This study examined whether message reactance mediates the cognitive effects of messages about the causal relationship between alcohol and cancer. We randomly assigned US adults (N = 799) recruited from a commercial online research panel to receive one of two types of messages about the alcohol-cancer link: (1) high-certainty (e.g., “Drinking alcohol causes cancer”), and (2) low-certainty, employing the modal verb “may” (e.g., “Drinking alcohol may cause cancer”). We evaluated whether message reactance mediated the effects of message certainty vs. uncertainty on (1) perceived causal certainty about the alcohol-cancer link, and (2) perceived alcohol-related cancer risk. We also explored whether heavy vs. non-heavy alcohol consumption moderated these effects. Message reactance mediated the effects of high-certainty (vs. low) messages on perceived causal certainty (direct: b=0.54; indirect: b=-0.11; both ps<0.001) and alcohol-related cancer risk (direct: b=0.37; indirect: b=-0.13; both ps<0.001)—suppressing the positive effects of expressed certainty on both outcomes. The suppressive effects of message reactance on perceived causal certainty were stronger for participants reporting heavy (b=-0.50) vs. non-heavy alcohol consumption (b=-0.35; p=.034). Conditional indirect effects for the perceived causal certainty model only remained significant for participants with non-heavy alcohol consumption (b=-0.10; p=.004). Effects of high-certainty (vs. low) messages were negatively mediated by message reactance and moderated by alcohol consumption. Findings suggest that although high-certainty risk messages may increase cancer risk perceptions, their effect is attenuated by inciting negative reactance to the messages, particularly for those who consume a heavy amount of alcohol. These mixed effects should be considered in future messaging initiatives aimed at communicating the alcohol-cancer relationship to the public.

In the wake of the COVID-19 pandemic, a critical question for health communication is whether misinformation exposure and misperceptions about one health topic have far-reaching, or "spillover," effects on health behavior in general. The present longitudinal study of U.S. adults (T1 n = 1012, T2 n = 607) examines the potential effects of COVID-19 misinformation endorsement at T1 (Jul. 30-Aug. 12, 2020) on both topically related prevention behavior (COVID-19 vaccine intention/behavior) and unrelated behavior (exercise, alcohol consumption, vaping, and smoking) one year later, at T2 (Jul. 20-Aug. 12, 2021), controlling for behavior at baseline. We found misinformation endorsement negatively predicted related behavior (COVID-19 vaccination); it did not predict unrelated behaviors. These findings are consistent with behavior change theories and do not support spillover effects, suggesting false beliefs about a topic are unlikely to directly predict unrelated health behaviors. Implications for public health communication are discussed.

OBJECTIVES:To investigate the effects of causal language in warning messages about alcohol and cancer risk. METHODS:In an online factorial experiment conducted in 2023, 799 US adults were randomly assigned to view one of eight messages employing different combinations of causal verbs (e.g., "causes") and modal verbs (e.g., "may") to describe the alcohol-cancer relationship. Analyses compared the effects of causal language on perceptions of causal certainty, alcohol-related cancer risk, message credibility, message reactance, and alcohol consumption intentions. RESULTS:Causal language did not affect perceived causal certainty, perceived cancer risk, or alcohol consumption intentions, but decreased perceived message credibility and increased reactance. Modal language decreased perceived causal certainty and cancer risk, increased perceived credibility of messages containing "causes," and decreased reactance to all messages. CONCLUSIONS:Causal language in alcohol warning messages has complex, countervailing effects: higher-certainty causal verbs do not increase risk perceptions but increase negative reactance, whereas higher-uncertainty modal verbs decrease risk perceptions but also reactance. These results suggest causal language may pose potential tradeoffs for risk communication efforts, raising the need for caution and more research to understand its effects.

