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Purpose: Smokeless tobacco (SLT) use is more common among White male youth in rural locations than among other youth. Previous literature documents risk factors for SLT use (e.g., perceived harm). However, no research has examined whether SLT initiation is associated with the use of social media and video games, despite the high prevalence of those behaviors among adolescent males., Methods: As part of the evaluation of "The Real Cost" smokeless prevention campaign, we conducted a baseline survey of a cohort of US males aged 11-16 in 2016 and four follow-up surveys conducted approximately every 8 months. We used discrete-time survival analysis to examine factors associated with SLT initiation. Logistic regression estimated the odds of initiation as a function of lagged values of key predictors (social media use in tertiles and frequency of gaming) and other baseline and lagged correlates. The model controlled for campaign exposure., Results: Relative to the lowest tertile of social media use, moderate (odds ratio [OR] = 1.80) or high use (OR = 2.77) was associated with increased risk of SLT initiation at the subsequent survey wave. Relative to playing every few weeks or less, playing video games once a day (OR = 0.50) or several times a day (OR = 0.33) was associated with decreased risk of SLT initiation., Discussion: SLT initiation was positively associated with social media use and negatively associated with gaming. Future research should explore reasons for the protective nature of gaming (e.g., social support, improved mood) and whether parental supervision of social media use could mitigate its negative impact., (Published by Elsevier Inc.)

Background: Scientists identified vitamin E acetate (VEA) and "Dank Vapes" (a fake brand of tetrahydrocannabinol [THC] vaping products) as contributors to the 2019-2020 outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). On social media, people who post about vaping or THC discussed the causes of EVALI. We examined whether Reddit conversations may have served as early signals of the outbreak., Methods: We collected Reddit posts from March 2018 to February 2020 on vaping- and THC-related subreddits that mentioned VEA or Dank Vapes. We identified peaks in post volume, examined post content, and used natural language processing to identify terms most characteristic of posts., Results: There were almost no posts about VEA before EVALI. Subsequently, there were two peaks, both referencing media coverage of scientific findings that linked VEA to EVALI. Discussion regularly referenced concerns about the legitimacy of Dank Vapes before EVALI; peaks in posts were largely unrelated to scientific findings or media coverage of those findings. The terms most characteristic of VEA posts were EVALI-related; those most characteristic of Dank Vapes posts were about quality or legitimacy., Conclusions: Although posts about VEA and Dank Vapes did not predict the outbreak, the public health community could use social media to encourage people who vape or use THC to report future health concerns (e.g., through FDA's Safety Reporting Portal). Researchers and regulators could also use social media to see if potentially problematic products, such as Dank Vapes, have a history of concern among individuals who use those products., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Cannabis warning labels can communicate risks, but there is little research on warning perceptions and differences by product type., Methods: In a 2019 online survey, 1,000 U.S. adults (500 cannabis users and 500 cannabis non-users who used tobacco) were randomly assigned to view no warning or one of four U.S. or Canadian warnings displayed on images of packaging for dried flower or edible cannabis. The warnings described cannabis risks related to psychosis, addiction, lack of FDA oversight, and impaired driving. We used linear regression to examine perceptions of warnings and product harm as a function of product type (dried or edible) and warning. We examined which warning participants selected as most effective for discouraging youth use and impaired driving., Results: Participants found the addiction warning (cannabis users: B = -1.04, p < 0.001; cannabis non-users: B = 1.17, p < 0.001) and psychosis warning (users: B = -0.65, p < 0.05; non-users: B = -0.71, p < 0.05) less believable than the driving warning but indicated that they learned more from the psychosis warning than the driving warning (users: B = 0.88, p < 0.01; non-users (B = 1.60, p < 0.001). Participants viewing any warning considered smoking cannabis to be more harmful than those viewing no warning (all p < 0.05). The psychosis warning was most frequently selected as the best warning for discouraging youth use., Conclusions: Warnings have the potential to educate consumers and impact cannabis harm perceptions. Warnings have similar effects across product types, potentially eliminating the need for product type-specific warnings. The association of cannabis use with risk for psychosis, a topic addressed in