This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on https://mhealth.jmir.org/, as well as this copyright and license information must be included.
The use of new and emerging tobacco products (NETPs) and conventional tobacco products (CTPs) has been linked to several alarming medical conditions among young adults (YAs). Considering that 96% of YAs own mobile phones, SMS text messaging may be an effective strategy for tobacco risk communication.
Project Debunk is a community-based randomized trial aiming to identify specific types of messages that effectively improve perceived NETP and CTP risk among YAs in community colleges.
With YAs recruited offline from 3 campuses at the Houston Community College (September 2016 to July 2017), we conducted a 6-month randomized trial with 8 arms based on the combination of 3 message categories: framing (gain-framed vs loss-framed), depth (simple vs complex), and appeal (emotional vs rational). Participants received fully automated web-based SMS text messages in two 30-day campaigns (2 messages per day). We conducted repeated-measures mixed-effect models stratified by message type received, predicting perceived CTP and NETP risks. Owing to multiple testing with 7 models, an association was deemed significant for
A total of 636 participants completed the baseline survey, were randomized to 1 of 8 conditions (between 73 and 86 participants per condition), and received messages from both campaigns. By the 2-month post campaign 2 assessment point, 70.1% (446/636) completed all outcome measures. By the end of both campaigns, participants had a significant increase in perceived NETP risk over time (
In this trial, YAs had an increase in perceived NETP risk. However, with stratification, we observed a significant increase in perceived NETP risk upon exposure to rational, emotional, simple, and gain-framed messages. In addition, YAs generally had an increase in perceived CTP risk and presented nonsignificant but observable improvement upon exposure to emotional, complex, and loss-framed messages. With the results of this study, researchers and practitioners implementing mobile health programs may take advantage of our tailored messages through larger technology-based programs such as smartphone apps and social media campaigns.
ClinicalTrials.gov NCT03457480; https://clinicaltrials.gov/ct2/show/NCT03457480
RR2-10.2196/10977
Tobacco use in many forms, such as combustible, vaporized, or smokeless, has been linked to several alarming medical conditions among young adults (YAs; aged 18-25 years). These include nicotine dependence [
YA tobacco use can be partly attributed to the relatively low perceived risk of products when compared with other adult age groups [
Despite known health consequences, aggressive tobacco marketing to young people has been found to reduce risk perception and promote continued tobacco use [
Tobacco advertising to YAs has become particularly successful through mobile media channels [
Health promotion experts and activists ought to respond to tobacco marketing by communicating tobacco risk to YAs as delineated by the educational mission and research priorities of the US Food and Drug Administration [
The goal of our project (Project Debunk) was to develop a library of risk communication messages. Our message design was based on a combination of 3 main message categories, each with 2 message types: (1) framing (gain-framed or loss-framed messages), (2) depth (ie, simple or complex messages), and (3) appeal (ie, emotional or rational messages). Framing and appeal were supported by previous research [
Available theoretical frameworks have described that the success of message characteristics depends on individual differences in the way they process information. First, according to the elaboration likelihood model (ELM) [
The objective of this paper on Project Debunk is to present the results of a community-based randomized trial. The trial aims to identify specific types of messages that are effective in increasing the perceived risk of NETP use and CTP use among YAs in community colleges. Considering the limited research, we cannot predict or anticipate differences among message types in improving perceived tobacco risk [
A detailed description of the study design has been presented elsewhere [
Participants received SMS text messages on their mobile phones for free in 2 waves or campaigns. Each campaign comprised 2 SMS text messages per day for 30 days (ie, 60 text messages). This resulted in a total of 120 messages considering both campaigns. Participants were randomized into 8 arms, with 8 permutations based on message types. As a result, there was a total of 960 messages disseminated for this study. The 2 campaigns were performed 1 week apart. The development process and content of messages were
For ethical reasons, all participants received both NETP and CTP messages. To control for the order in which SMS text messages were received, the study included a crossover design. Participants within each arm were randomly divided into 2 groups: the first group received messages on CTPs during the first campaign and then NETPs during the second campaign, whereas the second group received messages on NETPs during the first campaign and then CTPs during the second campaign (
Study design and randomization to 8 conditions followed by 2 crossover conditions (total of 16 conditions). CTP: conventional tobacco product; NETP: new and emerging tobacco product; G: gain-framed messages, L: loss-framed messages, C: complex messages, S: simple messages, R: rational messages, and E: emotional messages.
