Nicotine & Tobacco Research Advance Access published October 12, 2015 Nicotine & Tobacco Research, 2015, 1–8 doi:10.1093/ntr/ntv223 Original investigation
Original investigation
The Effects of Brief Waterpipe Tobacco Use Harm and Addiction Education Messages Among Young Adult Waterpipe Tobacco Users Darren Mays PhD, MPH1, Kenneth P. Tercyak PhD1, Isaac M. Lipkus PhD2 Downloaded from http://ntr.oxfordjournals.org/ at University of Newcastle on March 15, 2016
Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC; 2Duke University School of Nursing, Durham, NC
1
Corresponding Author: Darren Mays, PhD, MPH, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street NW, Suite 4100, Washington, DC 20007, USA. Telephone: 202-687-8937; Fax: 202-687-8444; E-mail: [email protected]
Abstract Introduction: This study investigated the immediate effects of brief education messages delivered online about harms and addictiveness of waterpipe tobacco use among young adult waterpipe users aged 18 to 30 years. Methods: Participants (n = 327, mean age 24.8 years, 62.1% male, 77.6% white, 67.8% used waterpipe monthly, 26.4% weekly, 5.8% daily) were recruited online and randomized to one of three experimental conditions: (1) Control condition viewing no messages; (2) Harms condition viewing messages about harms of waterpipe tobacco; (3) Harms and addiction condition viewing messages about harms and addictiveness of waterpipe tobacco. Outcomes included perceived harm and addictiveness of waterpipe, worry about harm and addiction, and desire to quit. Results: Compared to the control condition, participants in the harms condition reported significantly greater perceived harm and addictiveness of waterpipe relative to cigarettes, perceived risk of harm and addiction, worry about harm and addiction, and desire to quit. There were few significant differences in these outcomes between participants in the harms condition and the harms and addiction condition. Mediation analyses suggest waterpipe tobacco use harm messages may increase desire to quit by producing greater worry about harm and addiction. Conclusions: Brief education messages about waterpipe tobacco use harm increased young adult’s perceptions of harm and addictiveness of waterpipe tobacco use and generated stronger desire to quit. The waterpipe tobacco use addiction messages tested had little added impact. Studies should prospectively examine the real-world impact of waterpipe tobacco use harm messages and investigate more effective strategies for designing addiction messages. Implications: This study demonstrates that brief education messages about waterpipe tobacco use harm can increase young adult waterpipe tobacco user’s perceptions of harm and addictiveness of waterpipe tobacco use and generate stronger desire to quit. The findings indicate messages on addictiveness of waterpipe tobacco use have no added impact on these outcomes.
Introduction Waterpipe tobacco use among young adults is a public health concern globally1 and in the United States.2 Prevalence estimates of current
waterpipe tobacco use among young adults range from 8.8% to 18.2% depending upon the sampling frame, definition of current use (eg, past month, past year), and other factors.3–5 Young adulthood is
© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
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perceived risk (ie, likelihood) of harm and addiction from waterpipe tobacco use, worry about harm and addiction from waterpipe tobacco use, and desire to quit using waterpipe tobacco would be greater among young adults in the harms and harms and addiction conditions than the control condition, with the strongest effect in the harms and addiction condition. In mediation analyses we also examined whether the effect of education messages on desire to quit using waterpipe tobacco may be explained by differences across experimental conditions in perceived risk and worry about harms and addictive potential of waterpipe tobacco use.
Methods Setting and Sample Participants were recruited in February 2015 through Amazon Mechanical Turk, a crowdsourcing Internet marketplace26 that has been used in similar studies of tobacco use27–29 and other behaviors.30,31 All screening, enrollment, and data collection occurred at a single time point through a series of steps. After a brief description of the study, Amazon Mechanical Turk members residing in the United States who were interested in participating reviewed a complete study description with a link to a consent form and eligibility screener. Individuals 18 to 30 years of age who reported using waterpipe tobacco in the past 30 days were eligible to participate. Eligibility criteria were assessed using screening questions from population-based surveys.3 Eligible, consenting participants proceeded immediately to the online experiment. Participants completing all study procedures were given a small monetary credit through Amazon Mechanical Turk. Study procedures were approved by the Georgetown University Institutional Review Board.