Public health communication campaign planners must carefully consider whether misinformation beliefs are important to target and, ideally, correct. Guided by the reasoned action approach, we hypothesized that behavior-specific beliefs regarding COVID-19 vaccination would account for any observed relationship between general coronavirus misinformation beliefs (misinformation beliefs that are not specific to the anticipated consequences of COVID-19 vaccination) and subsequent vaccine uptake. To test our hypothesis, we used panel data from a two-wave nationally representative sample of U.S. adults pre- and post-vaccine availability (T1: July 2020, T2: April/June 2021, analytic sample: n = 665). Contrary to our hypothesis, we find a residual observed relationship between general coronavirus misinformation beliefs and subsequent vaccine uptake (AOR = 0.40, SE = 0.10). Intriguingly, our post-hoc analyses do show that after also adjusting for T2 behavioral beliefs, this association was no longer significant. With this and other justifications, we recommend that messages promoting vaccination prioritize targeting relevant behavioral beliefs.

IntroductionEfforts to prevent youth tobacco use are critical to reducing smoking-related deaths in the USA. Anti-tobacco messaging often focuses on the severe long-term consequences of smoking (eg, fatal lung disease, cancer). It is unclear whether these long-term consequences are more likely to deter youth use than shorter term consequences (eg, headaches, friend disapproval).MethodsA nationally representative 3-year rolling survey of adolescents and young adults (ages 13–26 years) measured belief in potential consequences of two types of tobacco products: combustible cigarettes (n=11 847) and electronic cigarettes (n=4470) as well as intentions and current use. Independent coders classified 23 consequences as either short or long term. Logistic regression tested the associations between short-term (vs long-term) beliefs and current intentions, as well as non-smoking behaviour at 6-month follow-up.ResultsBelieving in both short-term and long-term consequences was associated with outcomes, but short-term beliefs were more highly associated with anti-smoking (OR=1.40, 95% CI (1.30 to 1.51)) and anti-vaping (OR=2.10, 95% CI (1.75 to 2.52)) intentions and better predicted non-smoking behaviour at follow-up, controlling for prior use (OR=1.75, 95% CI (1.33 to 2.31)).ConclusionsThese results support temporal discounting by adolescents and young adults and suggest health communication efforts aiming to reduce youth tobacco use should emphasise shorter term consequences.

In today's complex media environment, does media coverage influence youth and young adults' (YYA) tobacco use and intentions? We conceptualize the "public communication environment" and effect mediators, then ask whether over time variation in exogenously measured tobacco media coverage from mass and social media sources predicts daily YYA cigarette smoking intentions measured in a rolling nationally representative phone survey (N = 11,847 on 1,147 days between May 2014 and June 2017). Past week anti-tobacco and pro-tobacco content from Twitter, newspapers, broadcast news, Associated Press, and web blogs made coherent scales (thetas = 0.77 and 0.79). Opportunities for exposure to anti-tobacco content in the past week predicted lower intentions to smoke (Odds ratio [OR] = 0.95, p < .05, 95% confidence interval [CI] = 0.91-1.00). The effect was stronger among current smokers than among nonsmokers (interaction OR = 0.88, p < .05, 95% CI = 0.77-1.00). These findings support specific effects of anti-tobacco media coverage and illustrate a productive general approach to conceptualizing and assessing effects in the complex media environment.

Vaccine hesitancy remains a major barrier to ending the COVID-19 pandemic in the United States (U.S.) and an important target for communication interventions. Using longitudinal survey data, we examined whether baseline levels and changes in beliefs about the COVID-19 vaccines predicted change in vacci-nation intention/behaviour. Repeated measures were collected from a nationally representative sample of U.S. adults (n = 665) in July 2020 and April/June 2021. Linear regressions associated change in COVID-19 vaccination intention/behaviour with changes in beliefs about the COVID-19 vaccines' safety, effectiveness in protecting others from infection, and effectiveness in protecting oneself from infection. Changes in beliefs from T1 to T2 were significantly associated with change in vaccination outcomes for all belief types (safety B = 0.39, SE = 0.07; effectiveness for self B = 0.38, SE = 0.09; effectiveness for others B = 0.43, SE = 0.07). Cross-lagged models suggested a reciprocal causal relationship between pro-vaccine beliefs and vaccination intention/behaviour: Intention to get vaccinated at T1 predicted strengthened safety and effectiveness beliefs at T2. T1 effectiveness beliefs predicted T2 vaccination intention/be-haviour, though T1 safety beliefs did not. Communication interventions highlighting the protective ben-efits of COVID-19 vaccines may be particularly successful in reducing vaccine hesitancy.(c) 2022 Elsevier Ltd. All rights reserved.