YAs were recruited from 3 campuses at the Houston Community College. The campuses were selected based on their ethnically diverse populations [
At each of the 3 campuses, recruitment took place face to face at highly visible recruitment stations or booths, and printed materials announcing the study (posters and fliers) were displayed in high traffic areas. Research staff screened interested students for eligibility, and eligible students provided informed consent to participate in the study. During the face-to-face consent process, participants received information regarding the objective of the study, study procedures, potential risks, potential benefits, compensation information, and contact information. Following consent, participants completed a 20-minute web-based baseline survey on their phones. Participants received a US $25 gift card for completing the baseline survey and each of the 2 postcampaign surveys.
After 3 days of receiving the baseline survey, YAs began to receive SMS text messages through the MD Anderson Cancer Center resource called assessment, intervention, and measurement. A password-protected allocation sequence was generated by the assessment, intervention, and measurement resource, automatically sending SMS text messages on the basis of allocation and keeping the research team blind to participant allocation. Participants were blinded to the type of message they received. Research assistants were available over the phone in case of usability issues.
Through web-based skip-pattern surveys, we assessed a series of previously validated and pretested measures [
Sample size determination has been previously described [
Our central hypothesis is that, controlling for all other message types, campaign participants receiving each message type will have an increase in perceived NETP risk and perceived CTP risk over time. To test the success of improving perceived risk over time among participants exposed to specific message types, 6 models were used for participants receiving (1) rational messages, (2) emotional messages, (3) complex messages, (4) simple messages, (5) loss-framed messages, and (6) gain-framed messages. These 6 models were conducted to predict perceived CTP risk and then perceived NETP risk. All 7 models that predicted each main outcome controlled for crossover group assignment and the differential effect of crossover group assignment on time. In addition, after examining potential covariates through a series of regression analyses, all models controlled for age, gender, having a child, basic expenses, education plan, numeracy level, and past 30-day tobacco use at baseline (
Study flow diagram. CG: crossover group; CG1 receive messages about new and emerging tobacco products (NETP) during campaign 1 and then messages about conventional tobacco product (CTP) during campaign 2; CG2 receive messages about CTP during campaign 1 and then messages about NETP during campaign 2; GCE: gain-framed, complex, emotional; GCR: gain-framed, complex, rational; GSE: gain-framed, simple, emotional; GSR: gain-framed, simple, rational; LCE: loss-framed, complex, emotional; LSE: loss-framed, simple, emotional; LCR: loss-framed, complex, rational; LSR: loss-framed, simple, rational.
Demographic characteristics for the entire sample and stratified by group at baseline were described under the trial protocol [
G stands for gain-framed, L stands for loss-framed, C stands for complex, S stands for simple message, R stands for rational, and E stands for emotional. CG1 stands for crossover group 1 (receiving messages about NETPs during campaign 1 and then messages about CTPs during campaign 2). CG2 stands for crossover group 2 (receiving messages about CTPs during campaign 1 and then messages about NETPs during campaign 2). Retention is based on completing all survey questions pertaining to perceived NETP and CTP risk.