Procedures Before randomization, participants answered initial questions about demographics, waterpipe tobacco use, and use of other tobacco products. Then, using an algorithm embedded in the online survey software participants were randomized in equal numbers to one of three conditions: (1) control; (2) harms; or (3) harms and addiction. Participants in the control condition completed measures only immediately after randomization. Participants in the harms and harms and addiction conditions viewed education messages immediately after randomization and then completed remaining study measures. Participants randomized to harms condition viewed educational messages about harms of waterpipe tobacco use; those randomized to the harms and addiction condition viewed the same messaging about harms of waterpipe tobacco plus additional content on addictiveness of waterpipe tobacco use. All education messages were evidence-based, developed from research surrounding waterpipe tobacco use and adapted from a prior study that tested a waterpipe tobacco education intervention.25 As in a previous study,25 to emphasize the evidence-based nature of the content messages were followed by a list of supporting scientific references. Pilot content was pretested with a sample of 46 young adult waterpipe tobacco users recruited using the methods described above. Pilot participants rated the messages favorably, with suggestions to incorporate graphics and imagery to enhance visual appeal of the messages (eg, depictions of health effects). Pilot message content was revised based on this feedback for the experiment. Participants randomized to the harms condition viewed a presentation consisting of four slides describing potential health harms
Downloaded from http://ntr.oxfordjournals.org/ at University of Newcastle on March 15, 2016
a period when nonusers often initiate waterpipe tobacco use,6–8 and waterpipe tobacco use during adolescence and young adulthood has been associated with more than a twofold increase in the likelihood of initiating cigarette smoking and progressing to regular cigarette smoking in the future.9 Although waterpipe tobacco use is typically intermittent (eg, weekly, monthly),10–13 these patterns of use can lead to health harms and addiction. A typical waterpipe tobacco smoking session exposes users to markedly higher levels of toxicants than smoking a single cigarette,2,14 and waterpipe tobacco use is associated with acute (eg, increased heart rate and blood pressure, impaired pulmonary function, infection) and chronic (eg, bronchitis, emphysema, heart disease) health effects.15 Nicotine exposure through waterpipe tobacco use also produces addiction symptoms, including unsuccessful quit attempts and withdrawal.16–18 Among young adults perceptions that waterpipe tobacco is less harmful and less addictive than cigarette smoking are associated with current use11,19–21 and initiation among nonusers.6 Consistent with health behavior change theories (eg, value-expectancy models22,23), these inaccurate beliefs may promote waterpipe tobacco use among young adults and deter quitting. Thus, education interventions that correct misperceptions about risks of harm and addiction may motivate quitting.20,24 One recent experimental study found that educating college student waterpipe tobacco users about exposure to harmful toxicants in waterpipe tobacco smoke and associated health harms increased their perceptions of harms and addictiveness of waterpipe tobacco use and strengthened their desire to quit.25 Changes in perceived risk of harm and addictiveness of waterpipe tobacco use mediated the effects of the interventions on desire to quit.25 However, this study tested somewhat lengthy education content (ie, a 15–20 slide presentation) and did not examine the potential added effects of educating young adults about waterpipe tobacco addiction. The goal of the current study was to examine the immediate effects of brief education messages delivered online about harms and addictiveness of waterpipe tobacco use among young adult waterpipe tobacco users ages 18 to 30 years. Specifically, we examined whether messages on addictiveness of waterpipe tobacco would have added effects above and beyond messages on harms of waterpipe tobacco use. Brief waterpipe tobacco use education messages may be useful for promoting more accurate perceptions of harms and addictiveness of waterpipe tobacco use and increasing desire to quit among young adults because they can be communicated through diverse media (eg, posters, ads, online, in product warning labels) and in various settings (eg, college campuses, healthcare settings, bars, and restaurants). Moreover, by understanding the relative effects of harm only versus harm and addiction messages, education content can be honed to maximize its effects on perceived harm and addictiveness and for dissuading waterpipe tobacco use. We used a three-group additive design where participants were randomized to a control condition (no education messages), a harms condition (education messages about harms of waterpipe tobacco use), or a harms and addiction condition (education messages about harms and addictiveness of waterpipe tobacco use). We examined whether the messages produced more accurate perceived harm and addictiveness of waterpipe tobacco use and perceived risk of harms and addiction, increased worry about harms and addiction, and increased desire to quit waterpipe tobacco use. Our primary hypotheses were that perceived relative harm and addictiveness of waterpipe tobacco use compared with cigarettes,
Nicotine & Tobacco Research, 2015, Vol. 00, No. 00
Measures
tobacco?”25 Responses were based on 1 (no chance) to 7 (certain to happen) scale. Worry About Harm Worry about the harms of waterpipe tobacco use was measured with two items: “How much do you worry that your health is being hurt by your waterpipe tobacco smoking?” and “How worried are you about getting a serious smoking-related disease, such as cancer, lung disease, or heart disease, if you continue to smoke waterpipe tobacco?”25 Responses to both items were based on a 1 (not at all) to 7 (very much) scale and averaged (Cronbach’s α = 0.92). Perceived Relative Addictiveness Perceived addictiveness of waterpipe tobacco use relative to cigarettes was measured by “Compared to regular cigarettes, how addictive do you think waterpipe tobacco use is?”27,32 Responses were based on a 5-point scale (1 = much less addictive, 2 = less addictive, 3 = as addictive, 4 = more addictive, 5 = much more addictive).
