Read more about our ongoing research, as well as studies already completed.
Project lead: Jinha Kim
Previous research and available theory show that pro and con beliefs created by cigarette ads mediate the impact on attitudes and intentions. Typically, this mediated sequence is based on statistically sound patterns. But a statistical pattern of causality to outcomes is causally weak due to lack of random assignment at the mediator phase. To establish the causal sequence from the belief-as-mediator to the outcomes, this study utilizes the parallel encouragement (PE) design which randomly assigns subjects to take a particular value of the mediator by manipulating the mediator instead of only measuring the mediator as in the conventional approach. Establishing belief as an actual causal mediator and not just a statistical mediator is crucial in designing public health interventions that focus on manipulating actual causes rather than ones that are actually effects.
The PE design in this study was carried out by subtly manipulating the expected mediator after exposure to Natural American Spirit (NAS) ads. Manipulation of the expected mediator was through a simple reaction time word task. Positive and negative words ‘encourage’ beliefs in different directions without directly evoking thoughts about NAS cigarettes. The words used in the game were based on 1) thematic relevance and non-relevance to beliefs known to be mediators of NAS ad content, and 2) valence in connotation. Then, these words were combined in different ratios by word types to constitute each of 2 (relevance - relevant vs non-relevant) x 3 (valence - balanced vs positive vs negative) encouragement treatment conditions. After viewing the ad, 1,403 current and former smokers were randomly assigned to one of these 6 encouragement conditions or the control (similar reaction task identifying word vs non-word).
After the encouragement manipulation, beliefs, attitudes, and intentions regarding NAS cigarettes were assessed. For former smokers, results so far show no effects of “tweaking” on the mediational role of beliefs. For smokers, beliefs exhibit a causal mediation between ad claims and intentions to try NAS cigarettes. Tweaking through word identifications using words relevant to the false beliefs produced evidence of causal mediation.
FDA graphic warning labels
Project lead: Nathan Silver
This pilot project aims to examine the role of avoidance inducing message characteristics on the new FDA pictorial warning labels to increase recall and recognition of lesser known smoking consequences highlighted by the labels. Participants viewed 11 warning labels of different health effects of smoking — amputation, bladder cancer, diabetes, cataracts, COPD, fetal growth, heart disease, child harm, macular degeneration, neck cancer, erectile dysfunction. For each health effect, they were randomized to view one of four warnings — a text-only warning or a graphic warning using a low, medium, or high avoidance image. Each warning was viewed by 240-266 participants.
Replication of the unintended effects study
Project lead: Jennifer Morgan
This study aims to use data from a warning label study to replicate the finding that exposure to higher avoidance tobacco warnings increases intentions to use non-cigarette tobacco products (NCTPs). Participants viewed 11 warning labels different health effects of smoking — amputation, bladder cancer, diabetes, cataracts, COPD, fetal growth, heart disease, child harm, macular degeneration, neck cancer, erectile dysfunction. For each health effect, they were randomized to view one of four warnings — a text-only warning or a graphic warning using a low, medium, or high avoidance image. Each warning was viewed by 240-266 participants.
Novelty, exposure, and acceptance (a.k.a. the truthiness study)
Project lead: Jennifer Morgan
Modified risk tobacco products (MRTPs) are new to the tobacco product marketplace and, as a result, the claims made about such products are novel. This study is looking at mechanisms through which the public comes to accept (or not) unfamiliar health information about novel tobacco projects. As unfamiliar tobacco products and claims about them are introduced, it’s important for tobacco control efforts to understand the process through which novel beliefs are formed and accepted or rejected.
‘Netography’ of MRTP beliefs
Project lead: Jennifer Morgan
A review of the published literature, government documents, web content from companies, news articles and comments on news articles, and social media posts identified 104 beliefs about products with the potential to be designated as modified risk tobacco products. We grouped these beliefs into similar categories and tested 15 beliefs in a national survey.