The results indicate that the groups did not differ with respect to their preferred method of communication (
A series of 1-way analyses of variance indicated no significant difference in attention scores between emotional and rational messages (
Change over time in perceived risk of using NETPa and CTPb for the sample (N=636).c
Characteristics | Perceived NETP risk | Perceived CTP risk | ||||||||
|
B (SE) | B (SE) | ||||||||
Timed | 0.23 (0.06) | <.001 | 0.13 (0.05) | .008 | ||||||
Crossover group | −0.04 (0.06) | .49 | −0.04 (0.05) | .45 | ||||||
Crossover group by time | 0.02 (0.08) | .79 | 0.05 (0.07) | .50 | ||||||
Age | 0.02 (0.01) | .08 | −0.001 (0.01) | .93 | ||||||
Being female | −0.01 (0.06) | .78 | 0.01 (0.05) | .77 | ||||||
Having a child | −0.05 (0.09) | .55 | 0.09 (0.08) | .23 | ||||||
|
||||||||||
|
Just meet | 0.08 (0.10) | .44 | 0.08 (0.09) | .37 | |||||
|
Meet adequately | 0.14 (0.11) | .19 | 0.17 (0.09) | .06 | |||||
|
Meet comfortably | 0.10 (0.11) | .38 | 0.02 (0.09) | .84 | |||||
|
Cannot meet (reference) | —e | — | — | — | |||||
|
||||||||||
|
Associate degree | −0.09 (0.14) | .52 | 0.12 (0.12) | .33 | |||||
|
Bachelor’s degree | −0.14 (0.13) | .28 | 0.003 (0.10) | .19 | |||||
|
Master’s degree | −0.11 (0.13) | .38 | 0.06 (0.10) | .08 | |||||
|
Doctorate degree | −0.09 (0.13) | .49 | 0.16 (0.10) | .13 | |||||
|
Certificate (reference) | — | — | — | — | |||||
Numeracy level | 0.01 (0.02) | .48 | 0.01 (0.12) | .28 | ||||||
Baseline use of NETPf | −0.16 (0.06) | .009 | — | — | ||||||
Baseline use of CTPf | — | — | −0.10 (0.06) | .10 | ||||||
Receive gain-framed messagesg | 0.10 (0.05) | .05 | 0.05 (0.04) | .21 | ||||||
Receive emotional messagesg | 0.01 (0.05) | .84 | 0.02 (0.04) | .57 | ||||||
Receive simple messagesg | 0.13 (0.05) | .01 | 0.07 (0.04) | .11 |
aNETP: new and emerging tobacco product.
bCTP: conventional tobacco product.
cTwo models are presented in this table. Unstandardized coefficients are presented, and the significance level is examined at .007.
dThe unadjusted time effect predicting perceived NETP risk was B (SE)=0.24 (0.04),
eFor reference factors (eg, cannot meet), this indicates that data is not applicable. For actual variables (eg, baseline NETP use), this indicates that the variable was not included in the model.
fBaseline use of NETP or CTP indicates past 30-day use of NETPs and CTPs at baseline.
gThese variables compare receiving 1 message type with its counterpart (gain-framed vs loss-framed, emotional vs rational, and simple vs complex).
To check for potential demographic confounders of perceived CTP risk, we determined whether intervention effects varied by demographic characteristics, particularly those identified as covariates. Overall, the results failed to identify effects as a moderating function of age (
As presented in
Change in perceived risk of using NETPa among participants receiving emotional messages, those receiving complex messages, and those receiving loss-framed messages.b
Characteristics | Emotional (n=314) | Complex (n=324) | Loss-framed (n=321) | ||||||||||
|
B (SE) | B (SE) | B (SE) | ||||||||||
Timec | 0.24 (0.09) | .006 | 0.21 (0.08) | .01 | 0.20 (0.08) | .01 | |||||||
Crossover group | 0.03 (0.09) | .72 | −0.09 (0.09) | .32 | −0.04 (0.09) | .63 | |||||||
Crossover group by time | −0.11 (0.13) | .41 | 0.11 (0.12) | .34 | 0.19 (0.12) | .11 | |||||||
Age | 0.02 (0.02) | .23 | 0.02 (0.02) | .15 | 0.02 (0.02) | .18 | |||||||