Covariates Demographics Demographic characteristics assessed included age, gender, race/ethnicity, college/university student status, educational attainment, and employment.
Perceived Risk of Addiction Perceived risk of addiction to waterpipe tobacco was assessed by “What do you think is your chance of becoming addicted to nicotine in tobacco from waterpipe if you continue to smoke?”25 Responses were based on a 1 (no chance) to 7 (certain to happen) scale.
Waterpipe Tobacco Use Frequency of waterpipe tobacco use was measured by asking participants whether they smoked waterpipe tobacco monthly, weekly, or daily.25 Based on their response, participants were asked to indicate how many waterpipes they smoked monthly/weekly/daily.25 A single variable converting responses to the number of waterpipes smoked per week was created.
Worry About Addiction Worry about addiction was measured using a question that asked “How worried are you about becoming addicted to nicotine in waterpipe if you continue to smoke it?” Responses were based on a 1 (not at all) to 7 scale (very much).
Other Tobacco Product Use Using validated epidemiologic survey items, current cigarette smokers were defined as those who had smoked at least 100 lifetime cigarettes and now smoke every day or some days.3 Among current smokers, a single item assessed the number of cigarettes smoked per day. Participants also reported past-month use of large cigars, little cigars/cigarillos, smokeless tobacco, and electronic cigarettes based on a single item for each product.3 We created a variable indicating whether participants only used waterpipe tobacco, used waterpipe tobacco and one other product (ie, dual users), or used waterpipe tobacco and at least two other products (ie, poly users) for use as a covariate. Outcome Variables Perceived Relative Harm Perceived harm of waterpipe tobacco use relative to cigarettes was measured using a single item “Compared to regular cigarettes, how harmful do you think waterpipe tobacco use is?” Responses were based on a 5-point scale (1 = much less harmful, 2 = less harmful, 3 = as harmful, 4 = more harmful, 5 = much more harmful).27,32 Perceived Risk of Harm Perceived risk of harm was assessed by “What do you think is your chance of getting a serious smoking-related disease, such as cancer, lung disease, or heart disease, if you continue to smoke waterpipe
Desire to Quit Desire to quit waterpipe tobacco was measured by asking “How strong is your desire to quit waterpipe smoking right now?” with response options ranging from 1 (not at all) to 7 (very).25
Statistical Analysis Bivariate analyses confirmed that no participant characteristics differed at P < .05 by experimental condition, thus none were included in multivariable analyses. Given the prevalence of use of tobacco products other than waterpipe, a categorical variable for tobacco product use (waterpipe only, dual use, poly use) was included as a covariate in all models. Analysis of covariance was used to determine whether outcomes differed by study condition, adjusting for tobacco product use. Least-square means were examined for the study condition main effect for each dependent variable using Tukey’s adjustment for multiple comparisons. Mediation analyses were conducted to examine whether the effects of the experimental conditions on desire to quit may be explained by differences across conditions in perceived relative harm and addictiveness, perceived risk of harm and addiction, and worry about harm and addiction. These analyses estimated the direct and indirect effects of experimental conditions on desire to quit. Indirect effects were estimated using a bias-corrected bootstrapping approach with 1000 resamples to address nonnormality in the product of coefficients.33 Asymmetric 95% confidence intervals around estimates that do not include zero indicate statistically significant indirect effects.33 Mediation analyses were conducted using Mplus
Downloaded from http://ntr.oxfordjournals.org/ at University of Newcastle on March 15, 2016
of waterpipe tobacco smoking and levels of harmful chemicals contained in waterpipe tobacco smoke relative to cigarettes. Content conveyed that waterpipe tobacco use is associated with chronic (eg, lung cancer, heart disease) and acute (eg, impaired respiratory function, potential infections) health effects, and provided a comparison of estimated ratios of toxicants found in waterpipe tobacco smoke relative to cigarette smoking. Participants randomized to the harms and addiction condition viewed the same content on waterpipe tobacco harms and also viewed two additional slides describing the addictive potential of waterpipe tobacco. The slides with addiction content conveyed information such as that nicotine levels from waterpipe tobacco smoke can lead to addiction, levels of nicotine exposure from smoking waterpipe tobacco compared with cigarettes, and described research evidence that many users report they are hooked on waterpipe tobacco. The messages tested are included in the Supplementary Material. Participants were instructed to read the slides carefully for as long they desired, and then proceeded to complete outcome measures.
