in cigarettes, e-cigarettes, and nicotine replacement therapy (NRT); and demographic differences. Regressions assess whether w4 nicotine perceptions predicted w4.5 tobacco use. RESULTS: Most youth correctly responded that nicotine is the main cause of addiction (77.1%) but incorrectly responded that nicotine is the main substance that causes smoking-related cancer (74.7%). Youth distinguished between the harm of nicotine in different products, and on average rated the nicotine in cigarettes as most harmful, followed by e-cigarettes and NRT. Among youth who did not use at w4, greater harm perceptions of nicotine in cigarettes, e-cigarettes, and NRT were associated with lower likelihood of reporting current tobacco use at w4.5. Among youth who currently used cigarettes or e-cigarettes at wave 4, nicotine perceptions did not predict switching to e-cigarettes or cigarettes, respectively, at wave 4.5. CONCLUSIONS: These findings underscore the challenge of developing effective and comprehensive communication strategies that accurately convey the effects of nicotine without encouraging tobacco use. IMPLICATIONS: Many U.S. adults have misperceptions about nicotine, incorrectly believing it is the substance that causes most smoking-related cancers; studies have not assessed youth's perceptions of nicotine and how these perceptions relate to tobacco use. This study found that similar to adults, most youth incorrectly believed nicotine is the main substance that causes smoking-related cancer; youth also distinguish between the harmfulness of nicotine in different products, and rated the nicotine in cigarettes as most harmful, followed by e-cigarettes and NRT. Perceptions of the harm in different nicotine and tobacco products negatively predicted becoming a person who used tobacco a year later, but did not predict switching between e-cigarettes and cigarettes. Findings highlight the challenges of accurately communicating about the harms of nicotine without encouraging tobacco use; findings can be considered in the context of FDA's potential nicotine product standard that would lower nicotine levels in combustible tobacco products to a minimally or nonaddictive level.

Predicting tobacco product initiation from intentions to use: Comparing the validity of item analysis methods.

Items measuring tobacco use intentions are used to predict future use. Researchers combine items using different methods; however, no research has compared these methods' predictive validity. Here, we compare how well six methods of analyzing four intention items predict initiation of cigarettes, e-cigarettes, snus pouches, and other smokeless tobacco one year later. We analyzed youth and young adult never users from the US Population Assessment of Tobacco and Health Study. We compared six methods of analyzing Wave 3 intention items in predicting Wave 4 use: susceptibility scoring (susceptible is not answering "definitely no" to all items); dichotomizing the four-item average using two cut-points on the 1-4 response scale; and dichotomizing one item (next year use intention) with three cut-points. Analyses (1) tested whether each single-item predicted initiation; and (2) compared each method's (a) true positive rate (rate of correctly identifying future initiators), (b) true negative rate (rate of correctly identifying future non-initiators), and (c) model fit. Results were similar across products and age groups. Averaging items best predicted initiation in regression. Susceptibility scoring had the highest true positive rate but lowest true negative rate. False positives (incorrectly identifying someone as a future initiator) were best minimized by averaging items with a cutoff of 3, or using the single item with a 3 or 4 cutoff. Findings suggest researchers predicting tobacco use initiation using regression should average the four items; and researchers seeking to identify likely initiators should use different analytic methods depending on if they seek to maximize true positives or minimize false positives.

Absolute and Relative Smokeless Tobacco Product Risk Perceptions: Developing and Validating New Measures that are Up-to-Snuff.

