Development and Assessment of Nicotine Continuum of Risk Education on Tobacco Use Among Lower Income Adults

Virginia Commonwealth University, Richmond VA

Investigators

Abstract

Adults with lower income are at increased risk of heavy smoking, face reduced cessation success, and bear a heavy burden of smoking-attributable morbidity and mortality. For adults who are not yet ready or able to quit smoking, switching to a lower harm, non-combustible nicotine product could reduce exposure to smoke from combustible cigarettes. However, smokers who are not yet ready or willing to quit nicotine use completely are less likely to switch products without understanding that the health risks of nicotine-containing products are not identical but lie along a continuum of risk (COR), where combustible products are most harmful and noncombustible products less harmful. Studies have identified a general lack of knowledge about the relative risks of nicotine-containing products across the population, and evidence suggests that low-income adults may be least knowledgeable. There is still a lack of evidence about COR perceptions among low-income smokers, the effectiveness of educational messages designed to boost COR knowledge, and whether increasing COR knowledge may impact intentions to switch products and reduce combustible product use. This proposal aims to 1) use qualitative methods to assess COR perceptions among low-income smokers, 2) design and test candidate COR educational messages, and 3) investigate the effects of exposure to COR educational messages on COR knowledge, intentions to switch from combustible to noncombustible products, and reductions in combustible product use among low-income smokers. A comprehensive training plan will ensure successful execution of these aims, with four overall goals for the PI during the training period: 1) proficiency in qualitative research methodology, 2) acquire expertise in clinical trial administration, leadership, and methodology, 3) acquire expertise in advanced statistical methods to evaluate the effects of interventions, and 4) develop expertise in designing, optimizing, and testing health communications. Training will be guided by a team of expert mentors with complementary areas of expertise and current, strong collaborative relationships with one another. This research and training will also be supported by the strong training environment at Virginia Commonwealth University, and prepare the PI to successfully lead independent studies focused on reducing the harms of tobacco and other substance use. Modified Specific Aims People with lower income and/or lower educational attainment have more difficulty quitting smoking and high rates of smoking-related morbidity and mortality. While “no tobacco product is safe”, the FDA’s Center for Tobacco products (CTP) recognizes that tobacco products lie along a continuum of risk (COR), with combusted cigarettes being the most harmful to health. Low-income smokers are less likely to accurately perceive the relative health risks of combusted versus non-combusted products than other smokers and are more likely to incorrectly attribute much of the health harm associated with smoking to nicotine. Further, low-income adults who smoke are less likely to use medicinal nicotine or alternative, non-combusted nicotine products, such as electronic cigarettes (e-cigarettes). While educational campaigns about health risks posed by nicotine and tobacco products have been developed, none have focused on low-income adults, who have higher prevalence of smoking. They also have not delivered comprehensive COR information, nor examined whether increasing COR knowledge will result in behavior change among low-income adults. It is essential to specifically assess COR message effectiveness among low-income adults, not only because of their increased risk of tobacco-related disease, but because they face different tobacco marketing environments and advertising than higher-income adults. Studies have examined the effectiveness of general population smoking cessation campaigns, finding that such campaigns may be less effective among low-income adults, particularly in the absence of complementary tobacco control programs or incentives. The inability of current public health education campaigns to increase knowledge about the health risks posed by nicotine and tobacco products among low-income adults is a critical gap that must be addressed. Consistent with FDA CTP’s stated goal of “educating adults who smoke about the relative risks of tobacco products,” this K01 seeks to answer a critical, unanswered question: does increasing the accuracy of perceptions about the continuum of risk (COR) for tobacco products hold promise for reducing the health harms from smoking combusted cigarettes among low-income adults? Phase 1: Develop, test, and refine nicotine COR educational messages to increase accuracy of nicotine/tobacco risk perceptions. We will conduct qualitative interviews with low-income adults who smoke (n=30) to inform the development of a set of relative risk messages. Next, we will use an iterative series of online population studies to refine and test candidate messages varying in content and design attributes, to identify those most likely to be effective in increasing the accuracy of perceptions of the risks of combustible and non-combustible tobacco products among low-income smokers. Aim 1: Assess accuracy of relative risks of combustible and noncombustible nicotine products among low-income adults who smoke and develop 30 COR candidate messages. Aim 2: Optimize candidate COR educational messages developed in Aim 1 via an iterative series of 3 online population studies conducted among low-income adults who smoke (n=500 per study). Refine messages (e.g., content, design, delivery) based on participants’ assessments of the credibility, likeability, and perceived effectiveness of candidate messages. Identify the 4-6 most effective messages to form a final COR messaging module. Phase 2: Investigate the effects of exposure to COR educational messages on nicotine/tobacco risk perceptions and tobacco use behavior. It is crucial to examine the effects of messages on behavior in addition to perceptions and intentions. We will recruit 60 low-income smokers to participate in a pilot randomized controlled trial testing the effects of COR messaging on perceptions, intentions, and use behaviors. After a one-week baseline in which they can purchase their usual brand (UB) cigarettes via a tobacco marketplace, participants will be randomized 1:1 to exposure to the COR messages developed during Phase 1 or control messages. Starting in Week 2, all participants will have access to UB cigarettes, medicinal nicotine products, and noncombustible products in the tobacco marketplace for two weeks. We will assess effects of messaging on product perceptions, use intentions, and reductions in smoking. We will conduct brief qualitative exit interviews to assess reasons for use among participants who purchased any non-UB products. Aim 3a: Test the hypothesis that exposure to COR messaging will increase the accuracy of risk perceptions, increase switch intentions, and reduce cigarettes smoked per day compared to controls. Aim 3b: Examine reasons for alternative product use among study participants. Hypothesis: COR messaging exposure will increase health reasons for trying alternative products compared to controls. Formal training in qualitative research methods, health communications and clinical trials design will build on the applicant’s prior media, policy, and econometric training, resulting in expertise in the underlying principles essential to delivering complex, targeted health communications. This research will inform an R01 proposal focused on effective use of health communication campaigns to reduce smoking and related health risks among adults who use combusted tobacco products.