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Final MPH Project Paper-1

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Kiarash P. Rahmanian

This document summarizes a study on assessing the knowledge, attitudes, and beliefs of college students at risk of becoming first-time electronic cigarette users. The study found high awareness but also openness to trying e-cigarettes among students. Based on testing message designs with the target group, designs depicting a hand with text, an aerosol spray can, and an infographic were most effective. The study concluded these three designs should be implemented and evaluated for an e-cigarette health communication campaign on campus.

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E-Cigs ≠ Safe: A Health Communication Campaign Dissuading First Time Users of Electronic Cigarettes Kiarash P. Rahmanian, B.S., MPH Candidate Department of Behavioral Sciences and Community Health College of Public Health and Health Professions University of Florida
2 E-Cigs ≠ Safe: A Health Communication Campaign Dissuading First Time Users of Electronic Cigarettes Kiarash P. Rahmanian Introduction Electronic cigarettes are devices that are powered by lithium batteries in which heat is applied to cartridges of flavored, liquid nicotine (along with other additives and chemicals) in order to deliver to the user in the form of an aerosol or ‘vapor’ ("DrugFacts: Electronic Cigarettes"). These ‘e-cigarettes’ are not lit, but produce the lit effect with an LED light when the user inhales the ‘vapor’ (Bhatnagar et. al. 2014). Often times, these electronic cigarette devices are made to look similar to tobacco products, particularly conventional cigarettes and cigars ("DrugFacts: Electronic Cigarettes"). Most e-cigarettes are comprised of five different components, which include the following ("DrugFacts: Electronic Cigarettes"): a.) A cartridge, b.) A heating device (an atomizer or vaporizer); c.) A power source (typically a lithium battery), d.) A sensor, and e.) A Smart Chip Microprocessor. The cartridge houses a built-in heating device (or atomizer) built in and comes prefilled with “nicotine juice”. The cartridges are attached onto one end of the lithium ion cell battery. The other end of includes the silicon mouthpiece. This holds the liquid solution, which contains the varying amounts of nicotine, flavorings, and other chemicals- such as nicotine, formaldehyde, acetaldehyde, propylene glycol, acrolein, glycerine‐based oils, flavorings and other chemicals (“Parts of an E-Cigarette and How They Work Together”). The heating device (an atomizer or vaporizer) is responsible for heating the liquid nicotine, which creates the nicotine-infused vapor that is inhaled (Bhatnagar et. al. 2014). This atomizer reacts to an electrical signal sent by the lithium ion cell battery. The power source (typically a lithium battery) is the most critical part of the Background: Data from the Healthy Gators survey of 2015, showed a staggering 84.54% of the students know what an electronic cigarette was; 40.9% stated that they had observed e-cigarette use on UF’s campus; 20.75% have tried an e-cigarette, 35.61% are unsure or do not think that e-cigarettes are harmful; 11.55% stated they would try an e-cigarette or start using regularly in the next 6 months; 3.2% of respondents used electronic cigarettes regularly in the past 30 days. The results of this survey show the rate of UF Students to be higher or equal to the national surveys for ever-use, attempted use, and awareness of electronic cigarettes. Objectives: The purpose of this study was to assess the knowledge, attitudes, and beliefs of students at the University of Florida that were defined as “at-risk” of becoming first-time users of electronic cigarettes in order to guide message designs for a health communication campaign to be rolled out in the Summer and Fall terms of 2015 that target the “at-risk” target population on campus by educating and promoting awareness of the negative health outcomes of electronic cigarettes. Methods: This study consists of 5 stages: 1) Recruitment; 2.) Two-Part Questionnaire of participants; 3.) Development of preliminary health communication products (based on findings from Two-Part Questionnaire); 4.) Pre-testing the first drafts of health communication products with the study participants; and 5.) Pre-testing the revised health communication products with the study participants. Results: 455 University of Florida students were recruited through convenience sampling, with 39 “at-risk” participants continuing in the study. Amongst the overall sample (n=455), 98% are aware of what e- cigarettes are, 57% have tried an e-cigarette (66% for “at-risk”), 53% are open to try an e-cigarette (83% for “at-risk”), 35% would become regular users of e-cigarettes (71.8% for “at-risk”), 57% are in the contemplation or preparation stage of becoming first-time users of e-cigarettes (59% for “at-risk” sample in the contemplation stage, and 40% in the preparation stage). Based on pre-testing results, design 1 (Only a hand with text), design 2 (aerosol spray can), and design 3 (Infographic) tested the most favorably amongst the “at-risk” target population. Conclusions: Design 1 (Only a hand with text), design 2 (aerosol spray can), and design 3 (Infographic) will be implemented and evaluated for effectiveness following GatorWell protocol in the Fall of 2015.
3 e-cigarette (“Parts of an E-Cigarette and How They Work Together”). A sensor inside the battery activates when a user begins inhaling or presses a button. This "Smart Chip Microprocessor" as it's known signals the e- cigarette to turn on, and sends a charge to the atomizer inside the cartridge. There are two settings- automatic and manual, which allow the user to just inhale (automatic), or press a button then inhale (manual). The sensor known as the “Operating Mode Sensor” or OMS triggers the smart chip, which signals the lithium ion cell battery to charge the atomizer upon inhalation (“Parts of an E-Cigarette and How They Work Together”). The Smart Chip Microprocessor is known as the “Microcomputer Smart Chip”. This component prompts the battery, through sending an electrical signal, which then employs the atomizer (“Parts of an E-Cigarette and How They Work Together”). In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The resulting aerosol or vapor is then inhaled (called "vaping"). Literature Review The cause for concern about e-cigarettes is plentiful but the primary concern lies in their potential ingredients being chemicals that are known to be toxic to humans. Because of the lack of regulation by the U.S. Food and Drug Administration (FDA), clinical studies about the safety of e-cigarettes have not been released to the public (“Electronic Cigarettes”, 2014, September 22). Users of e-cigarettes have no means of knowing: a.) Whether they are safe, b.) What chemicals they contain and at what dosages, and c.) How much nicotine the user is inhaling with each usage (Bhatnagar et. al. 2014). Atop these concerns are the concerns for those around e-cigarette users with secondhand smoke, nicotine digestion for children and pets, and the obvious long-term concerns about e-cigarettes. E-Cigarette Growth In the year 2014, the sales of electronic cigarettes have topped $1.7 million dollars (“Electronic Cigarettes”, 2014, September 22). According to Bhatnagar and colleagues (2014), electronic cigarette sales margins are predicted to grow to over $10 billion by 2017, which would surpass the sales of conventional cigarette sales margins. In addition, the 3 largest major tobacco companies have been purchasing independent e- cigarette companies and will potentially be sharing 75% of the profit pool from e-cigarette sales in the next 10 years (Bhatnagar et. al. 2014). The number of current electronic cigarette users stands at over 2.5 million. The awareness and use of electronic cigarettes is not as negligible as you may think. Currently, 4 out of 10 smokers or users of tobacco products use electronic cigarettes (“Electronic Cigarettes”, 2014, September 22). With the college student population, the largest cause for concern is that the number of never‐smokers who used electronic cigarettes rose. According to Bunnell (2014), that number rose from 79,000 to 263,000 between 2011 and 2013. Chemical Contents Some further concerns lie in the chemical contents (and solvents) of most e-cigarettes, the amount of nicotine intake per usage, the vapor of e-cigarettes, inequities of production / lack of quality control amongst all electronic cigarette products, and the gateway to conventional tobacco use. The solvents of most e-cigarettes in which nicotine and flavorings are dissolved in are contained as an aerosol and are also known as lung irritants that can transform into carbonyls ("DrugFacts: Electronic Cigarettes"). These carbonyls are cancer-causing chemicals- such as formaldehyde and acetaldehyde. In a study on E-cigarettes, toxic chemicals such as mercury, acrolein, aerosol, formaldehyde, diethylene glycol (found in antifreeze), acetaldehyde, propylene glycol (PG), glycerin, and various toxic metals- such as tin, nickel, cadmium, and lead, were found ("DrugFacts: Electronic Cigarettes"). A 2013 study notes that some of those toxic metals, such as nickel, are found in concentrations 2 to 100 times that of conventional cigarettes (“What's in Your E-Cigarette?”). Propylene glycol (PG) is used to make artificial smoke or fog that is used for stage pyrotechnics (Breland et. al., 2014). Glycerin is found in many food and prescription or over the counter (OTC) drugs and when heated becomes Acrolein, which can severely harm the lungs and can agitate heart conditions or disease in current or former smokers (“What's in Your E-Cigarette?”). Formaldehyde and acetaldehyde are
4 said to be potential carcinogens (Breland et. al., 2014). Aerosol is the state in which the chemicals above are contained. This state is a colloidal suspension of the metal and silicate particles dispersed in a gas. The natural flavoring that electronic cigarettes state they contain is even dangerous. There have been multiple cases of lipoid pneumonia reported that are cased by the recurrent exposure to the natural ingredient, glycerin-based oils, that is contained in electronic cigarette’s nicotine-based vapor (“What's in Your E-Cigarette?”). According to Farsalinos and colleagues (2013), the results of this study found from the “20 commercially-available EC liquids that were tested in vapour form, four were found to be cytotoxic on cultured cardiomyoblasts”. The results of the study further stated: “this study’s findings support the concept that ECs may be useful as tobacco harm reduction products, but the harm is still there and therefore, e-cigarettes should not be used because they are still harmful to human beings” (Farsalinos et. al., 2013). According to Torjesen, I. (2014), found that e- cigarette vapor could actually hurt non-smokers in the vicinity of those that use e-cigarettes and “although the data were preliminary, they provide evidence for a possible exposure risk to passive smokers in enclosed spaces with limited ventilation if all the emissions from e-cigarettes were exhaled”. This presents another consideration to be addressed in terms of e-cigarette regulation and use, since one of the primary arguments for using electronic cigarettes is their lack of harm to others around the users (Torjesen, I., 2014). Harm of E-Cigarettes Due to the 1st generation electronic cigarettes’ inability to deliver a similar powerful hit of nicotine that conventional tobacco products do, engineers and product developers worked on a 2nd generation electronic cigarettes that allows users to increase the device’s voltage, which increases the temperature to atomize substantially more nicotine per puff from the user (“Electronic Cigarettes”, 2014, September 22). This is a clear issue as the effect of nicotine could be worsened through further intake of nicotine. The lethality of nicotine does not change though, even a small dose of liquid nicotine is very lethal- less than one tablespoon of many of the “nicotine juices” currently available on the market is enough to kill an adult (“Electronic Cigarettes”, 2014, September 22). According to Cobb and colleagues (2010), a cigarette contains a “highly toxic dose of 10–15mg of nicotine” but serious poisoning is rare due to “pre-systemic metabolism and spontaneous vomiting limits the systemic absorption of nicotine in swallowed tobacco”, but these limits do not apply in the case of the high concentration of nicotine in “nicotine juice” and can “introduce a new set of risks similar to those in nicotine- based pesticides and not normally present in leaf tobacco products”. The nicotine poisoning has become such a large issue that the monthly poison control calls related to e-cigarettes (nationwide) increased from 1 in 2010 to 215 in 2014-- a rise from 0.3 percent to 41.7 percent of all emergency calls (Bunnell, 2014). Of those calls, 42% of them involved accidental poisoning of adults 20 or older (Bunnell, 2014). Overall, the U.S poison centers reported over 2,405 calls surrounding e-cigarette exposures from September 2010 to February 2014 (Bunnell, 2014). Another detail that is alarming is that the calls related to e-cigarettes were more likely than conventional cigarette calls to involve a report of a negative health effect following exposure (Cobb et. al., 2010). The potential effects of nicotine generally deal with the last segments of the brain to mature- the decision-making, and impulse control aspects. Particularly, the limbic system (otherwise known as the “reward system”) is affected, which regulates one’s responses to stimuli (including attention span) and dopamine production that deals with the feeling or pleasure and addiction (Breland et. al., 2014). Thusly, the level of harm of the potential nicotine exposure is very high and to be taken more seriously than conventional cigarettes. Research in the field of electronic cigarette usage is expanding rather rapidly with researchers who have already discovered that electronic cigarette users are experiencing diminished lung function, airway resistance and various negative cellular changes, regardless of whether they currently (or have ever) smoked conventional cigarettes or used other tobacco products (“E-cigarettes Not Without Risk”). These researchers exposed cells to e-cigarette vapor, which resulted in cells with similar unhealthy changes that occur to cells that are exposed to conventional cigarette smoke (“E-cigarettes Not Without Risk”). Those that use “nicotine-free electronic cigarettes” are not discounted from the side effects either. These users also experience inflammation of the cells in their lungs along with distinctive airway resistance (“E-cigarettes Not Without Risk”). The cause of the inflammation deals with the mass of the particles in the vapors of electronic cigarettes. The mass of these particles is about 3 milligrams per cubic meter of air (“E-cigarettes Not Without Risk”). This is approximately 100 times as greater than the Environmental Protection Agency’s (EPA) 24-hour exposure limit for the levels of