Being female | −0.12 (0.08) | .14 | 0.04 (0.08) | .61 | 0.08 (0.08) | .29 | |||||||
Having a child | 0.04 (0.13) | .76 | −0.22 (0.13) | .09 | 0.16 (0.13) | .23 | |||||||
|
|||||||||||||
|
Just meet | 0.06 (0.15) | .66 | 0.06 (0.17) | .71 | 0.09 (0.14) | .54 | ||||||
|
Meet adequately | 0.08 (0.15) | .59 | 0.11 (0.17) | .51 | 0.04 (0.14) | .78 | ||||||
|
Meet comfortably | 0.09 (0.16) | .55 | 0.04 (0.17) | .84 | 0.05 (0.15) | .72 | ||||||
|
Cannot meet (reference) | —d | — | — | — | — | — | ||||||
|
|||||||||||||
|
Associate degree | −0.25 (0.21) | .23 | −0.04 (0.20) | .84 | −0.29 (0.21) | .17 | ||||||
|
Bachelor’s degree | −0.26 (0.19) | .17 | −0.22 (0.18) | .22 | −0.22 (0.19) | .24 | ||||||
|
Master’s degree | −0.23 (0.19) | .20 | −0.22 (0.18) | .22 | −0.26 (0.19) | .15 | ||||||
|
Doctorate degree | −0.23 (0.19) | .22 | −0.19 (0.18) | .28 | −0.25 (0.19) | .18 | ||||||
|
Certificate (reference) | — | — | — | — | — | — | ||||||
Numeracy level | 0.03 (0.02) | .15 | −0.02 (0.02) | .36 | −0.02 (0.02) | .43 | |||||||
Baseline NETP usee | −0.22 (0.09) | .009 | −0.16 (0.08) | .06 | −0.02 (0.08) | .01 | |||||||
Receive simple messagesf | 0.06 (0.07) | .41 | — | — | 0.15 (0.07) | .04 | |||||||
Receive gain-framed messagesf | 0.16 (0.07) | .04 | 0.13 (0.07) | .08 | — | — | |||||||
Receive emotional messagesf | — | — | 0.09 (0.07) | .20 | −0.02 (0.07) | .78 |
aNETP: new and emerging tobacco product.
bThree models are presented in this table. Unstandardized coefficients are presented with the significance level at .007.
cThe unadjusted time effects for participants receiving emotional, complex, and loss-framed messages were B(SE)=0.18 (0.06),
dFor reference factors (eg, cannot meet), this indicates that data is not applicable. For actual variables (eg, receive simple messages), this indicates that the variable was not included in the model.
eBaseline NETP use indicates past 30-day use of NETPs at baseline.
fThese variables compare receiving 1 message type with its counterpart (gain-framed vs loss-framed, emotional vs rational, and simple vs complex).
Change in perceived risk of using NETPa among participants receiving rational messages, those receiving simple messages, and those receiving gain-framed messages.b
Characteristics | Rational (n=322) | Simple (n=312) | Gain-framed (n=315) | ||||||||||||
|
B (SE) | B (SE) | B (SE) | ||||||||||||
Timec | 0.22 (0.08) | .005 | 0.25 (0.08) | .003 | 0.25 (0.08) | .002 | |||||||||
Crossover group | −0.12 (0.09) | .16 | −0.02 (0.09) | .85 | −0.04 (0.09) | .65 | |||||||||
Crossover group by time | 0.14 (0.11) | .21 | −0.08 (0.12) | .50 | −0.14 (0.12) | .24 | |||||||||
Age | 0.02 (0.02) | .16 | 0.02 (0.02) | .27 | 0.02 (0.02) | .17 | |||||||||
Being female | 0.07 (0.08) | .36 | −0.07 (0.08) | .39 | −0.10 (0.08) | .21 | |||||||||
Having a child | −0.16 (0.13) | .22 | 0.12 (0.13) | .33 | −0.22 (0.13) | .10 | |||||||||
|
|||||||||||||||
|
Just meet | 0.01 (0.15) | .52 | 0.10 (0.14) | .45 | 0.04 (0.16) | .80 | ||||||||
|
Meet adequately | 0.16 (0.15) | .28 | 0.15 (0.14) | .28 | 0.20 (0.16) | .22 | ||||||||
|
Meet comfortably | 0.09 (0.16) | .58 | 0.16 (0.14) | .27 | 0.13 (0.16) | .43 | ||||||||
|
Cannot meet (reference) | —d | — | — | — | — | — | ||||||||
|
|||||||||||||||
|
Associate degree | 0.04 (0.20) | .82 | −0.17 (0.20) | .39 | 0.07 (0.19) | .71 | ||||||||
|
Bachelor’s degree | −0.02 (0.18) | .88 | −0.04 (0.18) | .83 | −0.09 (0.17) | .60 | ||||||||
|