MRTP beliefs survey
Under US law, tobacco products may be authorized to claim lower exposure to chemicals, or lower risk of health harms. We sought to examine the harm perceptions and beliefs about potential modified risk tobacco products (MRTPs). We recruited 864 adult current and former smokers in August 2019. Participants read a paragraph describing the potential for the FDA to authorize MRTPs and a brief description of MRTPs. The most endorsed beliefs for each product were that they contained nicotine and that they were risky. Believing that e-cigarettes can help smokers quit smoking, that they tasted good, and looked cool were associated with greater odds of intending to try e-cigarettes after controlling for demographic and use factors. For snus, the beliefs that the product was not addictive and tasted good were associated with increased odds of intending to try snus. The beliefs that heated tobacco would taste good and would be a good quit aid was associated with increased odds of intentions to try heated tobacco products. Understanding what the public believes about products currently or potentially authorized to be marketed as modified risk tobacco products can inform communication efforts.
E-cigarette beliefs after EVALI
Project lead: Jennifer Morgan
Exposure to media content can shape public opinions about tobacco. In early September 2019, the outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI) became headline news in the United States. In August and September 2019, we conducted two cross-sectional online surveys with current and former smokers assessing attitudes and beliefs about e-cigarettes. Study one (n=865) was collected before the EVALI outbreak was widely covered and study two (n=344) was collected after the outbreak had become nation-wide news. We examined differences in perceptions and beliefs between time points. E-cigarette harm perceptions increased between study one (mean=2.67) and study two (mean=2.90, p<.05). Ever-users of e-cigarettes largely account for this change. Endorsement of the belief that e-cigarettes were risky and more likely to cause lung damage compared to cigarettes increased between studies (p<.05). Seventy eight percent of participants at study two were aware of the vaping illness story. Being aware of the story was associated with more endorsement of the belief that e-cigarettes were risky to use, but not that using e-cigarettes would make the participant more likely to get damaged lungs. When the stories about the health and safety of tobacco products dominate the public information environment, it presents an opportunity to change beliefs that are frequently targeted by paid health campaigns. Changes in participant’s perceptions of e-cigarettes were associated with coverage of this large news story, underscoring the importance of working to ensure that coverage is a scientifically accurate as possible.
Natural American Spirit inoculation
Project lead: Stefanie Gratale
Misinformation is a growing concern in the public health realm, as it is persistent and difficult to correct. One strategy recently considered to address misinformation is “inoculation,” which leverages forewarning and refutation to defend against a subsequent persuasive message. We assessed whether we can use inoculation to forestall implicitly arising misinformation such as that from misleading natural cigarette ads, which have been shown to prompt widespread misbeliefs. Three randomized online experiments assessed inoculation against misinformation. The first study tested inoculation tactics to determine whether particular message formats are more effective (i.e., exemplar, narrative, or exposition), and to assess whether inoculations must refute the exact arguments from the misinformation or can more generally match argument themes. The second study tested an attenuated generic versus a specific refutation, and explored results over time. The final study focused on a particular inoculation strategy — highlighting prior deceptive messaging by the persuasive source. Results indicate that inoculations can successfully defend against misinformation from misleading ads; further, they do not need to match exact arguments or even exact themes from the arguments in order to reduce misbeliefs. In fact, high level, generic refutations successfully reduced misbeliefs both immediately and with a time delay, and, crucially, so too did inoculations that included an explicit forewarning but only an implicit refutation. Furthermore, multiple inoculation message formats were successful, and the effectiveness of inoculations was enhanced, to a limited degree, by identifying prior deceptive messaging by the persuasive source. Finally, findings supported counterarguing as a potential mediator of effects of inoculation messages on misbeliefs. The significance of the results here lies in their support for key inoculation components — forewarning and refutation — as well as the much-hypothesized mechanism of counterarguing, when attempting to combat misinformation. The core contribution of these studies is the consistent finding that we can successfully inoculate against implicit misinformation without directly addressing the exact misinformation claims, which is particularly important with implicitly arising, often difficult-to-anticipate misbeliefs from misleading advertising.