5 fine air particles, which is why 40% of these inhaled particles get deposited in the deepest and smallest airways of the lungs (“E-cigarettes Not Without Risk”). A study on pulmonary effects showed that 5 minutes of electronic cigarette usage led to a vast increase in peripheral airway flow resistance, impendence, and oxidative stress among health smokers (“E-cigarettes Not Without Risk”). Thus, these incredibly small particles are heavier than expected and are very harmful to the body, causing blood vessel damage, inflammation of the cells in the lungs, and other various negative effects on the nervous system. But, this does not discount former smokers that are using electronic cigarettes or current smokers who intend to use them for quit purposes. Considering all of the dangers of the chemical makeup of electronic cigarettes, the ingredient that stays uniform between conventional and electronic cigarettes is nicotine (“10 Little-known Facts About E-cigarettes – HowStuffWorks”). The FDA completed initial testing, which found that the cartridges for the e-cigarettes under the same manufacturing label release considerably different levels of nicotine (“10 Little-known Facts About E- cigarettes – HowStuffWorks”). These levels could range from 26.8 to 43.2 micrograms of nicotine per 100- milliliter puff (“10 Little-known Facts About E-cigarettes – HowStuffWorks”). Alongside this finding, the FDA’s lab tests indicate that those nicotine-free cartridges are still providing a low dose to users, notwithstanding the claims. Gateway to Conventional Cigarette Use The last and most disconcerting aspect to consider in terms of the need for a public health intervention and/ or education is that electronic cigarettes can prove to be a gateway to conventional tobacco product use, which is far worse and vastly proven through countless research studies showing all of the negative health effects both long-term and short-term. Studies have shown that those that identify as “never smokers” who went on to use an electronic cigarette were nearly twice as likely to smoke conventional cigarettes than those “never smokers” who had not used electronic cigarettes at all (Bunnell, 2014). According to Coleman and colleagues (2014), the “harm of e-cigarettes does not stop at the source, studies show that they can even serve as a gateway to using conventional cigarettes”. Based on the results of this study, “among young adults who had never established cigarette smoking behavior (unweighted 4,310), 7.9% reported having ever tried e-cigarettes—14.6% of whom reported current use of the product” (Coleman et. al., 2014). This “ever e-cigarette use was associated with being open to cigarette smoking (adjusted odds ratio = 2.4; 95% confidence interval = 1.7, 3.3), as was being male, aged 18–24, less educated, and having ever used hookah or experimented with conventional cigarettes” (Coleman et. al., 2014). In conclusion, this “ever use of e-cigarettes, as well as other tobacco products, was associated with being open to cigarette smoking”, and is therefore a rather large concern for those that use e- cigarettes (Coleman et. al., 2014). Concern for College Students Electronic cigarette (also called e-cigarettes or electronic nicotine delivery systems) usage is becoming a more frequent occurrence among college-aged students. According to Saddleson and colleagues (2015), “college students are involved with riskier behaviors than adults; and therefore are more susceptible to using e- cigarettes, alcohol, and drugs”. This statement aligns with the idea that though electronic cigarettes pose a threat and are harmful and considered “risky”, college-aged students are more prone to using them, which makes this target population “at-risk” and needing further study and education in order to effectively guide their decision- making process. This study went on to “evaluate susceptibility of future e-cigarette use among college students who have never used e-cigarettes” and discovered that the prevalence of those that will try or have tried e- cigarettes is very high (Saddleson et. al., 2015). According to Enofe and colleagues (2014), “never daily and nondaily smokers were 3 times as likely as former daily and non-daily smokers to use alternative nicotine products with a p < .001”. Adding to the risk of being a college-aged student, being a never-user of tobacco products also furthers the risk of the target population of concern. All of these factors melded together have and continue to create a high level of alarm among healthcare providers and public health professionals in the coming years. 2015 Health Gators Survey
6 With all of the concerns about electronic cigarettes circulating, there have been very minimal studies done dealing with the potentially “at-risk” population similar to the Healthy Gators Survey of 2015, but their results are invaluable in guiding this study. According to Sutfin and colleagues (2013), there is “limited data on e- cigarette use and correlations exist, and to our knowledge, no prevalence rates among U.S. college students have been reported”. This study in particular aimed to “estimate the prevalence of e-cigarette use and identify correlates of use among a large, multi-institution, random sample of college students” (Sutfin et. al., 2013). This was a fully web-based survey taken in the fall term of 2009 with 4,444 students from 8 colleges in North Carolina responding. The results of the survey stated: “ever use of e-cigarettes was reported by 4.9% of students, with 1.5% reporting past month use”, with the correlates of ever-use including “male gender, Hispanic or "Other race" (compared to non-Hispanic Whites), Greek affiliation, conventional cigarette smoking and e- cigarette harm perceptions” (Sutfin et. al., 2013). The interesting aspect of this study was that “although e- cigarette use was more common among conventional cigarette smokers, 12% of ever e-cigarette users had never smoked a conventional cigarette” and “e-cigarette use was negatively associated with lack of knowledge about e-cigarette harm” (Sutfin et. al., 2013). In conclusion, this study found that “unlike older, more established cigarette smokers, e-cigarette use by college students does not appear to be motivated by the desire to quit cigarette smoking” (Sutfin et. al., 2013). The other study that stood out as similar to the Healthy Gators survey of 2015 from UF is “Risky behaviors, e-cigarette use and susceptibility of use among college students” by Saddleson and colleagues published in 2015. This study used cross-sectional data from 2013 in order to examine prevalence, correlates and susceptibility to e-cigarettes among young adults using an Internet survey from a convenience sample of 1,437 respondents, 18-23 year olds that attended four colleges and/ or universities in the Upstate New York area (Saddleson, Kozlowski, et. al. 2015). According to Saddleson, Kozlowski, and colleagues (2015), “95.5% of respondents reported awareness of e-cigarettes; 29.9% were ever users and 14.9% were current users” with “never e-cigarette users, individuals involved in risky behaviors or, with lower harm perceptions for e-cigarettes” being more susceptible to electronic cigarette use in the near future. Both of these studies are very similar to the Healthy Gators survey of 2015, but their results are far less concerning than those of the Healthy Gator survey for the University of Florida’s campus and students. Following the Healthy Gators survey of February 2015, the electronic cigarette portion revealed a staggering 84.54% of the students surveyed responded that they are aware of what an electronic cigarette was (GatorWell Health Promotion Services, 2015). Though awareness is not indicative of use, 40.9% of respondents stated that they had observed e-cigarette use on UF’s campus- with 20.75% of respondents having tried an e- cigarette (GatorWell Health Promotion Services, 2015). Based off of these survey results, 35.61% of respondents are either unsure or they do not think that using e-cigarettes is harmful to one’s health (Gatorwell Health Promotion Services, 2015). The target of this study is based around those that are defined as “at-risk” for becoming first time users of e-cigarettes, which based on the survey results stands at 11.55% of respondents that stated they would try an e-cigarette in the next 6 months or start using an e-cigarette regularly in the next 6 months (GatorWell Health Promotion Services, 2015). The 30-day prevalence of use based off of item 61 of the Healthy Gators E-Cigarette survey indicated that 3.2% of respondents use electronic cigarettes regularly in the past 30 days. According to Adkison and colleagues (2013), “46.6% (of participants) were aware of ENDS (Electronic Nicotine Delivery Systems)- with the U.S. in the lead at 73; 7.6% had tried ENDS (or 16% of those aware of ENDS); and 2.9% were current users. In this study, awareness of ENDS was highest among “younger, non-minority smokers with higher income” and the “prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than conventional cigarettes (79.8%)”. Need for Intervention The results of the Healthy Gators Electronic Cigarette Survey of 2015 are a large cause for concern for those that work in the healthcare and public health fields at the University of Florida with our campus statistics for ever-use, tried, and awareness being higher or equal to the national surveys, especially because current use of electronic cigarettes in 2013 was just 1.9% among adults, with ever-use being at 8.5% ("DrugFacts: Electronic Cigarettes").
7 The rising trend with Universities and colleges dealing with tobacco issues are indoor and outdoor tobacco- free campus policies. Despite the new policy changes, there is very little direct evidence that currently exists on the impact of these tobacco-free policies on the outcomes of tobacco use. According to (Lee et. al., 2013), “researchers collected cigarette butts (n=3427) at main building entrances (n=67) at baseline and follow-up on 19 community college campuses stratified by strength of campus outdoor tobacco policy (none, perimeter/designated area, 100% tobacco free)” and the “outcome measures included the number of butts per day at building entrances averaged to create a campus score”. The results of the study showed that “100% tobacco-free community college campuses had significantly fewer cigarette butts at doors than campuses with no outdoor restrictions” (Lee et. al., 2013). Therefore, this study provides “some of the first evidence on the impact of 100% tobacco-free outdoor policies on college campuses using an objective and reproducible measure” and the fact that “such policies likely provide a more healthful environment for students, staff, faculty and visitors” (Lee et. al., 2013). The University of Florida is among the list of universities that has already taken the first step toward tobacco product cessation back in 2010, with the UF Tobacco-Free Campus policy. According to Duke and colleagues (2014), the tobacco industry and e-cigarette industry’s marketing and advertisement campaigns pose a high risk to potential users “in the absence of evidence-based public health messaging” where “the current e-cigarette television advertising may be promoting beliefs and behaviors that pose harm to the public health”. This study states: “if current trends in e-cigarette television advertising continue, awareness and use of e-cigarettes are likely to increase among youth and young adults” (Duke et. al. 2014). According to Trumbo, and Kim (2015), the e-cigarettes market’s advertisement tactics to college students and young adults in particular in the U.S. is geared around being “less harmful”, “only water vapor”, and “not addictive due to the lack of nicotine”. This study’s results state that there is a “positive reaction to the ads and holding the belief that e-cigarettes are not as addictive were both independently associated with intention” alongside the change in attitudes and norms, which “were also associated but were controlled by inclusion of the other variables” (Trumbo, and Kim. 2015). This perception shift of e-cigarettes could be creating an “at-risk” user population that this study will be addressing. This “at-risk” college-aged population is basically created by these pro-electronic cigarette advertisements (Trumbo, and Kim. 2015). These articles very much encourage counter-marketing campaigns against electronic cigarettes. Thus, with a clear understanding that there is a dire need for anti-electronic cigarette marketing and campaigns, a creation of a health communication campaign was pursued in this study through a strong basis in literature and theoretical frameworks. Purpose The next stage involves educating and increasing awareness of the dangers of tobacco products in the college-age population through health communication campaigns and social marketing campaigns. According to Choi and Forster (2013), “69.9% of respondents were aware of e-cigarettes, 7.0% had ever used e-cigarettes, and 1.2% had used e-cigarettes in the past 30 days”. These numbers are far lower than the number presented in the Healthy Gators Survey of 2015. Therefore, this study showed that those young college-aged adults perceive e-cigarettes as “less harmful and less addictive than cigarettes, despite the lack of scientific evidence related to e-cigarettes” (Choi and Forster, 2013). This low perceived severity of e-cigarette usage is prevalent amongst all research studies and adds weight to this study’s intentions to create a strategic health communication campaign in order to intervene with young adults who are “at-risk” of becoming first time users of electronic cigarettes (Choi and Forster, 2013). According to Choi and Forster (2013), “strategic health communication interventions to communicate to the public that evidence to support these perceptions is lacking and strengthening tobacco control regulations to include e-cigarettes could potentially reduce the prevalence of e-cigarette use among young adults”. Thusly, this study will undertake the first two stages of a health communication campaign targeting University of Florida students who identify as “at-risk” (based on survey items in the Two-Part Questionnaire) to explore the characteristics (e.g., knowledge, attitudes, beliefs) and preferences for health communication material targeted college-age students at risk for becoming first-time users of electronic cigarettes. Exploratory data from this study will be used to guide message designs for a larger health communication campaign targeting the “at-risk” target population on campus in the Summer and Fall terms of 2015. The overall purpose of the larger campaign sponsored by GatorWell at the University of Florida (UF) is
8 to educate and promote awareness of the negative health outcomes of electronic cigarettes among UF college students. Research questions and specific aims that guided this pilot study listed below: Objectives and Specific Aims The research questions that the primary researcher looked at were the following:  Research Question 1: What are the perceptions of knowledge that the members of the “at-risk” population possess about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects?  Research Question 2: In general, what is attitude of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects?  Research Question 3: In general, what are the beliefs of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects?  Research Question 4: How can this health communication campaign increase the perceived susceptibility and severity of the negative health outcomes of using electronic cigarettes of the members of the at-risk target population to decrease campus-wide usage of electronic cigarettes at UF?  Research Question 5: What are some of the preferred communication campaign design characteristics (e.g., color, graphic, text, rhetoric, etc.) among college-age students at risk for e-cig use?  Research Question 6: Are college-aged students who have attempted to use in the past (ever use) more likely to have close friends that use electronic cigarettes? The objectives or specific aims of the study were to:  Objective 1: To describe perceptions of knowledge that the members of the “at-risk” population possess about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects.  Objective 2: To explore the general attitude of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects.  Objective 3: To examine general beliefs of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects.  Objective 4: To distinguish how a health communication campaign can be executed effectively in order to increase the perceived susceptibility and severity of the negative health outcomes of using electronic cigarettes of the members of the at-risk target population to decrease campus-wide usage of electronic cigarettes at UF.  Objective 5: To distinguish the design preferences (color, graphic, text, rhetoric, etc.) of this “at-risk” target audience in regards to a health communication campaign geared toward the dissuasion of electronic cigarette use (learner verification).  Objective 6: To explore the association between using electronic cigarettes and reporting close friends who currently use electronic cigarettes. Hypotheses Based on the vast literature review and the Healthy Gators Survey of 2015, I have hypothesized that majority of participants that fall into the “at-risk” population recruited from the Two-Part questionnaire will be White Males, as there is already data that displays this in the literature review above. The large majority of data collected from this study is intended primarily for exploratory purposes. Due to the nature of this campaign’s intention being dissuasion of use, the perceived benefits by the study participants (based on each message design) will be geared toward their effectiveness in creating behavioral intention to not use electronic cigarettes using the negative health aspects (toxic chemicals, vapor instead of aerosol, etc.). Thus, it can be predicted that