Wide-spread misinformation about the COVID-19 pandemic has presented challenges for communicating public health recommendations. Should campaigns to promote protective behaviors focus on debunking misinformation or targeting behavior-specific beliefs? To address this question, we examine whether belief in COVID-19 misinformation is directly associated with two behaviors (face mask wearing and social distancing), and whether behavior-specific beliefs can account for this association and better predict behavior, consistent with behavior-change theory. We conducted a nationally representative two-wave survey of U.S. adults from 5/26/20-6/12/20 (n=1074) and 7/15/20-7/21//20 (n=889; follow up response 83%). Scales were developed and validated for COVID-19 related misinformation beliefs, social distancing and face mask wearing, and beliefs about the consequences of both behaviors. Cross-lagged panel linear regression models assessed relationships among the variables. While belief in misinformation was negatively associated with both face mask wearing (B= -.27, SE=.06) and social distancing behaviors (B= -.46, SE=.08) measured at the same time, misinformation did not predict concurrent or lagged behavior when the behavior-specific beliefs were incorporated in the models. Beliefs about behavioral outcomes accounted for face mask wearing and social distancing, both cross-sectionally (B= .43, SE=.05; B= .63, SE=.09) and lagged over time (B= .20, SE=04; B= .30, SE=.08). In conclusion, belief in COVID-19-related misinformation is less relevant to protective behaviors, but beliefs about the consequences of these behaviors are important predictors. With regard to misinformation, we recommend health campaigns aimed at promoting protective behaviors emphasize the benefits of these behaviors, rather than debunking unrelated false claims

COVID vaccination intentions vary among the US population. We report the results of a nationally representative survey undertaken in July 2020 (N=889) that examined the association of six vaccine-specific beliefs with intentions to vaccinate. We find that four of the six beliefs have substantial associations with intention (Gammas between .60 and .77), that the associations mostly do not vary with gender, age, race/ethnicity, or misinformation (even though intentions do vary with each of those variables). Also, once adjusted for the vaccine-specific beliefs, level of misinformation is not related to intentions. We consider the implications of these results and argue both that persuasive campaigns can be informed by these specific results, and given rapid changes in vaccine availability, that there is a substantial need for elaborated and repeated follow-up studies.

Many emotional appeal theorists argue that negative affect and efficacy work together to promote adaptive behavioral responses to a threat, yet most research on cigarette warning label messages has not examined the intersection between negative affect, hope, and efficacy. The current study tests effects of exposure, at different points in a sequence, to an efficacy-focused warning label in the context of threat-focused warning labels. We conducted an online, between- and within-subjects experiment with 398 adult smokers, testing the effects of warning label exposure on negative affect, hope, efficacy beliefs, and intentions to quit. Exposure to the efficacy-focused "Quit" label aroused higher levels of reported hope and lower levels of reported negative affect than threat-focused labels. Negative affect increased with each additional exposure to a threat-focused warning label, regardless of the order in which respondents saw the "Quit" label. Exposure to the "Quit" label (within a larger set of three threat-focused labels) led to greater self-efficacy but did not influence response efficacy or intentions to quit. We conclude that "Quit" messaging on warning labels can inspire both hopeful feelings and efficacy beliefs. Future research should identify the optimal balance between threat-focused and hopeful quit messages.