INTRODUCTION: Tobacco risk perceptions impact behavior. Our 2018 systematic review of tobacco risk perception measures found no measures of smokeless tobacco (ST) risk perceptions with demonstrated validity and complete consistency with tobacco researcher recommendations (e.g. specifying use frequency). This study develops such measures to assess seven specific risk perceptions of market-leading ST products: absolute health and addiction risks, health and addiction risks relative to cigarettes, pregnancy health risks relative to cigarettes, health risks relative to nicotine replacement therapy, and health risks relative to tobacco cessation. METHODS AND RESULTS: We fielded 64 items assessing risk perceptions associated with tobacco in an online survey experiment (N = 2754) that tested effects of exposing participants to a modified risk claim on a leading ST product. Through reliability and validity analyses, we reduced this to 35 items representing seven constructs. Exploratory factor analyses indicated single-factor solutions for all but two constructs: absolute health risk and health risk relative to cigarettes, which were each represented by two-factors (respiratory and oral risks). Participants perceived respiratory risks differently than oral risks: a modified risk claim reduced ST relative respiratory risk perceptions but increased ST perceived oral risks. CONCLUSIONS: Absolute and relative risk perceptions were each represented by two factors that behaved differently, underscoring the utility of assessing respiratory and oral risk perceptions separately. These measures of seven risk perception constructs demonstrated some validity and can be used to assess perceptions of ST risk in future research, such as postmarket surveillance of tobacco products authorized for marketing by FDA. IMPLICATIONS: This study develops and validates publicly available measures of seven smokeless tobacco risk perception constructs: absolute health and addiction risks, health and addiction risks relative to cigarettes, pregnancy health risks relative to cigarettes, health risks relative to nicotine replacement therapy, and health risks relative to tobacco cessation. This study suggests that for both absolute and relative risk perceptions, risks of respiratory and oral health effects should be assessed separately, because these risk perceptions may be impacted differently by modified risk claims, and are differentially related to smokeless tobacco beliefs, use intentions, and current use.

Developing and Validating Measures of Absolute and Relative E-Cigarette Product Risk Perceptions: Single Items Can Be Surprisingly Comprehensive.

INTRODUCTION: Tobacco risk perceptions are important predictors of behavior and are impacted by tobacco communications. Our systematic literature review (completed in 2018) found there were no measures of e-cigarette risk perceptions that were completely consistent with tobacco researcher recommendations (eg, specifying use frequency) and had demonstrated validity and reliability. The current study develops measures to assess specific risk perceptions, including absolute risks and risks compared with cigarettes, nicotine replacement therapy, and all nicotine cessation. METHODS AND RESULTS: We generated a list of tobacco health effects based on our previous systematic review of tobacco risk perception measures. Based on health effects prioritized by regulatory science experts, we developed 63 items to assess seven types of e-cigarette risk perceptions: absolute health and addiction risks, health and addiction risks relative to cigarettes, pregnancy health risks relative to cigarettes, health risks relative to nicotine replacement therapy, and health risks relative to all nicotine cessation. We fielded these items in an online survey (N = 1642). Through reliability and validity analyses, we reduced this pool to 21 items, including many single-item measures. Supporting the measures' validity, each measure was negatively associated with current e-cigarette use, e-cigarette intentions, and skepticism about e-cigarette harms; and positively associated with perceiving e-cigarettes as equally or more harmful than cigarettes and intentions to quit e-cigarettes. DISCUSSION: This study developed and validated brief measures of several types of e-cigarette risk perceptions. Surprisingly, we found that for many types of risk perceptions, multi-item measures were redundant and these perceptions were well-represented by single-item measures. IMPLICATIONS: This study developed measures of seven types of e-cigarette health risk perceptions, including absolute health and addiction risk, and risk relative to cigarettes, nicotine replacement therapy, and cessation. We reduced 63 items to 21 to measure all of these constructs. These measures follow tobacco researcher recommendations, were developed using a rigorous measures development process, and demonstrated some aspects of reliability and validity. Because these measures are publicly available, they can be used by public health and industry researchers.

Adult perceptions of the relative harm of tobacco products and subsequent tobacco product use: Longitudinal findings from waves 1 and 2 of the population assessment of tobacco and health (PATH) study.