Master’s degree | −0.001 (0.18) | .99 | 0.03 (0.18) | .87 | −0.01 (0.17) | .96 | ||||||||
|
Doctorate degree | 0.04 (0.18) | .80 | 0.03 (0.17) | .87 | 0.04 (0.17) | .82 | ||||||||
|
Certificate (reference) | — | — | — | — | — | — | ||||||||
Numeracy level | −0.003 (0.02) | .86 | 0.04 (0.02) | .04 | 0.03 (0.02) | .13 | |||||||||
Baseline NETP usee | −0.09 (0.09) | .31 | −0.16 (0.09) | .06 | −0.10 (0.09) | .26 | |||||||||
Receive simple messagesf | 0.21 (0.07) | .003 | — | — | 0.07 (0.07) | .30 | |||||||||
Receive gain-framed messagesf | 0.07 (0.07) | .32 | 0.09 (0.07) | .04 | — | — | |||||||||
Receive emotional messagesf | — | — | −0.07 (0.07) | .34 | 0.03 (0.07) | .67 |
aNETP: new and emerging tobacco product.
bThree models are presented in this table. Unstandardized coefficients are presented, and the significance level is examined at .007.
cThe unadjusted time effects among participants receiving rational, simple, and gain-framed messages were B(SE)=0.30 (0.06),
dFor reference factors (eg, cannot meet), this indicates that data is not applicable. For actual variables (eg, receive simple messages), this indicates that the variable was not included in the model.
eBaseline NETP use indicates past 30-day use of NETPs at baseline.
fThese variables compare receiving 1 message type with its counterpart (gain-framed vs loss-framed, emotional vs rational, and simple vs complex).
On the other hand, as presented in
Change in perceived risk of using CTPa among participants receiving emotional messages, those receiving complex messages, and those receiving loss-framed messages.b
Characteristics | Emotional (n=314) | Complex (n=324) | Loss-framed (n=321) | ||||||||||
|
B (SE) | B (SE) | B (SE) | ||||||||||
Timec | 0.02 (0.07) | .01 | 0.16 (0.07) | .03 | 0.18 (0.07) | .01 | |||||||
Crossover group | 0.17 (0.07) | .76 | −0.09 (0.08) | .24 | −0.01 (0.08) | .94 | |||||||
Crossover group by time | −0.05 (0.10) | .64 | 0.03 (0.10) | .76 | 0.06 (0.10) | .54 | |||||||
Age | −0.01 (0.01) | .36 | −0.01 (0.02) | .66 | −0.01 (0.02) | .63 | |||||||
Being female | −0.01 (0.07) | .94 | 0.05 (0.07) | .45 | 0.04 (0.07) | .54 | |||||||
Having a child | 0.11 (0.11) | .33 | 0.04 (0.12) | .71 | 0.19 (0.11) | .09 | |||||||
|
|||||||||||||
|
Just meet | 0.25 (0.13) | .06 | 0.12 (0.15) | .43 | 0.22 (0.13) | .11 | ||||||
|
Meet adequately | 0.27 (0.13) | .04 | 0.24 (0.15) | .11 | 0.23 (0.13) | .07 | ||||||
|
Meet comfortably | 0.13 (0.14) | .35 | 0.11 (0.15) | .47 | 0.08 (0.13) | .55 | ||||||
|
Cannot meet (reference) | —d | — | — | — | — | — | ||||||
|
|||||||||||||
|
Associate degree | −0.08 (0.18) | .68 | 0.19 (0.17) | .27 | 0.04 (0.18) | .80 | ||||||
|
Bachelor’s degree | −0.002 (0.16) | .99 | 0.06 (0.16) | .71 | −0.002 (0.16) | .99 | ||||||
|
Master’s degree | 0.06 (0.16) | .71 | 0.08 (0.15) | .59 | 0.01 (0.16) | .96 | ||||||
|
Doctorate degree | −0.04 (0.16) | .79 | 0.10 (0.16) | .52 | −0.04 (0.16) | .81 | ||||||
|
Certificate (reference) | — | — | — | — | — | — | ||||||
Numeracy level | 0.02 (0.02) | .28 | −0.02 (0.02) | .31 | 0.01 (0.02) | .52 | |||||||
Baseline CTP usee | −0.16 (0.09) | .08 | 0.07 (0.09) | .45 | −0.14 (0.09) | .13 | |||||||
Receive simple messagesf | 0.04 (0.06) | .53 | — | — | 0.06 (0.06) | .47 | |||||||
Receive gain-framed messagesf | 0.14 (0.07) | .04 | 0.04 (0.07) | .57 | — | — | |||||||
Receive emotional messagesf | — | — | 0.06 (0.07) | .32 | −0.05 (0.06) | .47 |
aCTP: conventional tobacco product.