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4 7.1 (Los Angeles, CA); all other analyses were conducted using SAS 9.3 (Cary, NC).
Results Sample
Perceived Relative Harm, Perceived Risk of Harm, and Worry about Harm Analysis of covariance results for perceived relative harm, perceived risk of harm, and worry about harm are shown in Table 2. For these outcomes, there was a statistically significant main effect for study condition. For perceived relative harm, means for the harms (M = 3.16, SE = 0.09) and harms and addiction (M = 3.20, SE = 0.09) conditions were significantly greater than the control condition (M = 2.45, SE = 0.09, Ps < .001). For perceived risk of harm and worry about harm, means in the harms and harms and addiction
Table 1. Sample Characteristics
Demographics Age (M, SD) Gender Male Female Race Black/African American White Other Hispanic ethnicity Current student Non-student Education Less than college education Some college education or higher Employment Not full time employed Full time employed Waterpipe tobacco smoking Frequency of waterpipe use Monthly Weekly Daily Number of waterpipes smoked/wk (M, SD) Cigarette smoking Current cigarette smoker Yes No Cigarettes smoked/d (M, SD) Other tobacco product use, past month Large cigars Little cigars/cigarillos Smokeless tobacco Electronic cigarettes Tobacco product use Waterpipe only Dual use (waterpipe and 1 other product) Poly use (waterpipe and ≥2 other products)
Full sample (N = 327)
Control condition (N = 108)
Harms condition (N = 107)
Harms and addiction condition (N = 112)
24.8 (3.3)
24.8 (3.5)
24.9 (3.4)
24.7 (3.2)
203 (62.1) 124 (37.9)
67 (62.0) 41 (38.0)
68 (63.6) 39 (36.4)
68 (60.7) 44 (35.5)
31 (9.5) 253 (77.6) 42 (12.8) 43 (13.2) 141 (43.9) 180 (56.1)
9 (8.3) 83 (76.9) 16 (14.8) 16 (14.8) 49 (45.8) 58 (54.2)
11 (10.4) 86 (81.1) 9 (8.5) 14 (13.1) 44 (41.5) 62 (58.5)
11 (9.8) 84 (75.0) 17 (15.2) 13 (11.7) 48 (44.4) 60 (55.6)
42 (12.8) 285 (87.2)
8 (7.4) 100 (92.6)
16 (15.0) 91 (85.0)
18 (16.1) 94 (83.9)
153 (46.8) 174 (53.2)
57 (52.8) 51(47.2)
51 (47.7) 56 (52.3)
45 (40.2) 67 (59.8)
221 (67.8) 86 (26.4) 19 (5.8) 2.7 (7.3)
74 (68.5) 26 (24.1) 8 (7.4) 3.6 (9.7)
75 (70.7) 28 (26.4) 3 (2.8) 1.8 (4.2)
72 (64.3) 32 (28.6) 8 (7.1) 2.7 (7.0)
250 (76.4) 77 (23.6) 7.1 (6.7)
82 (75.9) 26 (24.1) 7.2 (7.1)
83 (77.6) 24 (22.4) 7.8 (7.1)
85 (75.9) 27 (24.1) 6.3 (5.8)
50 (15.3) 83 (25.4) 41 (12.5) 148 (45.3)
17 (15.7) 28 (25.9) 10 (9.3) 49 (45.4)
14 (13.1) 30 (28.0) 16 (15.0) 46 (43.0)
19 (17.0) 25 (22.3) 15 (13.4) 53 (47.3)
42 (12.8) 110 (33.6) 175 (53.5)
13 (12.0) 38 (25.2) 57 (52.8)
15 (14.0) 33 (30.8) 59 (55.1)
14 (12.5) 39 (34.8) 59 (33.7)
P .860 .911
.577
.794 .813 .115
.169
.525
.216 .946
.388 .719 .616 .427 .813 .960
Data display N and % unless otherwise indicated. Some totals do not add to the sample n or n within condition due to sporadic missing data (
Original investigation
The Effects of Brief Waterpipe Tobacco Use Harm and Addiction Education Messages Among Young Adult Waterpipe Tobacco Users Darren Mays PhD, MPH1, Kenneth P. Tercyak PhD1, Isaac M. Lipkus PhD2 Downloaded from http://ntr.oxfordjournals.org/ at University of Newcastle on March 15, 2016
Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC; 2Duke University School of Nursing, Durham, NC
1
Corresponding Author: Darren Mays, PhD, MPH, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, 3300 Whitehaven Street NW, Suite 4100, Washington, DC 20007, USA. Telephone: 202-687-8937; Fax: 202-687-8444; E-mail: [email protected]