OBJECTIVES: To examine: (1) How perceptions of harm for seven non-cigarette tobacco products predict subsequent use; (2) How change in use is associated with changes in perceptions of product harm; (3) Whether sociodemographic variables moderate the association between perceptions and use. METHODS: Data are from the adult sample (18+) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal cohort survey conducted September 2013-December 2014 (Wave 1 (W1) n = 32,320) and October 2014-October 2015 (Wave 2 (W2) n = 28,362). RESULTS: Wave 1 users and non-users of e-cigarettes, filtered cigars, cigarillos, and pipes, who perceived these products as less harmful had greater odds of using the product at W2. For the other products, there was an interaction between W1 perceived harm and W1 use status in predicting W2 product use. At W2, a smaller percentage of U.S. adults rated e-cigarettes as less harmful than cigarettes compared to W1 (41.2% W1, 29.0% W2). Believing non-cigarette products to be less harmful than cigarettes was more strongly associated with subsequent product use in the oldest age group (55+ years) while weaker effects were observed in the youngest age group (18-24 years). This moderating effect of age was significant for e-cigarettes, hookah, traditional cigars, and cigarillos. CONCLUSIONS: Strategies to prevent initiation and promote cessation of these products may benefit from understanding and addressing perceptions of these products.

Poisoning exposure cases involving e-cigarettes and e-liquid in the United States, 2010-2018.

Introduction: Poisoning exposure cases involving e-cigarettes have increased since 2010, coinciding with increasing rates of e-cigarette use in the United States (US). Given the increasing prevalence of e-cigarette use and ever-changing product designs, particularly the development of new products with high nicotine levels, it is important to conduct ongoing surveillance of poisoning exposure cases involving e-cigarettes. The objective of this study is to describe trends and characteristics of poisoning exposure cases involving e-cigarettes and e-liquids reported to poison control centers in the US.Methods: We analyzed e-cigarette exposure cases from the National Poison Data System (NPDS) during 2010-2018 by year and other characteristics.Results: The annual number of e-cigarette exposure cases increased greatly between 2010 and 2014, reaching a peak of 3742 in 2014, and then decreasing each year between 2015 and 2017. Between 2017 and 2018, the overall number of e-cigarette exposure cases increased by 25.0% (from 2320 to 2901). Approximately two-thirds (64.8%) of all cases were in children under age five, and 14.7% were in children aged 5-17 years or young adults aged 18-24 years. A small proportion of cases developed life-threatening symptoms (0.1%); and cases with more serious medical outcomes tended to be exposed to a higher e-liquid or nicotine quantity.Conclusions: Annual declines in e-cigarette exposure cases between 2015 and 2017 did not continue in 2018. The rapid changes in the occurrence of poisoning exposure cases involving e-cigarettes coupled with the development of new tobacco products and ever-evolving tobacco use landscape underscore the importance of continued surveillance of these poisoning exposure cases. Continuous monitoring of these poisoning exposure cases may inform efforts aimed at preventing e-cigarette poisoning exposures.

A review of risk perception measurement in tobacco control research.

OBJECTIVE: To describe the characteristics of risk perception measures used in tobacco control research and to evaluate whether these measures incorporate measurement suggestions put forward by risk perception measurement scholars. DATA SOURCES: Three databases (PubMed, PsycINFO and Web of Science) were searched in March 2015 for published English language peer-reviewed articles measuring tobacco risk perceptions (n=2557). The search string included terms related to tobacco products, perceptions and risk. STUDY SELECTION: Three coders independently coded abstracts for initial inclusion. In total, 441 articles met the initial inclusion criteria, and 100 were randomly selected for a full-text review. DATA EXTRACTION: A codebook was developed and tested through a training phase. Three coders independently coded the characteristics of each article (eg, population), multi-item measure (eg, validity) and item (eg, likelihood, affect, health outcome). Fifty-four articles, 33 measures and 239 items were coded. DATA SYNTHESIS: Twenty-one articles had a multi-item risk perception measure, and 12 articles had one risk perception item. Many of the items asked about general health outcomes (36%), did not specify the person for whom risk was being judged (44%; eg, self, average person) or did not specify the conditions of use (27%; eg, the product used, intensity of use). CONCLUSIONS: There is little consistency across risk perception measures in tobacco research. There may be value in developing and disseminating best practices for assessing tobacco risk perceptions. A set of risk perception consensus measures may also benefit researchers in the field to help them consistently apply measurement recommendations.