9 the message designs that best conveys the various negative aspects (toxic chemicals, vapor instead of aerosol, etc.) will parallel the greatest intention of not using electronic cigarettes in the future. This study’s hypotheses are as follows:  Hypothesis 1: Baseline, or Time 1 (T1), knowledge of the harms of electronic cigarettes (toxic chemicals, vapor instead of aerosol, etc.) will be low.  Hypothesis 2: General attitudes towards electronic cigarettes will be positive at T1.  Hypothesis 3: Beliefs of the harm (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes will be negative at T1.  Hypothesis 4: The perceptions of the harm and negative health effects of electronic cigarettes will be low at T1.  Hypothesis 5: Participants with low levels of knowledge will have lower understanding of the harm of electronic cigarettes at T1.  Hypothesis 6: Participants that have tried (ever-use) electronic cigarettes in the past have several close friends that currently use electronic cigarettes.  Hypothesis 7: Participants with positive attitudes and beliefs will have a lower understanding of the harm of electronic cigarettes at T1. Theoretical Framework This study examines the knowledge, attitudes, and beliefs of college-age students “at-risk” for e-cig use, as well as design preferences for color, graphics, textual content, rhetoric, etc. Thusly, this study will be using the following theoretical frameworks to aid in the objectives and goals of the study: the health belief model, the stages of change (the Transtheoretical Model or TTM), the information processing paradigm, the theory of reasoned action (TRA), and the Diffusion of Innovation theory (or DOI) (Lefebvre, 2000). The Health Belief Model The Health Belief model consists of constructs that delve into a person’s regard for their own safety and their likelihood of susceptibility to the disease or harm, which are effected heavily by their barriers to change or benefits to the change. This theory later gained the construct of self-efficacy, which can be defined as the power to create or sustain that behavior change. For the Health Belief Model, this study’s campaign materials will work to increase the “at-risk” population’s perceived severity, the perceived benefits of action of not using them (or quitting for those outside of the “at-risk” population) all while addressing their perceived barriers to action through creating more cues to action. Primarily for this study, the campaign materials will be working to increase the “at-risk” population’s perceived severity and perceived benefits of action through providing varying cues to action throughout campus in the form of health communication messages and designs. The perceived severity of electronic cigarettes will be increased through messaging that includes the harmfulness of using them and their toxic contents, while the perceived benefits of action will be addressed simply through understanding that not using electronic cigarettes brings an overall healthier life. The components of this theory can be found in Appendix I. According to Ambrose and colleagues (2014), the perceived susceptibility of the college-aged population as a whole is rather low and contributes to creating college students with low perceived susceptibility and severity, which in turn adds to the current problem of the “at-risk” users that this study plans to address. Basically, this article shows that “many youth perceive tobacco use on a continuum of harm”, stating that “youth who perceive gradations in harm—both by frequency and intensity of cigarette use and by type of product—may be particularly susceptible to e-cigarette use” (Ambrose et. al., 2014). The basis of using a health communication campaign is further supported by literature in regards to tobacco counter-marketing ads and their effects on college students in regard to their level of knowledge, their attitudes, and their general beliefs. According to Murphy-Hoefer and colleagues (2010), “health consequences ads significantly increased overall knowledge and negative attitudes and beliefs”. Using surveys “before and after viewing four 30-second anti- tobacco advertisements in 1 of 3 theme categories-social norms, health consequences, or tobacco industry manipulation”, the students were to determine their answers based on their “knowledge, attitudes, and beliefs”
10 (Murphy-Hoefer et. al., 2010). With further fervor of support from the literature, it can be stated that a health communication campaign was the correct choice in regard to this “at-risk” population of college-aged students. The Stages of Change theory (the Transtheoretical Model or TTM) In regard to tobacco prevention or tobacco cessation processes, people generally are said to progress through five varying levels of readiness to change—pre-contemplation, contemplation, preparation, action, and maintenance. At each of these stages, various tactics can be used in order to help students to progress to the next stage and get closer to the action or maintenance stage. Within this study, this theory will be used in reverse through asking what stage the participant believes himself or herself to be in regarding their willingness to use an electronic cigarette. This will later be used as part of the data analysis and cleaning of the data in order to only be targeting those that are deemed “at-risk” based on being in either the contemplation or preparation stages of this model. This won’t necessarily be used to guide message campaigns, but rather for surveying the “at-risk” target population. The components of this theory can be found in Appendix II. The Information Processing Paradigm This paradigm, often used to look at the ways in which people process information from health communication campaigns, was used to look at the impact of the persuasive communication, through the three phases of message processing—attention to the message, comprehension of the content, and acceptance of the content. Some of the concepts from this theory that this study will look at are: exposure to information, perception of the information presented, comprehension of what is perceived, and agreement with what is presented. The later half of this health communication campaign will look at retention of what is accepted, and acting on the basis of the decision. The message designs will be evaluated following the pre-testing survey of preliminary materials based on these components. The components of this theory can be found in Appendix III. The Theory of Reasoned Action If a person has control over their own behaviors, their behavioral intentions can be predicted through their actual behavior. These behavioral intentions are determined by two factors—attitude toward the behavior and beliefs regarding others people’s support of the behavior. The concepts of this theory are: attitude toward that behavior, outcome expectations, normative beliefs, subjective norms, the beliefs and evaluations of others, and desire to comply with others (or motivation to copy). All of these components together determine that individual’s behavioral intention, which then predicts their actual behavior. This theory was used to determine the at-risk target population’s reasoning behind their action and aid in the pre-testing campaign materials. The components of this theory can be found in Appendix IV. According to Trumbo and Harper (2013), “an important goal of this project is to examine behavioral intention to try e-cigarettes”. In order for the researchers in this study to do so, they used the Theory of Reasoned Action (TRA), with its’ parsimonious form- behavior that is under volitional control is best predicted by behavioral intention, which in turn is best predicted by the individual’s attitude toward the act and the individual’s perception of social norms involving the act (Trumbo, C., and Harper, R., 2013). The authors state that they used the TRA because “it is widely acknowledged that tobacco use is socially embedded and the inclusion of normative effects addresses this condition” (Trumbo, C., and Harper, R., 2013). Also, this study measures attitudes, which in their measurement “included three items with 5-point responses (strongly agree to strongly disagree): use of e-cigarettes should be legal for adults, e-cigarettes are a big step forward, and belief that e-cigarettes are a more modern way of using tobacco. This study also looks at individual norms, which are “consisted of three pairs of items: it would be acceptable to my closest friends (most people I know, closest family members) if I used e-cigarettes; when it comes to things like e-cigarettes it is important for me to follow the wishes of my closest friends” (Trumbo, C., and Harper, R., 2013). In conclusion, this study guided a lot of the design of the Two-Part Questionnaire with questions similar to those used within this study’s survey methods. The Diffusion of Innovation Theory (DOI)
11 Any new idea, product, or behavior is adopted at varying rates. This rate is affected by the concepts within the Diffusion of Innovation theory. The concepts that this study looks at are: relative advantage, compatibility, complexity, trialability, and observability (Lefebvre, 2000). This theory was used in order to determine the aspects of electronic cigarettes that the “at-risk” population likened to and their reasoning. Thus, using their logic and reasoning, this theory and the survey items were used to guide campaign messaging and countering their reasoning and unsound logic. The components of this theory can be found in Appendix V. According to Trumbo, and Harper (2015), the results of this study show that “television ranked first for exposure to e-cigarette information” and that “the most positive innovation attributes were observability and relative advantage”. These two factors from the Diffusion of Innovation theory showed that “information exposure and favorable perception of an innovation predicted use” and therefore the “high degree of e-cigarette awareness combined with depiction of the devices as a favorable innovation may contribute to their wider adoption and may argue for regulation of e-cigarette advertising” (Trumbo, and Harper, 2015). This study led the preliminary design of the messages along with the data analysis of the Two-Part Questionnaire items that dealt with the DOI theory concepts. Methods Using the above theoretical frameworks, this study has worked to marry the various components (relative advantage, compatibility, complexity, trialability, and observability of the Diffusion of Innovation Theory; attitude toward behavior, outcome expectations, normative beliefs, subjective norms, the beliefs and evaluations of others, and desire to comply with others of the Theory of Reasoned Action; attention to the message, comprehension of the content, and acceptance of the content of the Information Processing Paradigm; perceived severity, perceived benefits of action, perceived barriers to action, and cues to action of the Health Belief Model; and the stage in which our target population is in regard to their level of readiness to use electronic cigarettes—contemplation and preparation of the Stages of Change or Transtheoretical Model) of each theory in order to build a strong synergy of message design and content for the health communication campaign. Inclusion Criteria The “at-risk” first-time users of electronic cigarettes will be defined through a Two-Part Questionnaire that includes 4 items from the 2015 Healthy Gators survey (Q.29, 57, 59, and 60) to determine risk level of participants. These items include: 1.) Have you ever heard of an “e-cigarette” or electronic cigarette, a cigarette- looking electronic device that delivers nicotine aerosol when you puff it (Other names for e-cigarettes include: “hookah pens”, “personal vaporizers”, and “smokeless cigarettes”); 2.) Have you ever tried an e-cigarette, even one or two puffs; 3.) How likely do you think that you would try an e-cigarette in the next 6 months, even if offered a puff from a friend or family member; and 4.) How likely do you think that you would start (or continue) using an e-cigarette regularly in the next 6 months. If the participant did not answer the questions in a particular manner to be included in this study, they did not progress to the second part of the initial questionnaire. They were thanked for their participation at that point and exited the questionnaire. Study Design As part of a larger study, this pilot study completed stages 1 and 2 of a health communication process model (cite appendix). Data from this study will help plan for the next two stages (Stage 3 and 4) of the health communication campaign design and testing. Stage 1 of the health communication campaign is the “Planning and Strategy Development” stage. Stage 2 of the health communication campaign is the “Developing and Pretesting Concepts, Messages, and Materials” stage. Following the completion of this study, the GatorWell Design Team will make the final revisions and follow the created action plan and timeline to rollout the health communication campaign for the Summer B and Fall 2015 terms. A flowchart of this study’s process is available in Appendix XIV. This study’s recruitment channels disseminated recruitment materials to a maximum of 51,000 participants, who are 18 years and older. Informed Consent Process
12 For each stage of the research study (questionnaire, pre-testing survey of preliminary materials, and post-testing survey of revised materials), consent was requested at the beginning of the Qualtrics survey. The informed consents were online and consisted of a checkbox (Appendix VII) that will not allow the participant to progress without selecting ‘I Do Consent for consent. If consent was not given, the participant was exited from the survey automatically using a programmed Qualtrics command. Stage 1: Planning and Strategy Development In the “Planning and Strategy Development” stage of the health communication campaign, the primary researcher: 1.) Completed a full literature review, and 2.) Completed all formative research based on data, collaborators, and other resources. Stage 2: Developing and Pretesting Concepts, Messages, and Materials Upon Institutional Review Board approval, during the “Developing and Pretesting Concepts, Messages, and Materials” stage of the health communication campaign, the primary researcher: 1.) Completed recruitment, 2.) Disseminated the two-part questionnaire, 3.) Developed the preliminary health communication campaign materials, 4.) Pre-tested the preliminary materials, 5.) Revised the preliminary materials based on pre-test results, 6.) Pre-tested the revised materials, and 7.) Made final revisions to materials. Recruitment (Appendix VIII) Participants for this study were recruited through email solicitation (over various listservs), social media websites (Facebook), and the Gator Times (a weekly E-Newsletter that is sent out to all UF students). Two-Part Questionnaire (Appendix IX) The Two-Part Questionnaire (T.1 in the process), in the form of an online survey through the Qualtrics program, was part of the formative research process. This survey provided insight to the at-risk students’ knowledge, attitudes and beliefs about using electronic cigarettes. Upon completion of data collection, the primary researcher completed a comprehensive data analysis (themed and coded qualitative data, SPSS for the Quantitative data) defined the potential “at-risk” first-time users of electronic cigarettes. These chosen “eligible” participants were then sent an email to await a follow-up email to continue in this study by aiding in the conceptualization and guiding of message designs for this health communication campaign. Preliminary Health Communication Campaign Materials Development (Appendix X) The findings from the Two-Part Questionnaire informed health communication product development. Following data analysis, the primary researcher attended message design meetings with the GatorWell Junior Designer for the preliminary campaign materials, resulting in the 1st mock-ups of the preliminary campaign materials. The message designs included 2 designs in different variations accounting for inclusivity of demographic backgrounds and color / text variations and one infographic with 2 variations. Upon completion of designs, these designs and their variations were pilot tested with peer groups, public health professionals with experience on the health topic of tobacco and electronic cigarettes. These content reviewers included: Dr. Jane Emmerée, Ph.D., CHES; Health Promotion Specialist for GatorWell Health Promotion Services; Dr. Kathy Nichols, MS, CHES; Associate Director of Area Health Education Center Program (AHEC); John-Michal Gonzales, MPH, MA; Health Communication Consultant at Tobacco Free Alachua; and Joi Alexander, MA, CHES, RHEd, Health Promotion Specialist for GatorWell Health Promotion Services. Pre-testing of Preliminary Campaign Materials (Appendix XI) After finalizing the campaign materials, an email was sent to all participants from the Two-Part Questionnaire that were deemed as “eligible” to complete the Pre-testing Survey of Preliminary Materials through an online Qualtrics survey (T.2 in the process), requesting their feedback on message designs. The products were tested for clarity, appeal, and applicability of the message content of the health communication designs. Upon completion of data collection, the primary researcher completed a comprehensive data analysis