Canadian warnings, could be a useful topic of focus in U.S. warnings., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Some adolescent users of e-cigarettes and other electronic vaping products (EVPs) report performing "vape tricks" (exhaling aerosol to make shapes). However, little is known about this behavior. We examined the frequency of performing and watching vape tricks and the characteristics of those most likely to perform vape tricks among a sample of adolescent EVP users., Methods: We used social media ads to recruit a national convenience sample of U.S. adolescents (n = 1,729) to participate in an online survey in September 2016. Inclusion criteria required participants to be aged 15-17 years and to have used EVPs at least once in the past 30 days., Results: The majority of EVP-using adolescents reported trying (77.8%) and watching vape tricks in person (83.7%) or online (74.0%). Risk factors for performing tricks included using advanced vaping devices, vaping every day, white race, moderate levels of seeing and sharing vaping information on social media, and believing that EVP use is more normative among peers. Likelihood of trying vape tricks decreased as beliefs about the harmfulness of EVPs increased., Conclusions: Vape tricks pose a potential threat to adolescent health if they encourage nonusers to initiate or current EVP users to use more frequently or switch to advanced devices that produce more harmful chemical emissions. Further research should examine the possible health effects of performing vape tricks, and future public health campaigns should be informed by an understanding of the appeal of this activity for adolescents., (Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Pictorial cigarette pack warnings are a promising policy solution to increase smoking cessation among adults. However, little is known regarding adolescents' responses to pictorial warnings, particularly in real-world settings., Methods: Participants were 112 adolescent children, ages 13-17, whose parents received either text-only warnings on the side of their cigarette packs or pictorial warnings on the top half of the front and back of their cigarette packs for 4 weeks as part of a trial. We measured adolescents' recall and recognition of these warnings, negative emotional reactions to the warnings, perceived effectiveness of the warnings, social interactions about the warnings, and smoking risk beliefs., Results: Adolescents accurately recalled pictorial warnings more often than text-only warnings (82% vs. 19%, p < .001). Recognition of warnings was also higher for pictorial than text-only warnings (82% vs. 34%, p < .001). Pictorial warnings drew greater attention (p < .001), elicited greater negative emotional reactions (p < .05), and sparked more social interactions (p < .01) than text-only warnings., Conclusions: Pictorial warnings on cigarette packs may have important effects on adolescent children of smokers. Future research should further investigate the impact of such messages on adolescents' susceptibility to smoking initiation and interest in quitting smoking, particularly as the United States and other countries work to implement pictorial warning regulations., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Electronic cigarette (e-cigarette) use now surpasses the use of conventional cigarettes among U.S. adolescents. Given the important role of physicians in preventing adolescent risk behaviors, we sought to understand how physicians communicate about e-cigarettes when counseling adolescent patients and their parents. We also explored physicians' support for regulations aimed at discouraging adolescents' e-cigarette use., Methods: A national U.S. sample of 776 pediatricians and family medicine physicians who provide primary care to adolescent patients completed an online survey in Spring 2014., Results: Many physicians (41%) would, if asked, tell their patients that e-cigarettes are less harmful than cigarettes, and a substantial minority (24%) would recommend e-cigarettes to adolescents for smoking cessation. Most physicians reported routinely screening adolescent patients for cigarette smoking but few routinely screened for e-cigarette use (86% vs. 14%; p < .001). Routine counseling was similarly more common for avoiding cigarette smoking than for avoiding e-cigarette use (79% vs. 18%; p < .001). Support for government regulation of e-cigarettes was high, with 91% of physicians endorsing policies that prevent minors from buying e-cigarettes., Conclusions: Physicians infrequently screen or counsel their adolescent patients about e-cigarette use, although e-cigarettes often come up during visits. Additional efforts by physicians could help prevent future use by adolescents. Recommending e-cigarettes as a smoking cessation aid to adolescent patients is inadvisable given the lack of evidence for efficacy in that population. As federal regulation of e-cigarettes remains in limbo, pediatricians and family medicine physicians can offer a powerful voice for informing regulations aimed at reducing use by adolescents., (Copyright © 2015 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Electronic cigarettes (e-cigarettes) are battery-powered nicotine delivery systems that may serve as a "gateway" to tobacco use by adolescents. Use of e-cigarettes by U.S. adolescents rose from 3% in 2011 to 7% in 2012. We sought to describe healthcare providers' awareness of e-cigarettes and to assess their comfort with and attitudes toward discussing e-cigarettes with adolescent patients and their parents., Methods: A statewide sample (n = 561) of Minnesota healthcare providers (46% family medicine physicians, 20% pediatricians, and 34% nurse practitioners) who treat adolescents completed an online survey in April 2013., Results: Nearly all providers (92%) were aware of e-cigarettes, and 11% reported having treated an adolescent patient who had used them. The most frequently cited sources of information about e-cigarettes were patients, news stories, and advertisements, rather than professional sources. Providers expressed considerable concern that e-cigarettes could be a gateway to tobacco use but had moderately low levels of knowledge about and comfort discussing e-cigarettes with adolescent patients and their parents. Compared with pediatricians and nurse practitioners, family medicine physicians reported knowing more about e-cigarettes and being more comfortable discussing them with patients (both p < .05). Nearly all respondents (92%) wanted to learn more about e-cigarettes., Conclusions: Healthcare providers who treat adolescents may need to incorporate screening and counseling about e-cigarettes into routine preventive services, particularly if the prevalence of use continues to increase in this population. Education about e-cigarettes could help providers deliver comprehensive preventive services to adolescents at risk of tobacco use., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Electronic cigarettes (e-cigarettes) are a new type of device that delivers vaporized nicotine without the tobacco combustion of regular cigarettes. We sought to understand awareness of and willingness to try e-cigarettes among adolescent males, a group that is at risk for smoking initiation and may use e-cigarettes as a "gateway" to smoking., Methods: A national sample of 11-19-year-old males (n = 228) completed an online survey in November 2011. We recruited participants through their parents, who were members of a panel of U.S. households constructed using random-digit dialing and addressed-based sampling., Results: Only two participants (< 1%) had previously tried e-cigarettes. Among those who had not tried e-cigarettes, most (67%) had heard of them. Awareness was higher among older and non-Hispanic adolescents. Nearly 1 in 5 (18%) participants were willing to try either a plain or flavored e-cigarette, but willingness to try plain versus flavored varieties did not differ. Smokers were more willing to try any e-cigarette than nonsmokers (74% vs. 13%; OR 10.25, 95% CI 2.88, 36.46). Nonsmokers who had more negative beliefs about the typical smoker were less willing to try e-cigarettes (OR .58, 95% CI .43, .79)., Conclusions: Most adolescent males were aware of e-cigarettes, and a substantial minority were willing to try them. Given that even experimentation with e-cigarettes could lead to nicotine dependence and subsequent use of other tobacco products, regulatory and behavioral interventions are needed to prevent "gateway" use by adolescent nonsmokers. Campaigns promoting negative images of smokers or FDA bans on sales to youth may help deter use., (Copyright © 2013 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: We examined parents' and adolescents' preferences regarding potential strategies to increase human papillomavirus (HPV) vaccination rates, including offering the vaccine in alternative settings, concomitant administration of vaccines, and optimizing the structure of vaccination medical visits., Methods: A national sample of U.S. parents of adolescent boys aged 11-17 years (n = 506) and their sons (n = 391) completed online surveys in August and September 2010. We used analysis of variance for mixed designs to examine preferences for vaccination settings., Results: Parents and sons were most comfortable with sons receiving HPV vaccine in a doctor's office. Parents of sons who had not visited their regular health care providers in the past year were more comfortable with sons receiving HPV vaccine at a public clinic (p < .001) or school (p < .05) compared with parents whose sons had recent visits. Results from the son survey showed a similar pattern. Parents and sons reported moderate levels of acceptability of concomitant administration. They most preferred to have the three HPV vaccine shots administered during brief nurse visits., Conclusions: Offering HPV vaccine in alternative settings and administering it with other recommended adolescent vaccines may increase uptake among adolescent boys. Parents and sons may prefer HPV vaccines be administered during brief nurse visits., (Copyright © 2012 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)