Cigar package quantity and smoking behavior.

BACKGROUND: Several jurisdictions in the US and abroad limit the minimum number of cigars that can be sold per package. Research has not evaluated whether small packages might result in cigar use initiation, or whether adding cigars to packages might result in purchasers smoking more cigars. METHODS: Using nationally representative US adult data from Waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study, we assessed links between cigar package quantity (number of cigars in the package a person usually buys) and (1) price, and (2) cigar and cigarette use over time, for three cigar types: filtered cigars, cigarillos, and large cigars. RESULTS: Smaller quantity packages (i.e., packages with fewer cigars) were cheaper per-pack than larger quantity packages but more expensive per-stick for all three cigar types. For filtered cigars, past-year starters tended to buy smaller quantity packages compared to longer-term users (geometric mean = 6.31 vs. 11.75, respectively; b = -.18, 95%CI: -.32, -.04). Also, those who bought smaller quantity packages of filtered cigars tended to smoke fewer cigars over time compared to those who bought larger quantity packages (b = 1.16, 95%CI: 0.45, 1.87). Neither of these associations was observed for cigarillos or large cigars. We also found little evidence that buying larger quantity packages predicted continuing to use cigars or using cigarettes. CONCLUSIONS: Although we found consistent associations between package quantity and price, we found few associations between package quantity and changes in cigar smoking behaviors over time, particularly for cigarillos and large cigars. Key limitations include our adult-only analyses and inability to determine the package quantity that cigar users initiated with. Future studies could examine whether package quantity plays a causal role in filtered cigar use initiation or consumption rates.

Perceived relative harm of using e-cigarettes predicts future product switching among US adult cigarette and e-cigarette dual users.

BACKGROUND AND AIMS: People's perceptions of the harmfulness of e-cigarettes, compared with cigarettes, may influence their product use decisions. We tested if perceiving e-cigarettes as less harmful than cigarettes predicted whether cigarette and e-cigarette dual users switched their product use status 1 year later, becoming exclusive e-cigarette users, exclusive cigarette smokers, or non-users of both product types. DESIGN: Longitudinal analyses of waves 2 (2014-15) and 3 (2015-16) of the prospective, national Population Assessment of Tobacco and Health (PATH) Study. SETTING: United States. PARTICIPANTS: Adults who reported using both cigarettes and e-cigarettes within the past 30 days at wave 2 reported their perceptions of e-cigarette harm at wave 2, and reported whether they used cigarettes and e-cigarettes within the past 30 days at wave 3 (n = 2211). MEASUREMENTS: The key predictor was wave 2 perceptions of e-cigarette harm compared with cigarettes ('less harmful,' 'about the same', 'more harmful' or 'don't know'). The key outcome was wave 3 past 30-day use of e-cigarettes and cigarettes, classified into four categories: exclusive e-cigarette use (i.e. use of e-cigarettes but not cigarettes), exclusive cigarette smoking (i.e. use of cigarettes but not e-cigarettes), dual use of both product types and non-use of both product types. FINDINGS: At wave 2, 59.4% of dual users perceived e-cigarettes as less harmful than cigarettes [95% confidence interval (CI) = 56.9, 61.9]. Compared with those with other perceptions of e-cigarette harm, dual users who perceived e-cigarettes as less harmful than cigarettes were more likely to become exclusive e-cigarette users 1 year later [7.5 versus 2.7%; adjusted odds ratio (aOR) = 2.9, 95% CI = 1.7-4.8], more likely to remain dual users (39.6 versus 29.9%; aOR = 1.5, 95% CI = 1.2-1.8), less likely to become exclusive cigarette smokers (44.8 versus 59.4%; aOR = 0.6, 95% CI = 0.5-0.7) and similarly likely to become non-users of both product types (8.2 versus 8.0%; aOR = 1.1, 95% CI = 0.7-1.7). CONCLUSIONS: US adult dual users of e-cigarettes and cigarettes who perceive e-cigarettes as less harmful than cigarettes appear to be more likely to switch to exclusive e-cigarette use, more likely to remain dual users and less likely to switch to exclusive cigarette use 1 year later than dual users with other perceptions of e-cigarette harm.