Abstract Introduction: This study investigated the immediate effects of brief education messages delivered online about harms and addictiveness of waterpipe tobacco use among young adult waterpipe users aged 18 to 30 years. Methods: Participants (n = 327, mean age 24.8 years, 62.1% male, 77.6% white, 67.8% used waterpipe monthly, 26.4% weekly, 5.8% daily) were recruited online and randomized to one of three experimental conditions: (1) Control condition viewing no messages; (2) Harms condition viewing messages about harms of waterpipe tobacco; (3) Harms and addiction condition viewing messages about harms and addictiveness of waterpipe tobacco. Outcomes included perceived harm and addictiveness of waterpipe, worry about harm and addiction, and desire to quit. Results: Compared to the control condition, participants in the harms condition reported significantly greater perceived harm and addictiveness of waterpipe relative to cigarettes, perceived risk of harm and addiction, worry about harm and addiction, and desire to quit. There were few significant differences in these outcomes between participants in the harms condition and the harms and addiction condition. Mediation analyses suggest waterpipe tobacco use harm messages may increase desire to quit by producing greater worry about harm and addiction. Conclusions: Brief education messages about waterpipe tobacco use harm increased young adult’s perceptions of harm and addictiveness of waterpipe tobacco use and generated stronger desire to quit. The waterpipe tobacco use addiction messages tested had little added impact. Studies should prospectively examine the real-world impact of waterpipe tobacco use harm messages and investigate more effective strategies for designing addiction messages. Implications: This study demonstrates that brief education messages about waterpipe tobacco use harm can increase young adult waterpipe tobacco user’s perceptions of harm and addictiveness of waterpipe tobacco use and generate stronger desire to quit. The findings indicate messages on addictiveness of waterpipe tobacco use have no added impact on these outcomes.
Introduction Waterpipe tobacco use among young adults is a public health concern globally1 and in the United States.2 Prevalence estimates of current
waterpipe tobacco use among young adults range from 8.8% to 18.2% depending upon the sampling frame, definition of current use (eg, past month, past year), and other factors.3–5 Young adulthood is
© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
1
Nicotine & Tobacco Research, 2015, Vol. 00, No. 00
2
perceived risk (ie, likelihood) of harm and addiction from waterpipe tobacco use, worry about harm and addiction from waterpipe tobacco use, and desire to quit using waterpipe tobacco would be greater among young adults in the harms and harms and addiction conditions than the control condition, with the strongest effect in the harms and addiction condition. In mediation analyses we also examined whether the effect of education messages on desire to quit using waterpipe tobacco may be explained by differences across experimental conditions in perceived risk and worry about harms and addictive potential of waterpipe tobacco use.
Methods Setting and Sample Participants were recruited in February 2015 through Amazon Mechanical Turk, a crowdsourcing Internet marketplace26 that has been used in similar studies of tobacco use27–29 and other behaviors.30,31 All screening, enrollment, and data collection occurred at a single time point through a series of steps. After a brief description of the study, Amazon Mechanical Turk members residing in the United States who were interested in participating reviewed a complete study description with a link to a consent form and eligibility screener. Individuals 18 to 30 years of age who reported using waterpipe tobacco in the past 30 days were eligible to participate. Eligibility criteria were assessed using screening questions from population-based surveys.3 Eligible, consenting participants proceeded immediately to the online experiment. Participants completing all study procedures were given a small monetary credit through Amazon Mechanical Turk. Study procedures were approved by the Georgetown University Institutional Review Board.