Tobacco use and the associated consequences are much more prevalent among low-SES populations in the U.S. However, tobacco-based research often does not include these harder-to-reach populations. This paper compares the effectiveness and drawbacks of three methods of recruiting low-SES adult smokers in the Northeast. From a 5-year, [funding blinded] grant about impacts of graphic warning labels on tobacco products, three separate means of recruiting low-SES adult smokers emerged: 1) in person in the field with a mobile lab vehicle, 2) in person in the field with tablet computers, and 3) online via Amazon Mechanical Turk (MTurk). We compared each of these methods in terms of the resulting participant demographics and the "pros" and "cons" of each approach including quality control, logistics, cost, and engagement. Field-based methods (with a mobile lab or in person with a tablet) yielded a greater proportion of disadvantaged participants who could be biochemically verified as current smokers-45% of the field-based sample had an annual income of <$10,000 compared to 16% of the MTurk sample; 40-45% of the field-based sample did not complete high school compared to 2.6% of the MTurk sample. MTurk-based recruitment was substantially less expensive to operate (1/14th the cost of field-based methods) was faster, and involved less logistical coordination, though was unable to provide immediate biochemical verification of current smoking status. Both MTurk and field-based methods provide access to low-SES participants-the difference is the proportion and the degree of disadvantage. For research and interventions where either inclusion considerations or external validity with low-SES populations is critical, especially the most disadvantaged, our research supports the use of field-based methods. It also highlights the importance of adequate funding and time to enable the recruitment and participation of these harder-to-reach populations.

Exposure to cigarette advertising can increase the likelihood of youth smoking initiation and may encourage people who already smoke to continue. Requiring prominent, graphic warning labels could reduce these effects. We test whether graphic versus text-only warning labels in cigarette advertisements influence cognitive and emotional factors associated with youth susceptibility to smoking and adult intentions to quit. We conducted two randomized, between-subjects experiments with middle-school youth (n = 474) and adult smokers (n = 451). Both studies employed a two (graphic or text-only warnings) by two (advertisements with social cues or brand imagery) factorial design with a fifth, offset control group (social cue advertisements with the current US Surgeon General's Warning). Graphic warnings outperformed text-only warnings in reducing visual attention to the advertisement, generating visual attention to the warning and arousing more negative affect. Graphic warnings also reduced the appeal of cigarette brands among youth relative to social cue advertisements with the Surgeon General's warnings. None of the warnings (graphic or textual) influenced health risk beliefs. Graphic warning labels on cigarette advertisements appear to have effects similar to those observed on cigarette packs in previous work, with an added benefit of reducing cigarette brand appeal among youth.

Policy Points Political advertising can influence which issues are public policy priorities. Population health-relevant issues were frequently referenced in televised political advertising in the 2011-2012 and 2015-2016 US election cycles, with about one-fourth of all ads aired mentioning traditional public health and health policy topics and more than half referencing broader determinants of population health. The volume of population health-relevant issues referenced in political ads varied by geography, political office, political party, and election cycle. Ads referencing broader determinants of population health (such as employment, education, or gender equality) rarely tied these determinants directly to health outcomes. CONTEXT:Political discourse is one way that policymakers and candidates for public office discuss societal problems, propose solutions, and articulate actionable policies that might improve population health. Yet we know little about how politicians define and discuss issues relevant to population health in their major source of electoral communication, campaign advertisements. This study examined the prevalence of references to population health-relevant issues conveyed in campaign advertising for political office at all levels of government in the United States in 2011-2012 and 2015-2016. Understanding advertising as part of the political discourse on topics of relevance to population health yields insights about political agenda-setting and can inform efforts to shape opinion. METHODS:We conducted a content analysis of all English-language, candidate-related campaign advertisements aired on local broadcast, national network, and national cable television in the 2011-2012 and 2015-2016 election cycles (3,980,457 and 3,767,477 airings, respectively). We analyzed the volume of coverage in these ads about issues relevant to population health, including narrowly defined public health issues as well as a broad range of other social, economic, and environmental factors that affect population health. FINDINGS:Across both election cycles and all electoral races, 26% of campaign advertising discussed issues relevant for the narrowly defined conceptualization of public health and 57% discussed issues pertinent to topics within the more expansive population health conceptualization. There was substantial variation in population health-related content in ads across election cycles, by level of political office, political party, and geographic area. Geographic variation indicates that where a person lives affects their potential exposure to political communication about various health-related topics. CONCLUSIONS:Political campaign ads in the United States frequently referenced population health-relevant content at all levels of government, although the ads rarely connected population health-relevant issues to health. Variation in volume and content of these references likely shaped public opinion and the public will to address population health-related policy.