Multi-item Measures of Tobacco Health Perceptions: A Review.

Objective: In this paper, we review multi-item measures of tobacco risk perceptions and health beliefs, describe the measures' content and quality, and identify measure development opportunities. Methods: We identified 110 articles that included measures assessing perceptions of tobacco's health effects by combining multiple items into a score. We coded measures' provenance (newly developed vs built on prior measures), content, consistency with risk-perception researcher recommendations (eg, specifying use conditions), samples used, and reliability and validity. Results: Most measures were newly developed or built on the Smoking Consequences Questionnaire. Few measures assessed perceptions of non-cigarette products, and some health harms rarely were assessed. Few measures specified product use conditions. Over half of studies assessed reliability, which was typically high. Most assessed validity by comparing scores by use status, finding mixed results. Conclusions: Several measures of cigarette risk perceptions included a range of health effects and demonstrated reliability and validity, though they had other shortcomings (eg, they did not specify conditions of use). Researchers could help address gaps in measuring tobacco health perceptions by developing quality consensus measures for non-cigarette products, assessing a range of perceived health effects, assessing perceptions relative to other products, specifying use conditions, and showing multiple types of validity in diverse subpopulations.

Youth perception of harm and addictiveness of tobacco products: Findings from the Population Assessment of Tobacco and Health Study (Wave 1).

PURPOSE: We provide a US national assessment of youth perceptions of the harm and addictiveness of six separate tobacco products, identifying a continuum of perceived harm associated with a range of products in relation to patterns of current use, former use, and susceptibility to use tobacco products. METHODS: We evaluated youth respondents (N = 13,651) ages 12-17 from Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) Study. Analyses (2015-2016) focused on refining measures of perceived harm for each product and delineating youth characteristics (demographic, tobacco use status) associated with beliefs about the harmfulness and addictiveness of tobacco products. RESULTS: Cigars, hookah and e-cigarettes were each perceived as having significantly lower harm (p's < 0.05) than smokeless products, with the lowest ratings of harmfulness and addictiveness observed for hookah and e-cigarettes (p's < 0.001). Incrementally lower levels of harm and addictiveness perceptions were observed among youth at increasing risk for tobacco use (p's < 0.05). CONCLUSIONS: Among U.S. youth, lower perceptions of harm and addictiveness of tobacco products were associated with susceptibility to use tobacco and patterns of tobacco product use. Future longitudinal assessments from the PATH Study can provide key information on youth development of perceptions of harm and addictiveness and influences on patterns of tobacco use.

Transitions in electronic cigarette use among adults in the Population Assessment of Tobacco and Health (PATH) Study, Waves 1 and 2 (2013-2015).