13 (themed and coded qualitative data, SPSS for the Quantitative data) of the potential “at-risk” first-time users in regard to their feedback of the preliminary campaign messages. Health Communications Campaign Material Revisions (Appendix XII) The findings from the Pre-testing of Preliminary Products Survey informed health communication product development. Following data analysis, the primary researcher attended message design meetings with the GatorWell Junior Designer for the preliminary campaign materials, resulting in the final revised campaign materials. Pre-testing of Revised Campaign Materials (Appendix XIII) After finalizing the revised campaign materials, an email was sent to all participants from the Two-Part Questionnaire that were deemed as “eligible” to complete the Pre-testing Survey of Revised Materials (T.3 in the process), through an online Qualtrics survey, requesting their feedback on message designs. The products were tested for clarity, appeal, and applicability of the message content of the health communication designs. Upon completion of data collection, the primary researcher completed a comprehensive data analysis (themed and coded qualitative data, SPSS for the Quantitative data) of the potential “at-risk” first-time users in regard to their feedback of the revised campaign messages. Dr. Jane Emmeree and the GatorWell Junior Designer then revised the health communication products based on these findings for final products, to be implemented in the future. Incentives After sifting through all 455 surveys, only 39 participants were deemed “at-risk” and eligible for enrollment in this study. Each participant who completed the Two-Part Questionnaire and was deemed eligible based on the inclusion criteria was provided with a $5 Amazon gift card for the 1st stage of the study completed. Following this stage, every participant who completed the 2nd and 3rd survey or exited was awarded a $5 Amazon gift card for each one of the surveys. Plans for Analysis All statistical analyses within this study were performed using IBM SPSS, Version 22.0 (2013). Descriptive analysis was completed at each stage of data collection within the study (Two-Part Questionnaire, Pre-test of Preliminary Materials Survey, and the Pre-test of Revised Materials Survey). Descriptive statistics include demographic backgrounds for each data collection point as well as a fundamental Qualtrics data analysis based on frequency of answers. Qualtrics provided multivariate analysis measures through a Chi- Squared Test for Independence providing p-value comparisons (significance levels of p < 0.05) in order to take two categorical variables from the target sample and determine if there is a significant association between the two of them. Qualitative data analysis was completed for all qualitative items through coding, theming and quantifying through frequency of responses under each theme. Cross tabulations were completed for various questions from the Two-Part Questionnaire and the Pre-test of Revised Materials Survey. These cross tabulations were to explore potential associations. Due to the nature of this project and the shorten timeline, the participants’ selection of their favorite visual design and message content for each message design were collected for exploratory purposes and in order to determine the message designs to be implemented following the completion of this internship. Frequency tables were used in order to evaluate the differences between designs and the major themes that resulted from qualitative items following each quantitative question intended to provide a richer dataset to interpret from. The last three items on the pre-testing surveys provided options to participants through open-ended items requesting suggestions to improve upon the next round of message designs. The major themes are discussed throughout the results section. Continuation of Health Communication Campaign Process
14 Stage 3 and 4 were not completed by the primary researcher but instead will be completed by GatorWell staff and the preceptor. A cyclical flowchart of this study’s four stages is available in Appendix VI. These stages are: Stage 3: Implementing the Program, and Stage 4: Assessing Effectiveness and Making Refinements. Stage 3 will involve the roll out of the program through all the marketing channels from this study and the implementation plan that was formulated from this study. Stage 4 will involve evaluating the effectiveness of the campaign through surveying students at the University of Florida about the health communication campaign message designs and their content. An action plan was formed for stages 3 and 4 based on this study’s results and further collaboration with project partners, other professionals researchers in the public health field, as well as Dr. Jane Emmeree at the University of Florida’s GatorWell Health Promotion Services office. Stakeholder Involvement For this study, the stakeholders that were engaged were all UF Students (both graduate and undergraduate) in order to develop messages that are tailored toward the “at-risk” of use target population. The stakeholders were first recruited for the Two-Part Questionnaire, and then re-requested for feedback on messages designed based on their initial questionnaire results. Throughout the process, these stakeholders supported or opposed choices offered to them in order to influence the implementation of this campaign’s decisions. The purpose of collecting and using the demographic questions from the Two-Part Questionnaire are for screening and sampling purposes. This information was used to be informative and to “describe the group as a whole,” in order to test hypotheses about any gender differences. It was vital for this study to be able to understand the views of the stakeholder based on their community and identifying factors. Overall, this study’s stakeholder engagement provided GatorWell opportunities to further align their practices with the UF community’s needs and expectations, in order to help drive long-term solutions to health issues on the UF campus. Justification of Methods The methods used for this study were justified in the allotted timeline and deemed as valuable to GatorWell for further review and study. The idea of a health communication campaign geared toward UF students who are deemed as “at-risk” of becoming first-time users of electronic cigarettes was novel. There was no current running campaign that GatorWell had created around the topic area of electronic cigarettes, yet alone “at-risk” users. The need for an intervention, combined with a shortened timeline created vast justification for creating a novel health communication campaign around this target population within the health topic of electronic cigarette use. Results Two-Part Questionnaire Data- Descriptive Statistics Four hundred and fifty five University of Florida students were recruited through convenience sampling through social media solicitation, listserv mailings (Gator Times, Honors Daily), and emails to University of Florida professors to pass along to their students. The overall response rate was 89%; with the average time it took participants to complete the survey being 9 minutes. Amongst this group, awareness of E-Cigarettes was very high with 98% (n=455) stating that they know what an e-cigarette is. Attempted use amongst this sample sat at 57% of respondents who have tried an e-cigarette before (16%- “Yes, more than a year ago, but not in the past year”, 20%- “Yes, within the past year, but more than a month ago”, and 21%- “Yes, within the past month”). From this sample, only 179 have not tried an e-cigarette in their lifetime. In regards to future use, 53% stated they would try an electronic cigarette in the next 6 months, even if offered a puff from a friend or family member (12%- “Maybe yes, maybe no”, 15.4%- “Likely”, 13.7%- “Very likely”, and 11.8%- “Absolutely yes”). Regular use amongst this sample was 35% with respondents stating “You would start using an electronic cigarette regularly in the next 6 months” (6.7%- “Maybe yes, maybe no”, 10.4%- “Likely”, 10.6%- “Very likely”, 7.23%- “Absolutely yes”). Using the Stages of Change Model (or the Transtheoretical Model or TTM)
15 to look at the priority of risk, 57% stated they are in the contemplation or preparation stage of becoming first- time users of electronic cigarettes. Amongst the 403 completed surveys, 110 (or 27.3%) completed the entire survey (all questions- after meeting inclusion for being in the “at-risk” target population) with an average time of 18 minutes. Of the 110 potential “at-risk” users, 39 (or 35.5% of completed surveys for potential “at-risk” users or 8.8% of the original sample) were determined to not be using electronic cigarettes currently and be the true “at-risk” for use population and are representative of 0.08% of the Student Body. The students in this sample were 15.4% (n = 6) female, 84.6% (n = 33) male. There were 0 persons who identified as transgender or genderqueer who participated in this study. This target population consisted of 22 Undergraduate students (or 55%) and 17 Graduate / Professional students (or 44%). The undergraduate student makeup consisted of three 1st year undergraduate students (8%), five 2nd year undergraduate students (13%), six 3rd year undergraduate students (15%), seven 4th year undergraduate students (18%), one 5th year undergraduate student (3%), and seventeen Graduate or Professional students (44%). Participants ranged in age from 18-44 years old, with 38% in the 18- 24 range, 52% in the 25-34 range, and 10% in the 35-44 range. The demographic breakdown by race and ethnicity was 84% White (n=33), 13% Hispanic / Latino (n=5), 8% Asian (n=3), 5% Black or African- American (n=2), 3% American Indian / Alaskan Native (n=1), 0% Multi-race (n=0), 0% Unknown (n=0), and 0% Native Hawaiian / Pacific Islander (n=0). This is in comparison to the UF student population demographics of 49,878 students total (33,168 Undergraduates or 66.5% and 16,710 Graduate / Professional students or 33.5%) consisting of 18,189 female students and 14,979 male students (54.8% Female and 45.2% Male respectively) who are 59.1% White, 19.2% Hispanic / Latino, 7.6% Asian, 7.5% Black or African-American, 2.8% Multi-race, 2.8% Unknown, 0.7% Native Hawaiian / Pacific Islander, 0.3% American Indian / Alaskan Native (CollegeData.com, 2014). Two-Part Questionnaire Data- Background Attempted use amongst the “at-risk” sample sat at 66% of respondents who have tried an e-cigarette before (18%- “Yes, more than a year ago, but not in the past year”, 31%- “Yes, within the past year, but more than a month ago”, and 15%- “Yes, within the past month”). In regards to future use, 83% stated they would try an electronic cigarette in the next 6 months, even if offered a puff from a friend or family member (22.5%- “Absolutely yes”, 22.5%- “Very likely”, 40%- “Likely”, and 15%- “Maybe yes, maybe no”). Regular use amongst this sample was 71.8% with respondents stating “You would start using an electronic cigarette regularly in the next 6 months” (18%-“Absolutely yes”, 7.7%- “Very likely”, 46.2%- “Likely”, and 28.2%- “Maybe yes, maybe no”). Using the Stages of Change Model (or the Transtheoretical Model or TTM) to look at the priority of risk, 59% stated they are in the contemplation and 40% are in the preparation stage of becoming first-time users of electronic cigarettes. The qualitative portion of this question discovered that 42.5% (n=14) stated that they “needed more information before trying them”, 30.3% (n=10) stated that they “just want to try them”, 15.2% (n=5) stated that they “are concerned about the health consequences”, and 6.1% (n=2) stated that they “were concerned about the cost”. Two-Part Questionnaire Data- Social Norms Delving deeper into the data collected from the Two-Part Questionnaire, the situations in which participants would most likely try e-cigarettes were “when you are with friends” (43%, n=17), “in a social setting (a bar, restaurant, etc.)” (38%, n=15), and “when you are with family members” (20%, n=8). The social norms of this “at-risk” target population include that 43% (n=17) of the participants’ close friends or social groups currently use e-cigarettes with 82.5% citing a positive aspect to using electronic cigarettes (47.1%- “e- cigarettes are healthier than conventional cigarettes”, 35.4%- “electronic cigarettes are easy to use, cause no harm, and are low cost”, and 17.7%- “prefer electronic cigarettes”). The area of concern dealing with peer groups is that of close friend persuasion. 35% (n=14) of participants stated that their close friends who use electronic cigarettes have attempted to convince them to use them as well and they would comply with that request. Two-Part Questionnaire Data- Attitudes and Beliefs
16 The next segment of the Two-Part Questionnaire included questions about the participants’ attitudes and beliefs. Regarding the safety of electronic cigarettes versus conventional cigarettes, 68% (or 27 of 40 respondents) believe that electronic cigarettes are safer to smoke than regular cigarettes because “they are less harmful” (43%), “they have less nicotine” (36%), “they are not lit like a conventional cigarette” (14.3%), and because “they contain no tobacco” (4%). 56% (n=22) believe that using electronic cigarettes is either a habit or an addiction with 23% (n=9) believing it is both a habit and an addiction, and 21% (n=8) believing that it is neither a habit nor an addiction. 83% (n=33) believe that using electronic cigarettes is not as addictive as using other drugs. 85% (n=34) believe that the FDA should regulate electronic cigarettes. One item addressed the idea of the medical evidence that is being compiled against electronic cigarettes, through which 52% (n=19) stated they either believe the medical evidence about electronic cigarettes is exaggerated or they are unsure. In regard to the target audience’s perception of harm, 78% (n=31) have not heard anything negative about the dangers of using electronic cigarettes with 60% (n=3) having heard the negative statements about the dangers of using electronic cigarettes from “the Internet”, 20% (n=1) from “the News”, and 20% (n=1) from “Television commercials”. From these sources, 38% (n=3) stated that the negative statements about the dangers of using electronic cigarettes that they have heard through different media were about the “toxic chemicals in the vapor”, 25% (n=2) were about “incidents where electronic cigarettes burst while being used”, 25% (n=2) were about the “potential of causing various diseases”, and 12.5% (n=1) were about their “addictiveness”. 68% (n=27) believe that the electronic cigarettes are a less harmful alternative to smoking conventional cigarettes. 53% (n=21) believe that electronic cigarettes are not harmful. 43% (n=17) believe there are some benefits of not using electronic cigarettes. Of those, 65% (n=11) stated the biggest benefit to never using electronic cigarettes is “you would have better overall health”. Other reasons include “never being addicted to nicotine” (24%), “saving money rather than spending it on e-cigs” (6%), and “you would appear more classy” (6%). 57% (n=23) believe there are no benefits of not using electronic cigarettes. 27% (n=12) stated that the primary reason they would never use electronic cigarettes is because “of the health concerns”, with 18% (n=8) citing “the cost and price of electronic cigarettes”, 13% (n=6) citing “what others will think about me”, 13% (n=6) citing the “chance of the battery exploding or hurting me”, and 11% (n=5) citing “the possibility of addiction of presence of nicotine”. Other reasons that were cited for not using e-cigarettes were “the difference in the taste” (9%), “of the concern of my family members and friends” (7%), “of the law on UF’s campus” (2%). The final item addressed the participants’ thoughts on the use of electronic cigarettes by others. 32% (n=15) stated that their thoughts on others using electronic cigarettes is that they are “healthier than conventional cigarettes anyways”, 22% (n=10) “support their decision”, 19% (n=9) “don’t mind or care at all”, 15% (n=7) believe “it is that person’s choice”, and 13% (n=6) “don’t support their decision”. Two-Part Questionnaire Data- Knowledge The next segment of the Two-Part Questionnaire included questions about the participants’ knowledge in order to determine baseline knowledge on the topic of electronic cigarettes and their negative health aspects (toxic chemicals, aerosol instead of vapor, etc.). 77% (n=30) think that electronic cigarettes use among college students is very high. 52% (n=20) think that electronic cigarettes use among UF students is very high. 47% (n=18) think that electronic cigarettes use among their friend group is very high. Regarding the nicotine content of e-cigarettes, 20% (n=7) think that electronic cigarettes do not contain nicotine, and 15% (n=5) think that electronic cigarettes contain more nicotine than regular cigarettes or they are unsure. The reasons given for thinking e-cigarettes contain less nicotine than conventional cigarettes range from “they are unsure what else they contain” (60%), and “their purpose is not to be used as a quit aid, rather a continuation of tobacco use” (20%), to “they don’t use traditional tobacco” (17%). The item that addresses the chemical content of e- cigarettes discovered that 77% (n=30) are either unsure or believe that there are no harmful chemicals within what is exhaled from electronic cigarettes (the “vapor”). Instead, 60% (n=3) believe that e-cigarettes contain “filtrates” instead of nicotine, and 40% (n=2) believe they contain “vegetable juice”. The depth of this target population’s knowledge was uncovered through the final item in this segment. 53% (n=23) have heard that the chemicals in electronic cigarettes are “not harmful” with 21% (n=9) having heard that “there is not much known about the chemicals in electronic cigarettes”. Other responses regarding the chemicals in e-cigarettes include: “they contain nicotine” (16%), “they contain acetone” (5%), and “they contain formaldehyde” (5%).