Procedures Before randomization, participants answered initial questions about demographics, waterpipe tobacco use, and use of other tobacco products. Then, using an algorithm embedded in the online survey software participants were randomized in equal numbers to one of three conditions: (1) control; (2) harms; or (3) harms and addiction. Participants in the control condition completed measures only immediately after randomization. Participants in the harms and harms and addiction conditions viewed education messages immediately after randomization and then completed remaining study measures. Participants randomized to harms condition viewed educational messages about harms of waterpipe tobacco use; those randomized to the harms and addiction condition viewed the same messaging about harms of waterpipe tobacco plus additional content on addictiveness of waterpipe tobacco use. All education messages were evidence-based, developed from research surrounding waterpipe tobacco use and adapted from a prior study that tested a waterpipe tobacco education intervention.25 As in a previous study,25 to emphasize the evidence-based nature of the content messages were followed by a list of supporting scientific references. Pilot content was pretested with a sample of 46 young adult waterpipe tobacco users recruited using the methods described above. Pilot participants rated the messages favorably, with suggestions to incorporate graphics and imagery to enhance visual appeal of the messages (eg, depictions of health effects). Pilot message content was revised based on this feedback for the experiment. Participants randomized to the harms condition viewed a presentation consisting of four slides describing potential health harms
Downloaded from http://ntr.oxfordjournals.org/ at University of Newcastle on March 15, 2016
a period when nonusers often initiate waterpipe tobacco use,6–8 and waterpipe tobacco use during adolescence and young adulthood has been associated with more than a twofold increase in the likelihood of initiating cigarette smoking and progressing to regular cigarette smoking in the future.9 Although waterpipe tobacco use is typically intermittent (eg, weekly, monthly),10–13 these patterns of use can lead to health harms and addiction. A typical waterpipe tobacco smoking session exposes users to markedly higher levels of toxicants than smoking a single cigarette,2,14 and waterpipe tobacco use is associated with acute (eg, increased heart rate and blood pressure, impaired pulmonary function, infection) and chronic (eg, bronchitis, emphysema, heart disease) health effects.15 Nicotine exposure through waterpipe tobacco use also produces addiction symptoms, including unsuccessful quit attempts and withdrawal.16–18 Among young adults perceptions that waterpipe tobacco is less harmful and less addictive than cigarette smoking are associated with current use11,19–21 and initiation among nonusers.6 Consistent with health behavior change theories (eg, value-expectancy models22,23), these inaccurate beliefs may promote waterpipe tobacco use among young adults and deter quitting. Thus, education interventions that correct misperceptions about risks of harm and addiction may motivate quitting.20,24 One recent experimental study found that educating college student waterpipe tobacco users about exposure to harmful toxicants in waterpipe tobacco smoke and associated health harms increased their perceptions of harms and addictiveness of waterpipe tobacco use and strengthened their desire to quit.25 Changes in perceived risk of harm and addictiveness of waterpipe tobacco use mediated the effects of the interventions on desire to quit.25 However, this study tested somewhat lengthy education content (ie, a 15–20 slide presentation) and did not examine the potential added effects of educating young adults about waterpipe tobacco addiction. The goal of the current study was to examine the immediate effects of brief education messages delivered online about harms and addictiveness of waterpipe tobacco use among young adult waterpipe tobacco users ages 18 to 30 years. Specifically, we examined whether messages on addictiveness of waterpipe tobacco would have added effects above and beyond messages on harms of waterpipe tobacco use. Brief waterpipe tobacco use education messages may be useful for promoting more accurate perceptions of harms and addictiveness of waterpipe tobacco use and increasing desire to quit among young adults because they can be communicated through diverse media (eg, posters, ads, online, in product warning labels) and in various settings (eg, college campuses, healthcare settings, bars, and restaurants). Moreover, by understanding the relative effects of harm only versus harm and addiction messages, education content can be honed to maximize its effects on perceived harm and addictiveness and for dissuading waterpipe tobacco use. We used a three-group additive design where participants were randomized to a control condition (no education messages), a harms condition (education messages about harms of waterpipe tobacco use), or a harms and addiction condition (education messages about harms and addictiveness of waterpipe tobacco use). We examined whether the messages produced more accurate perceived harm and addictiveness of waterpipe tobacco use and perceived risk of harms and addiction, increased worry about harms and addiction, and increased desire to quit waterpipe tobacco use. Our primary hypotheses were that perceived relative harm and addictiveness of waterpipe tobacco use compared with cigarettes,
Nicotine & Tobacco Research, 2015, Vol. 00, No. 00
Measures
tobacco?”25 Responses were based on 1 (no chance) to 7 (certain to happen) scale. Worry About Harm Worry about the harms of waterpipe tobacco use was measured with two items: “How much do you worry that your health is being hurt by your waterpipe tobacco smoking?” and “How worried are you about getting a serious smoking-related disease, such as cancer, lung disease, or heart disease, if you continue to smoke waterpipe tobacco?”25 Responses to both items were based on a 1 (not at all) to 7 (very much) scale and averaged (Cronbach’s α = 0.92). Perceived Relative Addictiveness Perceived addictiveness of waterpipe tobacco use relative to cigarettes was measured by “Compared to regular cigarettes, how addictive do you think waterpipe tobacco use is?”27,32 Responses were based on a 5-point scale (1 = much less addictive, 2 = less addictive, 3 = as addictive, 4 = more addictive, 5 = much more addictive).