INTRODUCTION: This study assessed patterns of e-cigarette and cigarette use from Wave 1 to Wave 2 among adult e-cigarette users at Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. METHODS: We examined changes in e-cigarette use frequency at Wave 2 among adult e-cigarette users at Wave 1 (unweighted n=2835). Adjusted prevalence ratios (aPR) were calculated using a predicted marginal probability approach to assess correlates of e-cigarette discontinuance and smoking abstinence at Wave 2. RESULTS: Half (48.8%) of adult e-cigarette users at Wave 1 discontinued their use of e-cigarettes at Wave 2. Among dual users of e-cigarettes and cigarettes at Wave 1, 44.3% maintained dual use, 43.5% discontinued e-cigarette use and maintained cigarette smoking and 12.1% discontinued cigarette use at Wave 2, either by abstaining from cigarette smoking only (5.1%) or discontinuing both products (7.0%). Among dual users at Wave 1, daily e-cigarette users were more likely than non-daily users to report smoking abstinence at Wave 2 (aPR=1.40, 95% CI 1.02 to 1.91). Using a customisable device (rather than a non-customisable one) was not significantly related to smoking abstinence at Wave 2 (aPR=1.14, 95% CI 0.81 to 1.60). CONCLUSIONS: This study suggests that e-cigarette use patterns are highly variable over a 1-year period. This analysis provides the first nationally representative estimates of transitions among US adult e-cigarette users. Future research, including additional waves of the PATH Study, can provide further insight into long-term patterns of e-cigarette use critical to understanding the net population health impact of e-cigarettes in USA.

How tobacco companies have used package quantity for consumer targeting.

INTRODUCTION: Package quantity refers to the number of cigarettes or amount of other tobacco product in a package. Many countries restrict minimum cigarette package quantities to avoid low-cost packs that may lower barriers to youth smoking. METHODS: We reviewed Truth Tobacco Industry Documents to understand tobacco companies' rationales for introducing new package quantities, including companies' expectations and research regarding how package quantity may influence consumer behaviour. A snowball sampling method (phase 1), a static search string (phase 2) and a follow-up snowball search (phase 3) identified 216 documents, mostly from the 1980s and 1990s, concerning cigarettes (200), roll-your-own tobacco (9), smokeless tobacco (6) and 'smokeless cigarettes' (1). RESULTS: Companies introduced small and large packages to motivate brand-switching and continued use among current users when faced with low market share or threats such as tax-induced price increases or competitors' use of price promotions. Companies developed and evaluated package quantities for specific brands and consumer segments. Large packages offered value-for-money and matched long-term, heavy users' consumption rates. Small packages were cheaper, matched consumption rates of newer and lighter users, and increased products' novelty, ease of carrying and perceived freshness. Some users also preferred small packages as a way to try to limit consumption or quit. CONCLUSION: Industry documents speculated about many potential effects of package quantity on appeal and use, depending on brand and consumer segment. The search was non-exhaustive, and we could not assess the quality of much of the research or other information on which the documents relied.

Harm Perceptions of Intermittent Tobacco Product Use Among U.S. Youth, 2016.

PURPOSE: We aimed to describe U.S. youth harm perceptions of intermittent tobacco use. METHODS: Using data from the 2016 National Youth Tobacco Survey of U.S. students (grades 6-12; N = 20,675), we examined prevalence and correlates of all respondents' perceived harm of using four different tobacco products on "some days but not every day." Associations between current (past 30-day) use and harm perceptions were assessed using multivariable regression. RESULTS: Perceiving that intermittent use causes "no" or "little" harm was 9.7% for cigarettes, 12.0% for smokeless tobacco, 18.7% for hookah, and 37.5% for e-cigarettes. Compared with those who reported "a lot" of harm, youth with lower harm perceptions were more likely to report current use. CONCLUSIONS: One in ten youth perceived intermittent cigarette smoking as causing "little" or "no" harm; this perception was higher among current users. Efforts to educate youth about the risks of even intermittent tobacco product use could reduce misperceptions of harm.

US Adult Interest in Less Harmful and Less Addictive Hypothetical Modified Risk Tobacco Products.