- Gratale SK, Maloney EK, Cappella JN. Regulating language, not inference: an examination of the potential effectiveness of Natural American Spirit advertising restrictions. Tob Control. 2019;28(e1):e43-e48.
- Gratale SK, Sangalang A, Maloney EK, Cappella JN. Attitudinal Spillover from Misleading Natural Cigarette Marketing: An Experiment Examining Current and Former Smokers' Support for Tobacco Industry Regulation. Int J Environ Res Public Health. 2019;16(19):3554. Published 2019 Sep 23.
- Gratale SK, Maloney EK, Sangalang A, Cappella JN. Influence of Natural American Spirit advertising on current and former smokers' perceptions and intentions. Tob Control. 2018;27(5):498-504.
- Gratale S. Dismantling the art of deception: Using "inoculation" to combat misinformation from misleading cigarette advertising. [Order No. 28088348]. University of Pennsylvania; 2020.
Unintended effects of effective warning labels on MRTP use intentions
Project lead: Jennifer Morgan
Graphic cigarette warnings increase quit attempts. Perceived message effectiveness and message avoidance are predictive of later quit attempts. We sought to examine whether randomized exposure to warning messages would inadvertently increase intentions to use alternate tobacco products (ATPs) while enhancing attempts to quit cigarettes. An online survey of 1,392 adult smokers in the US asked participants to rate six randomly selected tobacco warnings (from a set of 319) on perceived effectiveness and avoidance intentions. These two indicators of message effectiveness were calculated at the message-level and then at the individual campaign-level to facilitate causal inference. After viewing a message campaign of six warning messages, participants indicated their intentions to use ATPs. 68% of participants reported some intention to use e-cigarettes and intentions to use other ATPs ranged from 31% to 40%. Campaigns of messages eliciting higher avoidance increased the odds of intending to use hookah (aOR:4.32), smokeless tobacco (aOR:4.88), and snus (aOR:8.06), but not the intention to use electronic cigarettes. These relationships are mediated by intentions to quit smoking (all p<.05). Viewing campaigns with higher campaign-level perceived effectiveness increased the intentions to quit, which in turn increased intentions to try alternate tobacco products. Our findings increase the tobacco control community’s understanding of unintended consequences of graphic tobacco warnings.
COVID-19 and tobacco
Project lead: Nathan Silver
Recent studies have shown that smoking poses an increased risk of complications from COVID-19. The potential danger to smokers due to compromised lung health and immune function may be an incentive to reduce smoking or quit altogether. On the contrary, economic and social impact of the pandemic could spur tobacco use. The primary objective of this study, therefore, is to understand the impact of the pandemic on cigarette smokers and vapers using social media data on Reddit. To examine the online discussion content between smokers during the progression of the COVID-19 pandemic, a total of 63,083 posts from smoking and vaping related sub-reddits were analyzed from December 31, 2019 to May 25, 2020. Posts were content analyzed for discussions related to COVID only, quitting only and both after conducting keyword searches. Topic modeling was used to identify latent topics/themes using Latent Dirichlet Allocation (LDA). Overall, posts about quitting saw an increase in mid to late March, coinciding with the time of COVID outbreak and lockdown announcements. Among cigarette smokers, the majority of posts discussing COVID are in the context of quitting smoking. The trend among vapers is quite the opposite; a very small portion of the COVID posts on vaping subreddits were about quitting. Topic modeling revealed that COVID-19 related posts centered around four major themes: News and current events, status updates, personal experiences, and vaping product information. COVID-19 appears to play dual roles in both motivating quitting behaviors while also exacerbating challenges to quitters. Moreover, though smokers appear aware of their heightened risk of severe complications from COVID-19 infection, vapers display both opposition and indignance with regards to a connection between vaping and COVID-19 complications. Our findings suggest among other things that the concerns and struggles of vapers and smokers in response to COVID-19 are quite different. These differences necessitate different messaging strategies and interventions to inform and persuade both parties to reduce or quit consumption to protect against severe complications from COVID-19.