bThree models are presented in this table. Unstandardized coefficients are presented, and the significance level is examined at .007.
cThe unadjusted time effects among participants receiving emotional, complex, and loss-framed messages were B (SE)=0.16 (0.05),
dFor reference factors (eg, cannot meet), this indicates that data is not applicable. For actual variables (eg, receive simple messages), this indicates that the variable was not included in the model.
eBaseline CTP use indicates past 30-day use of CTPs at baseline.
fThese variables compare receiving 1 message type with its counterpart (gain-framed vs loss-framed, emotional vs rational, and simple vs complex).
Change in perceived risk of using CTPa among participants receiving rational messages, those receiving simple messages, and those receiving gain-framed messages.b
Characteristics | Rational (n=322) | Simple (n=312) | Gain-framed (n=315) | ||||||
|
B (SE) | B (SE) | B (SE) | ||||||
Timec | 0.09 (0.07) | .20 | 0.11 (0.07) | .12 | 0.08 (0.07) | .23 | |||
Crossover group | −0.10 (0.07) | .19 | 0.02 (0.07) | .81 | −0.06 (0.07) | .41 | |||
Crossover group by time | 0.12 (0.10) | .22 | 0.05 (0.10) | .62 | 0.03 (0.10) | .75 | |||
Age | 0.01 (0.01) | .31 | 0.01 (0.01) | .48 | 0.01 (0.01) | .65 | |||
Being female | 0.04 (0.06) | .49 | −0.02 (0.06) | .81 | −0.002 (0.07) | .98 | |||
Having a child | 0.08 (0.11) | .47 | 0.18 (0.10) | .07 | 0.02 (0.11) | .84 | |||
|
|||||||||
|
Just meet | −0.14 (0.12) | .25 | 0.06 (0.11) | .58 | −0.12 (0.13) | .36 | ||
|
Meet adequately | 0.01 (0.13) | .96 | 0.10 (0.11) | .36 | 0.04 (0.13) | .78 | ||
|
Meet comfortably | −0.13 (0.13) | .31 | −0.05 (0.11) | .67 | −0.11 (0.14) | .42 | ||
|
Cannot meet (reference) | —d | — | — | — | — | — | ||
|
|||||||||
|
Associate degree | 0.31 (0.16) | .05 | −0.001 (0.16) | 1.00 | 0.18 (0.16) | .26 | ||
|
Bachelor’s degree | 0.28 (0.14) | .05 | 0.24 (0.14) | .09 | 0.24 (0.14) | .09 | ||
|
Master’s degree | 0.29 (0.14) | .04 | 0.32 (0.14) | .02 | 0.32 (0.14) | .02 | ||
|
Doctorate degree | 0.35 (0.14) | .01 | 0.24 (0.14) | .08 | 0.32 (0.14) | .02 | ||
|
Certificate (reference) | — | — | — | — | — | — | ||
Numeracy level | 0.01 (0.02) | .65 | 0.04 (0.01) | .004 | 0.01 (0.02) | .37 | |||
Baseline CTP usee | −0.03 (0.08) | .74 | −0.30 (0.08) | <.001 | −0.05 (0.08) | .51 | |||
Receive simple messagesf | 0.09 (0.06) | .11 | — | — | 0.06 (0.06) | .36 | |||
Receive gain-framed messagesf | −0.03 (0.06) | .64 | 0.10 (0.06) | .09 | — | — | |||
Receive emotional messagesf | — | — | −0.01 (0.06) | .89 | 0.09 (0.06) | .37 |
aCTP: conventional tobacco product.