Introduction: Tobacco companies have a history of making health claims about their new products. Such claims are now regulated by the US Food and Drug Administration. We examined consumer interest in hypothetical modified risk tobacco products (MRTPs) among current, former, and never established smokers and examined whether interest was associated with beliefs about tobacco and cancer. Methods: Data were analyzed from the US nationally representative 2015 Health Information National Trends Survey (HINTS-FDA 2015; N = 3738). Interest in hypothetical MRTPs was assessed by asking participants their likelihood of using tobacco products claiming to be less addictive and less harmful than other products. Results: About half of current smokers and a tenth of both former and never smokers reported they were "somewhat" or "very" likely to try hypothetical MRTPs claiming to be less harmful or less addictive. Female smokers, former smokers with lower smoking harm perceptions, and never smokers who are young adults or without college education expressed more interest in these products. Interest in using these products was positively associated with believing that smoking status is a changeable individual characteristic and that it is possible for tobacco products to be made without some harmful chemicals. Conclusion: We identified several subgroups of current, former, and never smokers who may be particularly affected by the marketing of MRTPs and therefore important to study to inform models of the potential population health impact of authorizing the marketing of MRTPs. Implications: Findings about interest in hypothetical MRTPs can inform models of how the marketing of MRTPs could affect population health. Understanding which subgroups are particularly interested in MRTPs can help determine who might be important to study to inform these models. We identified several groups who may warrant specific attention: smokers who are female, former smokers who hold low harm perceptions of smoking, never smokers who are young adults or have a high school education or less, people who believe that smoking is a changeable individual characteristic, and people who believe that it is possible to make low chemical tobacco products.

US Consumers' Understanding of Nutrition Labels in 2013: The Importance of Health Literacy.

INTRODUCTION: We examined US adults' understanding of a Nutrition Facts panel (NFP), which requires health literacy (ie, prose, document, and quantitative literacy skills), and the association between label understanding and dietary behavior. METHODS: Data were from the Health Information National Trends Survey, a nationally representative survey of health information seeking among US adults (N = 3,185) conducted from September 6, 2013, through December 30, 2013. Participants viewed an ice cream nutrition label and answered 4 questions that tested their ability to apply basic arithmetic and understanding of percentages to interpret the label. Participants reported their intake of sugar-sweetened soda, fruits, and vegetables. Regression analyses tested associations among label understanding, demographic characteristics, and self-reported dietary behaviors. RESULTS: Approximately 24% of people could not determine the calorie content of the full ice-cream container, 21% could not estimate the number of servings equal to 60 g of carbohydrates, 42% could not estimate the effect on daily calorie intake of foregoing 1 serving, and 41% could not calculate the percentage daily value of calories in a single serving. Higher scores for label understanding were associated with consuming more vegetables and less sugar-sweetened soda, although only the association with soda consumption remained significant after adjusting for demographic factors. CONCLUSION: Many consumers have difficulty interpreting nutrition labels, and label understanding correlates with self-reported dietary behaviors. The 2016 revised NFP labels may address some deficits in consumer understanding by eliminating the need to perform certain calculations (eg, total calories per package). However, some tasks still require the ability to perform calculations (eg, percentage daily value of calories). Schools have a role in teaching skills, such as mathematics, needed for nutrition label understanding.

Patterns of Use of Smokeless Tobacco in US Adults, 2013-2014.

OBJECTIVES: To examine patterns of smokeless tobacco (SLT) use, by type, in wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study in the United States. METHODS: We analyzed data from 32 320 adults (aged ≥ 18 years) to assess the use of pouched snus and other SLT products (loose snus, moist snuff, dip, spit, and chewing tobacco). RESULTS: Overall, SLT use was most common among men, younger adults, non-Hispanic Whites, and nonurban respondents. Pouched snus users were more likely to report nondaily and polytobacco use than users of other SLT products. Respondents who used SLT some days were more likely to be current established cigarette smokers than those who used SLT every day (57.9% vs 20.2%). Furthermore, current established smokers who used SLT some days were more likely to smoke every day and had a higher median number of cigarettes smoked per day than smokers who used SLT every day. CONCLUSIONS: Polytobacco use, especially cigarette smoking, is common among SLT users. Pouched snus users are more likely to report nondaily snus use and polytobacco use than users of other SLT products.