17 Two-Part Questionnaire Data- Advertising Preferences For the final segment of the Two-Part Questionnaire, items were asked to gauge message style preferences and to guide the development of the message designs for this health communication campaign. 18% (n=7) have noticed various messages lately that discourage tobacco use that have turned them off. Among those that have noticed various messages lately that discourage tobacco use that have turned them off, 43% (n=3) were turned off by both the message and smoking, and 57% (n=4) were more turned off by the message than the smoking. Specifically, 72% (n=5) stated that what turned them off about the messages that they have seen lately is that they “used a scare tactic” and 29% (n=2) stated that what turned them off was “the gruesomeness of the message”. Regarding memorable advertisements, 33% (n=7) stated a memorable advertisement that they have seen recently was “geared toward their particular brand”, 14.3% (n=3) stated it was “very specifically based on the product”, and 14.3% (n=3) stated it was “one with a celebrity involved or endorsing the brand and product”. Other memorable advertisements that the respondents mentioned that they liked were from: Corona, Diet Coke, Airheads, various Car companies, White Owl, Petsmart, and Dove. The reasons that this target population gave for their preferences were “brand loyalty” (30%), “they looked modern” (23%), “they were clever” (17%), “it made them fearful” (9%), and “it was simple and bright” (9%). Other reasons that were mentioned were: “women were involved”, “variety of choices”, and the “involvement of a celebrity or endorsement by a celebrity”. As far as this target audience’s preference in terms of types of advertising, 54% (n=21) stated that their preference in regard to advertising styles is “a modern look”, “one that includes a lot of knowledge or is like a PSA”, and or is “clever or different”, and 16% (n=6) stated that their preference in regard to advertising styles is “clear-cut and to the point”. Other preferences included styles that are “flashy”, “contain a storyline”, “humorous”, and or “that create fear”. Pre-Testing Survey of Preliminary Materials Data- Descriptive Statistics Following the completion of the design phase of this study, thirty-five University of Florida students consented to participate in the Pre-Testing Survey of Preliminary Materials. Out of this initial 35, 28 surveys were determined to be from the Stage 1 survey (2 participants completed the survey twice, and 5 participants were not eligible as they had not completed Stage 1 of this study). The overall response rate was 72% completion based on the eligible Stage 1 “at-risk” participants, with the average time it took participants to complete the survey being 19 minutes. This pre-test survey tested 6 various designs for: clarity, appeal, and relatability of the message content of the health communication designs (see Appendix X). Design 1 was of a hand holding an e-cigarette with no face on a white background and the word “Deets” used instead of “Facts” at the bottom of the message following the campaign slogan “E-Cigs =/= Safe”. Design 2 was of a darker skin tone hand holding an e- cigarette with a darker tone face on a white background and the word “Deets” used instead of “Facts” at the bottom of the message following the campaign slogan “E-Cigs =/= Safe”. Design 3 was of a light skin tone hand holding an e-cigarette with a light tone face on a dark background and the word “Facts” used instead of “Deets” at the bottom of the message following the campaign slogan “E-Cigs =/= Safe”. Design 4 was of an aerosol can spraying a fog containing the toxic chemical words in e-cigarettes, the slogan, and some facts on a dark background. Design 5 was of an aerosol can spraying a fog containing the toxic chemical words in e- cigarettes, the slogan, and some facts on a turquoise background. Pre-Testing Survey of Preliminary Materials Data- Favorite Design Following a comprehensive data analysis of all survey results, each design was scored on the following categories: 1.) Agreement with message; 2.) Relatability; 3.) Appeal; 4.) Complexity; 5.) Unpleasantness or distastefulness; 6.) Effectiveness in communicating the negative health effects; 7.) Dissuasion effectiveness; 8.) Consistency with personal values; and 9.) The participant’s favorite design amongst the five choices. According to participants, design 2 (White background, e-cig, dark face, “Deets”) was the most agreeable at 86% (n=24), while design 5 (Aerosol Spray, colorful background) was the least agreeable at 68% (n=19). Design 2 (White background, e-cig, dark face, “Deets”) was the most relatable at 36% (n=10), while design 5 (Aerosol Spray, colorful background) was the least relatable at 7% (n=2). Design 3 (Dark background,
18 e-cig, light face, “Facts”) was the most appealing at 21% (or 6 responses), while design 4 (Aerosol Spray, dark background) was the least appealing at 7% (or 2 responses). Design 1 (White background, e-cig, no face, “Deets”) was the most confusing at 14% (or 4 response), while design 2 (White background, e-cig, dark face, “Deets”) was the least confusing at 4% (or 1 responses). Design 2 (White background, e-cig, dark face, “Deets”) and Design 3 (Dark background, e-cig, light face, “Facts”) were tied for being the most unpleasant or distasteful at 7% (or 2 responses), while design 4 (Aerosol Spray, dark background) and Design 5 (Aerosol Spray, colorful background) were tied for being the least unpleasant or distasteful at 4% (or 1 responses). Design 4 (Aerosol Spray, dark background) was the best at communicating negative health effects at 82% (or 23 responses), while design 2 (White background, e-cig, dark face, “Deets”) was the worst at communicating negative health effects at 11% (or 3 responses). Design 4 (Aerosol Spray, dark background) was the most effective at dissuading students from using e-cigarettes at 82% (or 23 responses), while design 1 (White background, e-cig, no face, “Deets”) and design 2 (White background, e-cig, dark face, “Deets”) were tied for being the least effective at dissuading students from using e-cigarettes at 11% (or 3 responses). Design 5 (Aerosol Spray, colorful background) was the most effective at communicating the advantages of not using electronic cigarettes at 75% (or 21 responses), while design 3 (Dark background, e-cig, light face, “Facts”) was the least effective at communicating the advantages of not using electronic cigarettes at 32% (or 9 responses). Lastly, design 1 (White background, e-cig, no face, “Deets”) was the most consistent with their values at 79% (or 22 responses). All of the descriptive statistics of each design can be found in Appendix XVI. In terms of the participants’ favorite design, design 1 (White background, e-cig, no face, “Deets”) was the frontrunner at 39% (n=11). In second place was design 2 (White background, e-cig, dark face, “Deets”) at 21% (n=6). Third place was design 3 (Dark background, e-cig, light face, “Facts”) at 18% (n=5). The second to last ranking was design 4 (Aerosol Spray, dark background) at 18% (n=5). In last place was design 5 (Aerosol Spray, colorful background) at 4% (n=1). Using all of the above descriptive statistics, a point system was created to rank the message designs in order to proceed to the final pre-testing survey. The scoring system that was used in this study either added a positive point for being the highest ranking in each one of the 9 categories or a negative point for being the lowest ranking in each one of the 9 categories (agreement with message, relatability, appeal, complexity, unpleasantness or distastefulness, effectiveness in communicating the negative health effects, dissuasion effectiveness, consistency with personal values; and the participant’s favorite design amongst the five). The total point valuation for design 1 (White background, e-cig, no face, “Deets”) was three points. The total point valuation for design 2 (White background, e-cig, dark face, “Deets”) was two points. The total point valuation for design 3 (Dark background, e-cig, light face, “Facts”) was two points. The total point valuation for design 4 (Aerosol Spray, dark background) was zero points. The total point valuation for design 5 (Aerosol Spray, colorful background) was negative two points. Overall, design 1 (White background, e-cig, no face, “Deets”) and design 3 (Dark background, e-cig, light face, “Facts”) were chosen to continue (with revisions) to the final Pre-Testing Survey of Revised Materials. Based on this scoring, design 1 and 3 were chosen to continue as the primary message designs in this health communication campaign. The revisions for the message designs that were suggested (based on qualitative items in the survey) were in the areas of: 1.) Color / Layout; 2.) Image content; and 3.) Content. For the area of color and layout, the suggestion that resonated the most from participants was “you may want to use brighter colors to attract attention”. For the area of image content, the suggestions that resonated the most from participants were: "get rid of the beard. I don’t know any guys with a beard”, “get rid of the man”, and “get rid of the woman”. For the area of content, the suggestions that resonated the most from participants were: “mention more about the side effects”, “provide the laymen’s terms for the chemicals”, and "it would help better if there were tiny footnotes on how each of these chemicals are harmful”. Due to a shortage of time and the amount of time an infographic takes, the infographic for this study was not pre-tested in the first round of pre-testing. Instead, the infographic was revised based on content experts that aided in the content and design revisions for the message designs prior to being pre-tested. The edits that were suggested for the infographic were in the areas of: 1.) Color / Layout; and 2.) Content. For the area of color and layout, the suggestion that resonated the most from participants were: “it looks a bit cluttered”, “one of the best things about infographics is that, since they are usually designed for the web, they are free to break from typical size/dimensions. This looks like it would fit on an 8.5 by 11 sheet of paper
19 but (unless you DO want to print it) it doesn’t have to”, and “maybe space it out a bit or give some sections a lighter brown background to separate it visually”. For the area of content, the suggestions that resonated the most from participants were: “under “Concerns about e-cigs”, there ARE ways of knowing these things, we just don’t know yet. Your major premise is that they are not safe, so saying ” there is no way of knowing if they are safe” doesn’t connect”, “maybe “Toxic Chemicals” could use a statement underneath about e-cigs. Or at least call it “Toxic Chemical in E-cig vapor”, “for the “5 minutes of e-cig use” fact: consider rephrasing to something about making it harder to breath – which is basically what I guess that “peripheral airflow resistance and oxidative stress” means. But I don’t really know what it means”, “put quotes around “nicotine-free” in the FDA fact”, and “for the final fact: Don’t start with “it has been found that” Use more active language like “E- cigarette vapor has more than twice the concentration of harmful heavy metals as cigarette smoke – sometimes as much as 100 times more”. Pre-Testing Survey of Revised Materials Data- Descriptive Statistics Following the completion of the revisions of the preliminary message designs, forty-two University of Florida students consented to participate in the Pre-Testing Survey of Revised Materials. Out of this initial 38, 38 surveys were determined to be from the Stage 1 survey (4 participants completed the survey twice). The overall response rate was 97.4% completion based on the eligible Stage 1 “at-risk” participants, with the average time it took participants to complete the survey being 17 minutes. This pre-test survey tested 3 various designs for: clarity, appeal, and relatability of the message content of the health communication designs (see Appendix X). Design 1 was of a hand holding an e-cigarette with no face on a turquoise background and the word “Facts” used instead of “Deets” at the bottom of the message following the campaign slogan “E-Cigs =/= Safe”. Design 2 was of an aerosol can spraying a fog containing the toxic chemical words in e-cigarettes, the slogan, and some facts on a turquoise background. Design 3 was an infographic containing an e-cigarette in the middle with facts on both sides on a turquoise background. Pre-Testing Survey of Revised Materials Data- Favorite Design Following a comprehensive data analysis of all survey results, each design was scored on the following categories: 1.) Agreement with message; 2.) Relatability; 3.) Appeal; 4.) Complexity; 5.) Unpleasantness or distastefulness; 6.) Effectiveness in communicating the negative health effects; 7.) Dissuasion effectiveness; 8.) Consistency with personal values; and 9.) The participant’s favorite design amongst the five choices. According to participants, design 2 (Aerosol spray) and 3 (infographic) were the most agreeable at 97.4% (n=37), while design 1 (Turquoise background, e-cig, no face, “Facts”) was the least agreeable at 92.1% (n=35). This was a 10.1% increase for design 1, and a 29.4% increase for design 2. Design 1 (Turquoise background, e-cig, no face, “Facts”) was the most relatable at 11% (n=4), while design 3 (Infographic) was the least relatable at 8% (n=3). Design 1 (Turquoise background, e-cig, no face, “Facts”) was the most appealing at 11% (n=4), while design 2 (Aerosol spray) was the least appealing at 5% (n=2). This was a 4% increase for design 2. Design 3 (Infographic) was the most confusing at 8% (n=3), while design 1 (Turquoise background, e- cig, no face, “Facts”) and design 2 (Aerosol spray) was the least confusing at 0% (n=0). This was a 14% decrease in confusion for design 1, and an 11% decrease in confusion for design 2. No Designs were the most unpleasant or distasteful, while all Designs were tied for being the least unpleasant or distasteful. This was a 7% decrease in unpleasantness for design 1, and a 4% decrease in unpleasantness for design 2. Design 3 (Infographic) was the best at communicating negative health effects at 94.8% (n=36), while design 1 (Turquoise background, e-cig, no face, “Facts”) was the worst at communicating negative health effects at 76.3% (n=29). This was a 3% increase for design 1. Design 3 (Infographic) was the most effective at dissuading students from using e-cigarettes at 100% (n=38), while no Designs were the least effective at dissuading students from using e-cigarettes. Design 3 (Infographic) was the most effective at communicating the advantages of not using electronic cigarettes at 100% (n=38), while design 1 (Turquoise background, e-cig, no face, “Facts”) was the least effective at communicating the advantages of not using electronic cigarettes at 2.6% (n=1). Lastly, Design 1 (Turquoise background, e-cig, no face, “Facts”) was the most consistent with their values at 86.9% (n=33). This was a 7% increase for design 1. All of the descriptive statistics of each design can be found in Appendix XVII.