Covariates Demographics Demographic characteristics assessed included age, gender, race/ethnicity, college/university student status, educational attainment, and employment.
Perceived Risk of Addiction Perceived risk of addiction to waterpipe tobacco was assessed by “What do you think is your chance of becoming addicted to nicotine in tobacco from waterpipe if you continue to smoke?”25 Responses were based on a 1 (no chance) to 7 (certain to happen) scale.
Waterpipe Tobacco Use Frequency of waterpipe tobacco use was measured by asking participants whether they smoked waterpipe tobacco monthly, weekly, or daily.25 Based on their response, participants were asked to indicate how many waterpipes they smoked monthly/weekly/daily.25 A single variable converting responses to the number of waterpipes smoked per week was created.
Worry About Addiction Worry about addiction was measured using a question that asked “How worried are you about becoming addicted to nicotine in waterpipe if you continue to smoke it?” Responses were based on a 1 (not at all) to 7 scale (very much).
Other Tobacco Product Use Using validated epidemiologic survey items, current cigarette smokers were defined as those who had smoked at least 100 lifetime cigarettes and now smoke every day or some days.3 Among current smokers, a single item assessed the number of cigarettes smoked per day. Participants also reported past-month use of large cigars, little cigars/cigarillos, smokeless tobacco, and electronic cigarettes based on a single item for each product.3 We created a variable indicating whether participants only used waterpipe tobacco, used waterpipe tobacco and one other product (ie, dual users), or used waterpipe tobacco and at least two other products (ie, poly users) for use as a covariate. Outcome Variables Perceived Relative Harm Perceived harm of waterpipe tobacco use relative to cigarettes was measured using a single item “Compared to regular cigarettes, how harmful do you think waterpipe tobacco use is?” Responses were based on a 5-point scale (1 = much less harmful, 2 = less harmful, 3 = as harmful, 4 = more harmful, 5 = much more harmful).27,32 Perceived Risk of Harm Perceived risk of harm was assessed by “What do you think is your chance of getting a serious smoking-related disease, such as cancer, lung disease, or heart disease, if you continue to smoke waterpipe
Desire to Quit Desire to quit waterpipe tobacco was measured by asking “How strong is your desire to quit waterpipe smoking right now?” with response options ranging from 1 (not at all) to 7 (very).25
Statistical Analysis Bivariate analyses confirmed that no participant characteristics differed at P < .05 by experimental condition, thus none were included in multivariable analyses. Given the prevalence of use of tobacco products other than waterpipe, a categorical variable for tobacco product use (waterpipe only, dual use, poly use) was included as a covariate in all models. Analysis of covariance was used to determine whether outcomes differed by study condition, adjusting for tobacco product use. Least-square means were examined for the study condition main effect for each dependent variable using Tukey’s adjustment for multiple comparisons. Mediation analyses were conducted to examine whether the effects of the experimental conditions on desire to quit may be explained by differences across conditions in perceived relative harm and addictiveness, perceived risk of harm and addiction, and worry about harm and addiction. These analyses estimated the direct and indirect effects of experimental conditions on desire to quit. Indirect effects were estimated using a bias-corrected bootstrapping approach with 1000 resamples to address nonnormality in the product of coefficients.33 Asymmetric 95% confidence intervals around estimates that do not include zero indicate statistically significant indirect effects.33 Mediation analyses were conducted using Mplus
Downloaded from http://ntr.oxfordjournals.org/ at University of Newcastle on March 15, 2016
of waterpipe tobacco smoking and levels of harmful chemicals contained in waterpipe tobacco smoke relative to cigarettes. Content conveyed that waterpipe tobacco use is associated with chronic (eg, lung cancer, heart disease) and acute (eg, impaired respiratory function, potential infections) health effects, and provided a comparison of estimated ratios of toxicants found in waterpipe tobacco smoke relative to cigarette smoking. Participants randomized to the harms and addiction condition viewed the same content on waterpipe tobacco harms and also viewed two additional slides describing the addictive potential of waterpipe tobacco. The slides with addiction content conveyed information such as that nicotine levels from waterpipe tobacco smoke can lead to addiction, levels of nicotine exposure from smoking waterpipe tobacco compared with cigarettes, and described research evidence that many users report they are hooked on waterpipe tobacco. The messages tested are included in the Supplementary Material. Participants were instructed to read the slides carefully for as long they desired, and then proceeded to complete outcome measures.