Measuring youth beliefs about the harms of e-cigarettes and smokeless tobacco compared to cigarettes.

This study examined validity of direct and indirect measures of perceived harm of e-cigarettes and smokeless tobacco (SLT) compared to cigarettes. On direct measures, people compare one product to another, whereas on indirect measures, people rate each product separately and the researcher compares these ratings. Data from youth in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014) were analyzed (N=13,651 youth aged 12-17years). The study included direct measures of perceived harm of e-cigarettes and SLT compared to cigarettes, and indirect measures were created by comparing ratings of the products. Weighted multinomial logistic regressions tested criterion validity by assessing whether direct and indirect measures were associated with criterion variables, including use of e-cigarettes and SLT. Youth were more likely to rate e-cigarettes as less harmful than cigarettes on the indirect measure (67.3%) than the direct measure (50.2%). The same pattern held for ratings of SLT as less harmful than cigarettes (indirect: 29.7%; direct: 11.7%). Direct measures explained unique variance in product use criterion variables even after adjusting for indirect measures, as did indirect measures after adjusting for direct measures. However, the criterion variables were more often associated with the direct measures than the indirect measures. Results offer preliminary support for using both direct and indirect measures when assessing youth's perceived relative harm of various types of products. However, if researchers cannot include both direct and indirect measures in a study, associations with product use criterion variables support prioritizing direct measures.

Criterion validity of measures of perceived relative harm of e-cigarettes and smokeless tobacco compared to cigarettes.

Beliefs about the relative harmfulness of one product compared to another (perceived relative harm) are central to research and regulation concerning tobacco and nicotine-containing products, but techniques for measuring such beliefs vary widely. We compared the validity of direct and indirect measures of perceived harm of e-cigarettes and smokeless tobacco (SLT) compared to cigarettes. On direct measures, participants explicitly compare the harmfulness of each product. On indirect measures, participants rate the harmfulness of each product separately, and ratings are compared. The U.S. Health Information National Trends Survey (HINTS-FDA-2015; N=3738) included direct measures of perceived harm of e-cigarettes and SLT compared to cigarettes. Indirect measures were created by comparing ratings of harm from e-cigarettes, SLT, and cigarettes on 3-point scales. Logistic regressions tested validity by assessing whether direct and indirect measures were associated with criterion variables including: ever-trying e-cigarettes, ever-trying snus, and SLT use status. Compared to the indirect measures, the direct measures of harm were more consistently associated with criterion variables. On direct measures, 26% of adults rated e-cigarettes as less harmful than cigarettes, and 11% rated SLT as less harmful than cigarettes. Direct measures appear to provide valid information about individuals' harm beliefs, which may be used to inform research and tobacco control policy. Further validation research is encouraged.

A Most Odd Ratio:: Interpreting and Describing Odds Ratios.

INTRODUCTION: The OR is one of the most commonly used measures of association in preventive medicine, and yet it is unintuitive and easily misinterpreted by journal authors and readers. METHODS: This article describes correct interpretations of ORs, explains how ORs are different from risk ratios (RRs), and notes potential supplements and alternatives to the presentation of ORs that may help readers avoid confusion about the strength of associations. RESULTS: ORs are often interpreted as though they have the same meaning as RRs (i.e., ratios of probabilities rather than ratios of odds), an interpretation that is incorrect in cross-sectional and longitudinal analyses. Without knowing the base rate of the outcome event in such analyses, it is impossible to evaluate the size of the absolute or relative change in risk associated with an OR, and misinterpreting the OR as an RR leads to the overestimation of the effect size when the outcome event is common rather than rare in the study sample. In case-control analyses, whether an OR can be interpreted as an RR depends on how the controls were selected. CONCLUSIONS: Education, peer reviewer vigilance, and journal reporting standards concerning ORs may improve the clarity and accuracy with which this common measure of association is described and understood in preventive medicine and public health research.