20 In terms of the participants’ favorite design, design 3 (Infographic) was the frontrunner at 89% (n=34). In second place was design 1 (Turquoise background, e-cig, no face, “Facts”) at 3% (n=1). In last place was de design 2 (Aerosol spray) at 8% (n=3). Using all of the above descriptive statistics, a point system was created to rank the message designs in order to proceed to the final pre-testing survey. The scoring system that was used in this study either added a positive point for being the highest ranking in each one of the 9 categories or a negative point for being the lowest ranking in each one of the 9 categories (agreement with message, relatability, appeal, complexity, unpleasantness or distastefulness, effectiveness in communicating the negative health effects, dissuasion effectiveness, consistency with personal values; and the participant’s favorite design amongst the five). The total point valuation for design 1 (Turquoise background, e- cig, no face, “Facts”) was one point. The total point valuation for design 2 (Aerosol spray) was one point. The total point valuation for design 3 (Infographic) was eight points. Overall, all three designs tested positively with the target population and will be implemented following this study. The revisions for the message designs that were suggested (based on qualitative items in the survey) were in the areas of: 1.) Color / Layout; and 2.) Content. For the area of color and layout, the suggestion that resonated the most from participants was “if you make the slogan bolder and a bright color, it will stand out better against the background” - on the aerosol message, “the title looks good bold, but it doesn’t stand out” - on the infographic, and “make key points stand out by pictures clearly- text with hand. Based on the suggested edits, the following actions were taken: to make the slogan red on the aerosol message, make the word “Harmful” red on the infographic, and to make some of the chemicals different colors to stand out on the text with hand message. For the area of content, the suggestions that resonated the most from participants were: "add more attractive content”- hand with text, “needs a slogan”- Text with hand, and "reduce the text and add more graphical content”- Infographic. Based on the suggested edits, the following action was taken: use “Less harmful doesn’t mean safe” on the text with hand message design. Exploratory Analysis Completing data analysis through Qualtrics provided multivariate analysis measures through Chi- Squared Tests for Independence providing p-value comparisons (significance levels of p < 0.05) in order to take two categorical variables from the target sample to determine if there is a significant association between the two of them. From the Two-Part Questionnaire, the variables that were compared through cross tabulation were: 1.) Perception of harm of chemical contents and future use; 2.) Close friend use and future use; 3.) Age and gender; 4.) Gender and ever use; 5.) Ever use and close friend use; 6.) Awareness and future use; 7.) Stage of TTM and future use; 8.) Nicotine contents and future use; 9.) Amount of nicotine and future use; 10.) Perceptions of harm and future use; and 11.) Comparative harm (conventional cigarettes versus e-cigarettes) and future use. After a detailed analysis, the variables that may be associated are: 1.) Perception of harm of chemical contents and future use (p=0.40); 2.) Nicotine contents and future use (p-value=0.34); and 3.) Comparative harm (conventional cigarettes versus e-cigarettes) and future use (p-value=0.60). But due to the rather small sample size of 39 participants these variables were not associated to each other. Only one variable comparison showed significance, ever use and close friend use. For the comparison of participants’ ever use cross tabulation showed a p-value of 0.02 in regard to close friend use. Therefore, because the cross tabulation showed a p-value less than the significance level (0.05), therefore there was relationship between the two variables of ever use (use in the past at any point in time) and future use (within the next 6 months- regular use or attempted use). For each of the remaining comparisons, cross tabulation showed a p- value greater than the significance level (0.05), therefore there was no relationship between any of the remaining compared variables. These cross tabulations can be found in Appendix XVIII. Frequency tables were used in order to evaluate the differences between designs and the major themes that resulted from qualitative items following each quantitative question intended to provide a richer dataset to interpret from. These frequency tables, graphs, and charts can be found in Appendix XIV (for the Two-Part Questionnaire), XV (for the Pre-Testing of Preliminary Materials Survey), and XVI (for the Pre-Testing of Revised Materials Survey).
21 Relationship of Findings to Objectives, Aims, or Hypotheses Based on the findings of this study, majority of the objectives were met and exceeded. This study: 1.) Described perceptions of knowledge that the members of the “at-risk” population possess about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects; 2.) Explored the general attitude of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects; 3.) Examined general beliefs of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects; 4.) Distinguished how a health communication campaign can be executed effectively in order to increase the perceived susceptibility and severity of the negative health outcomes of using electronic cigarettes of the members of the at-risk target population to decrease campus-wide usage of electronic cigarettes at UF; 5.) Distinguished the design preferences (color, graphic, text, rhetoric, etc.) of this “at-risk” target audience in regards to a health communication campaign geared toward the dissuasion of electronic cigarette use (learner verification); and 6.) Explored the association between using electronic cigarettes and reporting close friends who currently use electronic cigarettes. Out of all seven hypotheses, the data were consistent with four hypotheses and inconsistent with three hypotheses. Baseline knowledge of the harms of electronic cigarettes (toxic chemicals, vapor instead of aerosol, etc.) was impartial (neutral) at T1. This was inconsistent with the hypothesis, based on this study’s findings. This study’s findings resulted in 2 out of 4 items being answered incorrectly (2 correct- 83% knew of nicotine content and 85% knew of less nicotine than conventional cigarettes; and 2 incorrect- 76% didn’t know about toxic chemicals and 90% chemicals were not harmful). The general attitude towards electronic cigarettes was more positive at T1. This was consistent with the hypothesis, based on this study’s findings. This study’s findings resulted in 3 out of 4 items being answered in the positive direction in regard to attitude (3 positives- 54% medical evidence exaggerated, 53% not harmful, 87% don’t care if others use; and 1 positive- 85% want FDA regulation). The beliefs of the harm (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes were more negative at T1. This was consistent with the hypothesis, based on this study’s findings. This study’s findings resulted in 7 out of 8 items being answered in the negative direction in regard to beliefs of the harms of e-cigarettes (1 positive- 68% safe; and 7 negative- 78% not heard of dangers, 60% believe not the same as conventional cigarettes, 48% doesn’t cause stroke, 45% doesn’t cause heart attacks, 43% doesn’t cause lung cancer, 57% no benefit of not using, 83% not as addictive). The perceptions of the harm and negative health effects of electronic cigarettes will be low at T1. This was consistent with the hypothesis, based on this study’s findings. This study’s findings resulted in 12 out of 14 items being answered in the negative direction in perception of the harms of e-cigarettes. The hypothesis associating low levels of knowledge to lower perception of harm was unproven, through cross tabulation and therefore was inconsistent with the hypothesis, based on this study’s findings. Participants’ ever use cross tabulation showed a p-value of 0.02 (a p-value less than the significance level 0.05) in regard to close friend use and therefore a relationship between the two variables of ever use (use in the past at any point in time) and future use (within the next 6 months- regular use or attempted use) exists, which is consistent with this study’s hypothesis. The hypothesis associating positive levels o f attitudes and beliefs to a lower perception of harm was unproven, through cross tabulation and therefore was inconsistent with the hypothesis, based on this study’s findings. Regarding the research questions, all of the research questions of this study were answered through findings as well. The level of knowledge that the members of the “at-risk” population possess about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects was neutral. The attitude of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects was more positive. The beliefs of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects were more negative. There was an association between ever use (attempted use in the past) to having close friends that use electronic cigarettes. This study discovered various communication campaign design preferences (color, graphic, text, rhetoric, etc.) for the at-risk participants for electronic cigarettes such as: being more colorful, including facts about electronic cigarettes, being clear-cut and to the point, providing valuable knowledge, being less wordy, being flashy to
22 catch attention, using a more modern look, creating an overarching brand for the campaign, and using clever rhetoric and text. The aspects that this sample did not like in regards to messaging were: using fear tactics, being humorous, using gruesome imaging, and being dull-colored or boring. Interpretation of Findings This study’s health communication campaign discovered tactics to increase the perceived susceptibility and severity of the negative health outcomes of using electronic cigarettes of the members of the at-risk target population to decrease campus-wide usage of electronic cigarettes through speaking about the harm of electronic cigarettes to educate more on the toxic chemicals, secondhand aerosol, long term effects, and facts to not normalize use amongst the college student group nationwide. These tactics could potentially aid in generating a negative attitude toward electronic cigarettes, bolstering baseline knowledge, and creating negative beliefs about e-cigarettes. With design 1 (text with hand) and design 2 (aerosol spray can) testing the highest among pre-tested message designs through providing appealing characteristics (based on design preferences) and educating on the harms of electronic cigarettes, these message designs convey all the desired aspects from GatorWell’s standpoint and will be received the best from the “at-risk” target audience (to be determined by GatorWell through evaluation protocol). Discussion Relationship of Findings to Literature The harm of electronic cigarettes starts with the lack of health communication messaging that provides accurate depictions of the harms of electronic cigarettes. According to Duke and colleagues (2014), the tobacco industry and e-cigarette industry’s marketing and advertisement campaigns pose a high risk to potential users “in the absence of evidence-based public health messaging” where “the current e-cigarette television advertising may be promoting beliefs and behaviors that pose harm to the public health”. This study states: “if current trends in e-cigarette television advertising continue, awareness and use of e-cigarettes are likely to increase among youth and young adults” (Duke et. al. 2014). According to Trumbo, and Kim (2015), the e-cigarettes market’s advertisement tactics to college students and young adults in particular in the U.S. is geared around being “less harmful”, “only water vapor”, and “not addictive due to the lack of nicotine”. This study’s results stated that there is a “positive reaction to the ads and holding the belief that e-cigarettes are not as addictive were both independently associated with intention” alongside the change in attitudes and norms, which “were also associated but were controlled by inclusion of the other variables” (Trumbo, and Kim. 2015). This perception shift of e-cigarettes is creating an “at-risk” user population that this study will be addressing. This “at-risk” college-aged population is basically created by these pro-electronic cigarette advertisements (Trumbo, and Kim. 2015). According to Choi and Forster (2013), “strategic health communication interventions to communicate to the public that evidence to support these perceptions is lacking and strengthening tobacco control regulations to include e-cigarettes could potentially reduce the prevalence of e-cigarette use among young adults”. According to Enofe and colleagues (2014), “never daily and nondaily smokers were 3 times as likely as former daily and non-daily smokers to use alternative nicotine products with a p < .001”. Adding to the risk of being a college-aged student, being a never-user of tobacco products also furthers the risk of the target population of concern. These articles from the literature review very much encourage counter-marketing campaigns against electronic cigarettes and stoically support the need for health communication messaging. The comprehensive literature revels a multitude of negative aspects (toxic chemicals, secondhand aerosol, aerosol state of contents, nicotine content, etc.) and health effects (causing blood vessel damage, inflammation of the cells in the lungs, and other various negative effects on the nervous system) of electronic cigarette use. With the Sutfin and colleagues (2013) study discovering that “unlike older, more established cigarette smokers, e-cigarette use by college students does not appear to be motivated by the desire to quit cigarette smoking”, using such tactics geared toward heightening harm perception of the “at-risk” target population allowed for effective message, in addition to using facts from the literature surrounding toxic chemicals (toxic chemicals such as mercury, acrolein, aerosol, formaldehyde, diethylene glycol found in antifreeze, acetaldehyde, propylene glycol, glycerin, and various toxic metals- such as tin, nickel, cadmium, and
23 lead, were found- "DrugFacts: Electronic Cigarettes") and nicotine poisoning (U.S poison centers reported over 2,405 calls surrounding e-cigarette exposures from September 2010 to February 2014- Bunnell, 2014). Relating the comprehensive literature review to this study shows that the UF students stand at 98% awareness of e-cigarettes (versus 84.54% aware of what an electronic cigarette was- GatorWell Health Promotion Services, 2015), 57% ever use (versus 20.75% ever use- GatorWell Health Promotion Services, 2015), and 53% have a low perception of their harm (versus 35.61% are unsure or do not think using e- cigarettes is harmful- GatorWell Health Promotion Services, 2015). The findings of this study align with the comprehensive literature review from this study and support the need for an intervention and the knowledge, attitudes, and beliefs being a large driving force for creating effective health communication messaging geared toward dissuading University of Florida students from becoming first time users of electronic cigarettes. Limitations As far as limitations for this study, the major limitation was the process of gaining IRB approval. The first submission was on April 2nd, and final approval was not given until May 6th. An added issue with IRB was the lack of notification until eight days following the approval on May 14th. This limitation created a bit of a time crunch, though nothing was impacted to a differing point. There could be a possibility of gaining more UF students who are truly “at-risk” of becoming first time users of electronic cigarettes. Another issue was the lack of parallel design in terms of all three surveys in order to gain an understanding of the effectiveness of message content in increasing the knowledge of participants, and promoting a negative attitude about e-cigarettes. A counter-argument for this limitation could be the potential of historical confounding that could arise between T1 and T2 testing. Generalizability Due to the fact that this study’s participants were recruited through convenience sampling, this target population might not necessarily be reflective of the whole University of Florida student population. Whites, Asians, and American Indian / Alaskan Natives were over-represented and Hispanics and Black or African- Americans were underrepresented when compared to the currently enrolled overall UF student population. The race / ethnicities that were not represented at all were Multi-race, Unknown, and Native Hawaiian / Pacific Islander. As far as genders, Males were over-represented (84.6%) and Females were underrepresented (15.4%) when compared to the currently enrolled overall UF student population. In addition, the demographics of this study’s target population did not include any members of the LGBTQ+ community (transgender or genderqueer) to provide a representative sample representative of the UF student population. Looking at the age representation, 25-34 year olds were over-represented (52%). The skew of the status of students was also skewed right with the largest population being Graduate / Professional students at 44%. Furthermore, participants were recruited through social media and other various electronic routes. This could add further availability of electronic research sources in order to add to the possibility of historical confounding through research between T1 and T2 in the study. Due to the target population of this study being UF students who are “at-risk” of becoming first time users of electronic cigarettes, the findings from this study are potentially less generalizable to the UF Student population. The intention of this campaign is to promote awareness of electronic cigarettes and their negative aspects in order to dissuade “at-risk” UF students from using them. Therefore, this study may not accurately reflect those of other campuses, as well as other types of users from varying subpopulations at the University of Florida. Next Steps Following final edits to the message designs, implementation will include release through a designated timeline developed by the Preceptor, Dr. Jane Emmeree and the intern. For the week of September 28th, all three designs (text with hand, aerosol spray, and the infographic) will be released through the following channels: 1.) The A-frame around campus; 2.) The Little Hall Bulletin Board; 3.) Flat Screen TV Image for GW Main Office (start this week); 4.) Tabling at Satellites; 5.) GatorWell Website under “The Basics- E-Cigarettes”; 6.) An