bThree models are presented in this table. Unstandardized coefficients are presented with the significance level at .007.
cThe unadjusted time effects among participants receiving rational, simple, and gain-framed messages were B(SE)=0.16 (0.05),
dFor reference factors (eg, cannot meet), this indicates that data is not applicable. For actual variables (eg, receive simple messages), this indicates that the variable was not included in the model.
eBaseline CTP use indicates past 30-day use of CTPs at baseline.
fThese variables compare receiving 1 message type with its counterpart (gain-framed vs loss-framed, emotional vs rational, and simple vs complex).
Tobacco marketing has successfully crafted messages to promote tobacco use among the general public, particularly among YAs. As a result, there has been evidence of limited public knowledge concerning the harms of tobacco products [
Previous research on risk perception among YAs supports our results pertaining to emotional and rational messages [
However, according to previous research, both gain-framed and loss-framed messages can be effective in increasing tobacco risk perception through different mechanisms [
There are some study limitations to be considered. First, this study involved a convenience sample. Nevertheless, the sample is representative of the diverse community college population in terms of demographic characteristics and tobacco use among Texan YAs [
With our current findings, we cannot conclude that one message type is more effective than another. Nevertheless, this study aimed to identify successful message types individually. Our results suggest that specific types of SMS text messages can be particularly successful. On the basis of our findings, we encourage future researchers to apply emotional, complex, and loss-framed messages when conveying the harm of CTPs. On the other hand, we recommend the use of simple and gain-framed messages to inform about the harms of NETPs. These messages may be emotional or rational.
Our messages can be strategically disseminated within campaigns conducted via social media, smartphone apps, or mass media. Our previous research has posited that YAs are interested in mobile health (mHealth) programs that help them learn about tobacco risks [
It is important to note that the appropriateness and impact of the messages are likely to be context-dependent, and the results may have limited transferability. Nevertheless, with the results of this study, researchers and practitioners implementing mHealth programs may take advantage of our tailored messages through larger technology-based programs such as smartphone apps and social media campaigns. If a program were to be designed where individuals could opt in to receive the messages, a separate study might be needed to examine the target populations’ needs and preferences with respect to these messages. One promising avenue for future research in this area is the integration of these messages into narratives that can facilitate accurate tobacco risk perception. Several studies have begun to consider the investigation of message framing strategies within narratives, indicating that narratives can be successful with both loss-framed and gain-framed messages [
Description and examples of SMS text messages.
CONSORT-eHEALTH checklist (V 1.6.1).
Associations between population characteristics and primary outcomes.
Demographic characteristics and risk perception ratings.
The 95% CIs for each coefficient and for all tables.
Consolidated Standards of Reporting Trials
CONSORT–Electronic and Mobile Health Applications and Online TeleHealth
conventional tobacco product
elaboration likelihood model
mobile health
new and emerging tobacco product
young adult
The authors would like to thank the leadership at Houston Community College for supporting their research. The authors would also like to thank all members of the scientific steering committee of the Texas Tobacco Center of Regulatory Science on youth and young adults for their support and valuable recommendations throughout this project. The committee includes Jerome Williams (Prudential Chair in Business, at the Rutgers Business School), Cornelia (Connie) Pechmann (Professor at the Paul Merage School of Business, University of California, Irvine), John Pierce (Professor at the Cancer Prevention Program, Moores Cancer Center, University of California, San Diego, La Jolla, California and the Department of Family Medicine and Public Health, University of California, San Diego), Lisa Hendrickson (Senior Research Scientist at the Stanford Prevention Research Center), and Lois Biener (Senior Research Fellow at the University of Massachusetts Boston). This study was funded by the Tobacco Center of Regulatory Science on Youth and Young Adults (5P50CA180906-02).
None declared.