3
Nicotine & Tobacco Research, 2015, Vol. 00, No. 00
4 7.1 (Los Angeles, CA); all other analyses were conducted using SAS 9.3 (Cary, NC).
Results Sample
Perceived Relative Harm, Perceived Risk of Harm, and Worry about Harm Analysis of covariance results for perceived relative harm, perceived risk of harm, and worry about harm are shown in Table 2. For these outcomes, there was a statistically significant main effect for study condition. For perceived relative harm, means for the harms (M = 3.16, SE = 0.09) and harms and addiction (M = 3.20, SE = 0.09) conditions were significantly greater than the control condition (M = 2.45, SE = 0.09, Ps < .001). For perceived risk of harm and worry about harm, means in the harms and harms and addiction
Table 1. Sample Characteristics
Demographics Age (M, SD) Gender Male Female Race Black/African American White Other Hispanic ethnicity Current student Non-student Education Less than college education Some college education or higher Employment Not full time employed Full time employed Waterpipe tobacco smoking Frequency of waterpipe use Monthly Weekly Daily Number of waterpipes smoked/wk (M, SD) Cigarette smoking Current cigarette smoker Yes No Cigarettes smoked/d (M, SD) Other tobacco product use, past month Large cigars Little cigars/cigarillos Smokeless tobacco Electronic cigarettes Tobacco product use Waterpipe only Dual use (waterpipe and 1 other product) Poly use (waterpipe and ≥2 other products)
Full sample (N = 327)
Control condition (N = 108)
Harms condition (N = 107)
Harms and addiction condition (N = 112)
24.8 (3.3)
24.8 (3.5)
24.9 (3.4)
24.7 (3.2)
203 (62.1) 124 (37.9)
67 (62.0) 41 (38.0)
68 (63.6) 39 (36.4)
68 (60.7) 44 (35.5)
31 (9.5) 253 (77.6) 42 (12.8) 43 (13.2) 141 (43.9) 180 (56.1)
9 (8.3) 83 (76.9) 16 (14.8) 16 (14.8) 49 (45.8) 58 (54.2)
11 (10.4) 86 (81.1) 9 (8.5) 14 (13.1) 44 (41.5) 62 (58.5)
11 (9.8) 84 (75.0) 17 (15.2) 13 (11.7) 48 (44.4) 60 (55.6)
42 (12.8) 285 (87.2)
8 (7.4) 100 (92.6)
16 (15.0) 91 (85.0)
18 (16.1) 94 (83.9)
153 (46.8) 174 (53.2)
57 (52.8) 51(47.2)
51 (47.7) 56 (52.3)
45 (40.2) 67 (59.8)
221 (67.8) 86 (26.4) 19 (5.8) 2.7 (7.3)
74 (68.5) 26 (24.1) 8 (7.4) 3.6 (9.7)
75 (70.7) 28 (26.4) 3 (2.8) 1.8 (4.2)
72 (64.3) 32 (28.6) 8 (7.1) 2.7 (7.0)
250 (76.4) 77 (23.6) 7.1 (6.7)
82 (75.9) 26 (24.1) 7.2 (7.1)
83 (77.6) 24 (22.4) 7.8 (7.1)
85 (75.9) 27 (24.1) 6.3 (5.8)
50 (15.3) 83 (25.4) 41 (12.5) 148 (45.3)
17 (15.7) 28 (25.9) 10 (9.3) 49 (45.4)
14 (13.1) 30 (28.0) 16 (15.0) 46 (43.0)
19 (17.0) 25 (22.3) 15 (13.4) 53 (47.3)
42 (12.8) 110 (33.6) 175 (53.5)
13 (12.0) 38 (25.2) 57 (52.8)
15 (14.0) 33 (30.8) 59 (55.1)
14 (12.5) 39 (34.8) 59 (33.7)
P .860 .911
.577
.794 .813 .115
.169
.525
.216 .946
.388 .719 .616 .427 .813 .960
Data display N and % unless otherwise indicated. Some totals do not add to the sample n or n within condition due to sporadic missing data (