24 email to Eta Sigma Gamma to disseminate through their social media, website, and membership listservs; 7.) An email to Alpha Epsilon Delta to disseminate through their social media, website, and membership listservs; 8.) An email to Health Science Student Organization to disseminate through their social media, website, and membership listservs; and 9.) An email to Public Health Student Association to disseminate through their social media, website, and membership listservs. For this week, only the “text with the hand” and “aerosol spray” will be released through the following channels: 1.) As a GatorWell website banner; 2.) As a flat screen TV Image for Housing TV Channel 8; 3.) As a flat screen TV Image for SHCC TV; 4.) The Gator Dining Table Tents; 5.) This method will be continued for the weeks of October 5th until the week of October 26th, when the following channels will be added (in addition to the previous weeks’ channels): 1.) A Facebook status update (the 1st post on Facebook) of the “text with the hand” message design; 2.) An Alligator Ad of the “text with the hand” message design; 3.) An Odyssey Ad of the “text with the hand” message design; and 4.) The SHCC Bulletin Boards with the “text with the hand” message design. Starting the week of November 2nd running until the 9th, the following channels will be added (in addition to the previous weeks’ channels): 1.) A Facebook status update (the 2nd post on Facebook) with the “aerosol spray” message; 2.) A Facebook status update (the final post on Facebook) with the infographic message; and 3.) Tabling for “Great American Smokeout” on November 9th with all three designs. For the Spring 2015 Semester, starting on the week of March 7th running until March 28th, the tabling for “Kick Butts Day” will be used as a channel for dissemination of all three messages. For the final stage (Stage 4: Assessing Effectiveness and Making Refinements) of the health communication campaign process, the evaluation methods of this health communication campaign will be completed as per GatorWell’s protocol and determined by Dr. Jane Emmeree. Implications The majority of current college students are aware of electronic cigarettes, but only a small amount of students currently use them. Those that currently use have a direct association with a lower level of knowledge of the harms of electronic cigarettes. With the University of Florida’s campus, the rates are higher for ever-use for students and therefore seen as an area of need for public health interventions. This approach in targeting the at-risk users through health communication methods aimed to take a perspective on increasing the perceived severity and susceptibility while breaking down the benefits to using electronic cigarettes as a safe nicotine delivery system, particularly for first time users. This campaign highlights specific aspects of electronic cigarettes (toxic chemicals, secondhand aerosol, and overall harm) that are relevant and potential risks for first time users of electronic cigarettes, who have never used tobacco products in the past, that are relevant and appealing to the University of Florida population based on formative research. If this health communication campaign is successful in dissuading students from becoming first time users of electronic cigarettes, GatorWell health education specialists should fervently consider researching the effectiveness of persuasive messaging in dissuading students from becoming conventional cigarette users as well. This could highly impact the larger number of students that could potentially be considering conventional cigarette or tobacco product use. Future studies should look to create associations in the data derived from this study in order to more effectively target the students who are potentially “at-risk” of becoming first time users of electronic cigarettes. Using the data from this overall study, future studies can also create associations in electronic cigarette use with the overall student population of current users to develop and implement a whole different health communication campaign or public health intervention. Another area of strong need is a public health intervention in the form of harm reduction, which works to persuade and convert users of conventional cigarettes to becoming users of electronic cigarettes in order to prevent a large majority of long term and short term health effects of using conventional cigarettes or tobacco products. In addition, it would be highly beneficial in future studies to create a brand for the health communication campaign and create a multi-faceted approach to intervening with students on campus. This might include campaign materials to aid in primary interventions, and even educational presentations for students to become more aware of the risks and not just the product and what the e-cigarette companies market and advertise to them as their primary target audience. Relationship of Project to Internship Experience
25 The internship with Dr. Jane Emmeree at GatorWell Health Promotion Services involved the development and implementation of a variety of programmatic efforts in the health topics of tobacco, interpersonal violence prevention, sexual health, and sleep. This section will review the key contributions of the intern to Gatorwell through the various different programs and health areas. Three of the major events conducted by the intern were: 1.) A project of engaging men with interpersonal violence prevention and sexual assault education through STRIVE, 2.) Developing and implementing a health communication on sleep for students to develop better habits in order to have better sleep hygiene, and 3.) Creating and presenting a presentation based on the Healthy Gators 2015 E-cigarette survey results. Upon reviewing internship expectations of the University of Florida’s Master of Public Health program, the areas of learning and development that are expected to be fostered are: 1.) SBS Planning Activities, 2.) Conducting Research, Community Assessments, and Evaluations, 3.) Data Management, Analysis, and Interpretation, and 4.) Communication. For the project of engaging men with interpersonal violence prevention and sexual assault education through STRIVE, the intern worked in the areas of: 1.) Identification of community priority concerns (negotiating with stakeholders and community participants); 2.) Literature reviews of relevant studies on theory, methods, and content issues; 3.) Study, intervention, and evaluation design review and selection; 4.) Data collection (observation, committee meetings); 5.) Developing and sustaining communication with stakeholder groups; 6.) Working productively as a member of a team (community partners in committee); 7.) Data analysis (qualitative), 8.) Creating tables, graphs, charts of analyses; 9.) Routine professional communication with team members and stakeholders; 10.) Written reports and findings for different stakeholders; 11.) Graphics, slides, or the aids in communicating results; 12.) Two oral presentations; and 13.) Disseminating results. For the project of developing and implementing a health communication on sleep for students to develop better habits in order to have better sleep hygiene, the intern worked in the areas of: 1.) Identification of community priority concerns (negotiating with stakeholders and community participants); 2.) Literature reviews of relevant studies on theory, methods, and content issues; 3.) Study, intervention, and evaluation design review and selection; 4.) Designing, testing, and adapting data collection methods; 5.) Data collection (interviews and surveys); 6.) Developing and sustaining communication with stakeholder groups; 7.) Working productively as a member of a team (research group and community partners); 8.) Designing data entry systems; 9.) Data analysis (qualitative and quantitative); 10.) Writing data methods; 11.) Routine professional communication with team members; 12.) Graphics, slides, or the aids in communicating results; and 13.) Three oral presentations. For the creating and presenting a presentation based on the Healthy Gators 2015 E-cigarette survey results, the intern worked in the areas of: 1.) Identification of community priority concerns; 2.) Study design review and selection, 3.) Data collection (Surveys); 4.) Working with data entry systems (Survey Monkey); 5.) Working productively as a member of a team (research group, community partners, Tobacco Free Taskforce Committee); 6.) Database tasks (data cleaning, programming, variable classification and coding); 7.) Data analysis (qualitative and quantitative); 8.) Creating tables, graphs, charts of analyses; 9.) Writing data methods; 10.) Routine professional communication with team members and stakeholders; 11.) Written reports and findings for different stakeholders; 12.) Graphics, slides, or the aids in communicating results; and 13.) Two oral presentations. For the actual internship special project, the intern worked in the areas of: 1.) Identification of community priority concerns (negotiating with stakeholders and community participants); 2.) Literature reviews of relevant studies on theory, methods, and content issues; 3.) Study, intervention, and evaluation design review and selection; 4.) IRB preparation and submission; 5.) Designing, testing, and adapting data collection methods; 6.) Data collection (online surveys); 7.) Working with data entry systems (Qualtrics); 8.) Developing and sustaining communication with stakeholder groups; 9.) Working productively as a member of a team (GatorWell, and Faculty Advisor); 10.) Database tasks (data cleaning, programming, skip logic, variable classification and coding); 11.) Data analysis (qualitative and quantitative); 12.) Creating tables, graphs, charts of analyses; 13.) Writing data methods; 14.) Routine professional communication with team members and stakeholders (content reviewers, participants, Faculty Advisor, and Preceptor); 15.) Graphics, slides, or the aids in communicating results (poster presentation); and 16.) One oral presentation.
26 The only area that the intern did not receive further development in was that of grant writing. The strongest areas of development were the study design, literature review, and communication areas. MPH Competencies Strengthened The culmination of the internship with GatorWell Health Promotion Services in conjunction with the other various programmatic efforts during the duration, aided in the furthered development, fostering, and strengthening of a number of the Public Health core and concentration competences as defined by the University of Florida’s Master of Public Health program. Core Competencies Monitoring health status to identify and solve community health problems. The internship special project looked at the at-risk population of potential first time electronic cigarette users. Alongside this project, the STRIVE project involved identifying how to target and engage men about interpersonal violence prevention and sexual assault. The intern worked diligently on both projects to identify the UF and Gainesville community’s problems under the three health topics of interpersonal violence, sexual assault and tobacco. Diagnosing and investigating health problems and health hazards in the community using an ecological framework. GatorWell Health Promotion Services uses the socio-ecological framework for all programmatic efforts. The Socio-Ecological framework looks at the various health factors through the relationships between each level of an individual’s interaction with their environment. Particularly, the intern engaged with students at the individual level for the STRIVE project, and the community level with the internship special project, where the use of electronic cigarette leading to further negative health outcomes and health hazards for the University of Florida community was brought up. The policy level was discussed during the STRIVE project’s advisory committee meetings in order to change University and Gainesville policies for more effective education about interpersonal violence and sexual assault. Informing, educating, and empowering people about health issues. The intern created and presented over five different presentations (on sleep, electronic cigarette use, Interpersonal Violence Prevention, and Sexual Assault) to various community partners, GatorWell Staff, and committee members over the duration of the internship. These presentations all included an educational, empowerment, and informative portion dealing within their particular health topic. Mobilizing community partnerships and action to identify and solve health problems. The intern worked diligently to create community partnerships for the formation of the STRIVE project’s advisory committee on the focus to engage UF males in Interpersonal Violence prevention on campus. This included a brain storming session, and introductory committee meeting to define the purpose, goals, and objectives of the advisory committee and each member’s role. Developing policies and plans that support individual and community health efforts. The intern worked closely with the UF Tobacco-Free Taskforce, created an advisory committee for the STRIVE project geared toward strategies of engaging men with sexual assault and interpersonal violence prevention education. Applying laws and regulations that protect health and ensure safety. The intern worked closely with the UF Tobacco-Free Taskforce, in order to further the research process and add weight to the argument of including electronic cigarettes in the University of Florida’s campus Tobacco-Free Policy. Alongside this, the intern looked for policy measures that could be implemented on the community level at UF for sexual assault education and interpersonal violence prevention.
27 Linking people to needed personal health services and assure the provision of health care when otherwise unavailable. All of GatorWell’s resources disseminated by the student intern included campus partners who specialized in various health services related to all health issues and wellness. These include, but are not limited to medical care, legal services, and counseling. Evaluating effectiveness, accessibility, and quality of personal and population-based health services. The intern evaluated the effectiveness of population-based health services for electronic cigarette users for the special project, as well as evaluating the health services provided around sleep for the Sleep Health Communication Campaign. Conducting research for new insights and innovative solutions to health problems. The intern conducted research about electronic cigarettes in order to gain further insight to solutions for the cessation and prevention of using electronic cigarettes for University of Florida students. The same process was followed for the Sleep Health Communication campaign as well as the STRIVE project’s formation of the “Engaging Men in Interpersonal Violence Prevention and Sexual Assault” advisory committee. Communicating effectively with public health constituencies in oral and written forms. Consistent communication was up kept with all parties and constituents from the Sleep Health Communication campaign, and the special project, but particularly the STRIVE project’s “Engaging Men in Interpersonal Violence Prevention and Sexual Assault” advisory committee. Following the special project, the intern released all final and draft designs and results to GatorWell for further use and research. None of the University of Florida’s Master of Public Health program’s core competencies were unmet throughout the duration of the intern’s internship with GatorWell Health Promotion Services. Social and Behavioral Science Competencies Critically describe and evaluate the state of public health social and behavioral science research and literature. The intern conducted a comprehensive literature review to inform the development of a health communication campaign for the topic of electronic cigarettes within the college student population (and overall) as well as for the topic area of engaging men with interpersonal violence prevention, and aiding college-aged students to develop and keep better sleep habits. Apply social and behavioral science theories and concepts to public health problems. The intern developed a theory based health communication campaign for both electronic cigarettes and the health topic of sleep, using several theories such as the health belief model, the diffusion of innovation, and the theory of reasoned action. Also, social and behavioral science theories were applied to the interpersonal violence prevention committee in order to formulate various ideas and strategies for engaging men on campus. Describe and apply the social ecological framework to public health problems. The intern worked in the development of various programs (including the creation of an advisory committee for STRIVE in the area of Engaging Men with IVP, the Sleep study health communication campaign, and the Health Gators Secondary data analysis future recommendations / PH interventions) directed at the various intrapersonal, interpersonal, and community levels. Understand and apply the principles of community participation in public health research and interventions. The intern worked closely with campus and community stakeholders throughout all four of the various projects (including the internship special project). This was done in order to gain a deeper insight into the target population, advisory aid, and steering of projects.
28 Demonstrate the knowledge and skills necessary to conduct social and behavioral science research. The intern conducted a comprehensive literature review for the health communication campaign on electronic cigarettes, sleep (improving sleep for an at-risk population of students who are receiving less than 4 days of sleep and believe that sleep is important), and pre-testing for sexual assault bystander intervention “It’s On Us” health communication campaign, as well as e-cigarette campaign). Demonstrate an understanding of health disparities in the US and the underlying role of power differentials to disparities. According to the CDC, the use of tobacco can cause very detrimental health effects to users alongside various forms of disease and untimely death in all varying demographic populations. The “disparity” lies with the college students that use tobacco and tobacco products, in unequal amounts to other age groups. Particularly with e-cigarettes, the populations that are the highest users are those who “are male, Hispanic or Other race, and Greek affiliated” according to Sutfin and colleagues (2013). Therefore, this disparaging inequality of health in the area of electronic use is a population that the intern worked closely with. Demonstrate knowledge and skills needed to design and implement a public health information campaign. The intern completed the first two stages of a health communication campaign on dissuading UF students from becoming first time users of electronic cigarettes and another health communication campaign on promoting cues to action for more rested sleep for UF students. Stage 3 and 4 were planned out by the intern and will be implemented by GatorWell in the Fall of 2015 and Spring of 2016. Demonstrate communication skills key to public health workforce participation and advocacy. The intern worked closely with the members the research team and GatorWell staff on various projects including the e-cigarette health communication campaign, the sleep health communication campaign, and the STRIVE Advisory Committee. Outside resources were also collaborated with, such as Brantley Jarvis, a doctoral candidate at the University of Florida. None of the University of Florida’s Master of Public Health program’s Social and Behavioral Sciences (SBS) competencies were unmet throughout the duration of the intern’s internship with GatorWell Health Promotion Services. Lessons Learned and Future Internship Recommendations Upon completing the duration of the MPH special project, the intern completed a final set of health communication campaign materials based on dissuading UF students from becoming first time users of electronic cigarettes. This health communication campaign will be released in Fall of 2015. The creation of the health communication messages from this study determined the area of focus for messaging based on the two- part questionnaire. The remaining stages of this study should focus on stage 3 and 4 of the hea lth communication campaign process. Another area of focus for this study should be determining the areas that this campaign did not address with the at-risk target population in order to reach those segmented audiences as well. The intern that will complete this project should focus on an implementation plan and evaluative measures for the message designs and their effectiveness in communication and persuasion. Future needs for this project require a post-test to be applied in order to compare to the pre-test (Two-Part Questionnaire) based on UF students’ knowledge, attitudes, and beliefs to compare following the launch of this health communication campaign. Understanding that a properly completed health communication campaign requires several months of planning and development in order to be effective and impactful, the largest lesson to be learned from this project was that a health communication campaign development requires a large amount of time. The limitation on time for the MPH internship did not allow for a proper needs assessment in order to directly evaluate students’ perceived barriers and benefits to electronic cigarette use. Though the Two-Part questionnaire was effective, the ideal timeline for a project would allow for the qualitative method of focus groups, which would have proven to provide a wider array of answers and data to guide this research project.
29 The chief recommendation to future interns working on any other health communication campaigns geared toward the use of electronic cigarettes (whether a primary or a secondary intervention) would be to spend a larger amount of time on the formative research and needs assessment portion of the health communication framework in order to develop the most effective and impactful campaign messaging tailored to that particular target population. Another chief recommendation to future interns working on health communication campaigns is to have an idea and most of their supplemental research done for their creative brief for campaign messaging in the different areas of focus. The largest quantity of time that was taken up was due to message design, at no fault of the graphic designer. Completing a plethora of the project ahead of time will save a lot of work and time toward the end of the study. A final recommendation would be to submit IRB a lot sooner than the MPH program’s deadline, as issues can arise along the way that might hinder a student from beginning their project. Overall, being conscience of the timeline, sticking to a fluid plan of action, and remembering the intention of this project are what will drive the study to successful completion.
30 Appendix I. The Health Belief Model Appendix II. The Stages of Change Model (Transtheoretical Model or TTM)
31 Appendix III. The Information Processing Paradigm
32 Appendix IV. The Theory of Reasoned Action
33 Appendix V. The Diffusion of Innovation Theory Appendix VI. The Health Communication Program Cycle Appendix VII. Informed Consent Process
34 Researchers in the Department of Behavioral Science and Community Health at UF, in collaboration with GatorWell, are recruiting UF students to develop a health communication campaign on electronic cigarettes. Interested students will complete a 30-minute survey to assess their knowledge, beliefs, and attitudes about electronic cigarettes, and to assess their eligibility for the study. Upon completion of this 30-minute survey, you will be eligible for a $5 Amazon gift card. If selected for further participation as described below, you can receive an additional $5 Amazon gift card for each section of this study (for a total of $15 in Amazon Gift cards): 1. Pre-testing of Preliminary Products (Upon Completion, you will receive a $5 Amazon Gift card): The preliminary products will be tested with the same participants, using a 10-minute online Qualtrics survey. The products will be tested for clarity, appeal, and relatability of the message content of the health communication designs. 2. Pre-testing of Revised Products (Upon Completion, you will receive a $5 Amazon Gift card): The health communication products will be revised based on the findings of the pre-test and the participants will complete another 10-minute survey in Qualtrics to provide feedback on the revisions. Your participation in this two-part questionnaire is voluntary and you maintain the right to withdrawal at any time without penalty. If you choose to withdraw, you must contact the study coordinator to receive your $5 Amazon gift card for participating in the first stage of this study. Your name will not be associated with your responses and will never be used in any report on project materials. Your responses will be used to determine if they are to be included in the subsequent phases; after that decision has been made, responses will be decoupled from their names, and so anonymous from then on. Your responses will be kept confidential by all those associated with this research project. Based on the results of this two-part questionnaire, you will be selected to participate in this study. This two-part questionnaire will last approximately 30-minutes. If you are selected to participate in the rest of this study following the results from this two-part questionnaire, you will be asked to complete two other online surveys lasting 10-minutes each. Upon completion of all three online surveys, you will receive a $15 gift card. Following this survey, the study coordinator will contact you for the next stage of this study. You will not directly benefit from participating in this study. However, your participation will allow GatorWell Health Promotion Services to create and enhance health messages for UF students. There is a minimal risk that security of any online data may be breached, but our survey host (QUALTRICS) uses strong encryption and other data security methods to protect your information. Only the researchers will have access to your information on the Qualtrics server. Whom to contact if you have questions about the study: Dr. Jane Emmeree, PhD, CHES, Health Promotion Specialist, 273-4450, emmeree@ufl.edu or Kiarash P. Rahmanian, BS, (863) 368-1526, rahmanian@ufl.edu. Whom to contact about your rights as a research participant in the study: UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; 392-0433 Statement of Consent: I have read the above information, have received answers to any questions I have asked, and I am at least 18 years of age. I consent to take part in this study. ______ I consent ______ I do not consent Appendix VIII Recruitment E-Cigarette Health Communication Campaign– Gator Times Announcement
35 Title: E-Cigarette Research Study. Participants receive $15 Amazon gift card! Researchers in the Department of Behavioral Science and Community Health at UF, in collaboration with GatorWell, are recruiting UF students to develop a health communication campaign on electronic cigarettes. Interested students will complete a brief survey to assess eligibility for the study, and will be compensated with a $15 Amazon gift card for further participation, if eligible. Please contact Kiarash P. Rahmanian at rahmanian@ufl.edu for more information or begin the two-part questionnaire now: https://ufl.qualtrics.com/SE/?SID=SV_6RRwdU3mjzRGzqt E-cigarette Health Communication Campaign– Social Media Announcement Researchers in the Department of Behavioral Science and Community Health at UF, in collaboration with GatorWell, are recruiting UF students to develop a health communication campaign on electronic cigarettes. Interested students will complete a brief survey to assess eligibility for the study, and will be compensated with a $15 Amazon gift card for further participation, if eligible. Please contact Kiarash P. Rahmanian at rahmanian@ufl.edu for more information or begin the two-part questionnaire now: https://ufl.qualtrics.com/SE/?SID=SV_6RRwdU3mjzRGzqt E-Cigarette Health Communication Campaign– Listserv Solicitation Hello, Researchers in the Department of Behavioral Science and Community Health at UF, in collaboration with GatorWell, are recruiting UF students to develop a health communication campaign on electronic cigarettes. Interested students will begin by completing a brief survey to assess eligibility for the study. If selected, participants will be compensated with a $5 Amazon gift card for completion of each portion of the study- up to $15 for completion of the entire study. Please contact Kiarash P. Rahmanian at rahmanian@ufl.edu for more information or begin the two-part questionnaire now: https://ufl.qualtrics.com/SE/?SID=SV_6RRwdU3mjzRGzqt Respectfully, Kiarash P. Rahmanian, B.S GatorWell Graduate Student Intern Appendix IX Two-Part Questionnaire Demographic Questions 1. Which best describes your current student status at UF? ____ 1st year undergraduate ____ 2nd year undergraduate ____ 3rd year undergraduate ____ 4th year undergraduate ____ 5th year or more undergraduate ____ Graduate or professionalstudent Other: ________________________ ____ Prefer not to answer 2. How old are you? (You must be 18 years or older to participate in this study) _________________________ ____ Prefer not to answer 3. What is your gender? ____ Female ____ Genderqueer ____ Male ____ Transgender ____ Identity not listed ____ Please indicate: _________________ ____ Prefer not to answer 4. Are you Hispanic or Latino? ____ Yes ____ No ____ Prefer not to answer 5. How would you describe yourself (Select all that apply) ____ American Indian or Alaska Native ____ Asian ____ Black/African-American ____ Native Hawaiian/other Pacific Islander ____ White ____ Bi-racial/Multiracial ____ I prefer not to respond to this question ____ Other (Please specify): ________________________ ____ Prefer not to answer Background Questions (Inclusion Criteria) 6. Have you ever heard of an “e- cigarette” or electronic cigarette, a cigarette-looking electronic device that delivers nicotine aerosol when you puff it? (Other names for e-cigarettes include:
36 “hookah pens”, “personal vaporizers”, and “smokeless cigarettes”) ____ Yes ____ No 7. Have you tried an electronic cigarette, even one or two puffs? ____ No ____ Yes, more than a year ago, but not in the past year ____ Yes, within the past year, but more than a month ago ____ Yes, within the past month 8. How likely do you think that you would try an electronic cigarette in the next 6 months, even if offered a puff from a friend or family member? ____ Absolutely Not ____ Very Unlikely ____ Unlikely ____ Maybe Yes, Maybe No ____ Likely ____ Very Likely ____ Absolutely Yes 9. How likely do you think that you would start using an electronic cigarette regularly in the next 6 months? ____ Absolutely Not ____ Very Unlikely ____ Unlikely ____ Maybe Yes, Maybe No ____ Likely ____ Very Likely ____ Absolutely Yes Background Questions 10. You indicated that you would possibly try electronic cigarettes, in which of the following situations would you be most likely to try them? (Please check only one) ____ When you are with friends ____ When you are with family members ____ In a social setting ____Other: ____________________ 11. Do you have any close friends that currently use electronic cigarettes? ____ Yes Continue to Q. 12. ____ No Skipto Q. 15. 12. Since you answered that some of your close friends currently use electronic cigarettes, have you heard them say anything about electronic cigarettes? 13. Since you answered that some of your close friends currently use electronic cigarettes, have any of those friends that use electronic cigarettes attempted to convince you to use them as well? ____ Yes Continue to Q. 14. ____ No Skipto Q. 15. 14. Since you answered that some of your close friends currently use electronic cigarettes and they have attempted to convince you to use them as well, would you comply with that request? ____ Yes ____ No 15. Which stage do you believe you are at in regards to your desire to use electronic cigarettes? ____ Pre-Contemplation (I’m not thinking about using electronic cigarettes) ____ Contemplation (I’m thinking about using electronic cigarettes) ____ Preparation (I’m planning to use electronic cigarettes) ____ Action (I’m using electronic cigarettes) ____ Maintenance (I have already been using electronic cigarettes for more than 6 months) 16. In the previous question, you were asked what stage you believe that you are in regards to your desire to use electronic cigarettes. Why did you indicate that particular stage in the model for behavior change? Knowledge Questions 17. Tell me a little bit about your perceptions of the harm of electronic cigarettes. 18. Does smoking electronic cigarettes cause the following: Stroke (blood clots in the brain that may cause paralysis)? ____ Yes ____ No ____ Unsure Heart attack? ____ Yes ____ No ____ Unsure Lung cancer? ____ Yes ____ No ____ Unsure 19. Do electronic cigarettes contain nicotine? ____ Yes Continue to Q. 20. ____ No Skipto Q. 21. 20. More or less nicotine than regular cigarettes? 21. Why do you think that electronic cigarettes do not contain Nicotine? 22. What do electronic cigarettes contain instead of nicotine? 23. There are no harmful chemicals within what is exhaled from electronic cigarettes (the vapor). ____ Yes ____ No ____ Unsure 24. What have you heard about the chemicals that are exhaled from electronic cigarettes? Belief Questions 25. Please indicate your level of agreement with the following statement: Electronic cigarettes are not harmful. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 26. Do you believe there are some benefits of not using electronic cigarettes? ____ Yes Continue to Q. 27.
37 ____ No Skipto Q. 28. 27. What do you think are those benefits of not using electronic cigarettes? 28. What would stop you from using electronic cigarettes? 29. Please indicate your level of agreement with the following statement: Electronic cigarette use among college students is very high. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 30. Please indicate your level of agreement with the following statement: Electronic cigarette use among UF students is very high. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 31. Please indicate your level of agreement with the following statement: Electronic cigarette use among groups that I affiliate with is very high. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 32. What do you think of other people’s decision to use electronic cigarettes? 33. Do you believe that electronic cigarettes are safer to smoke than regular cigarettes? ____ Yes Continue to Q. 35. ____ No Skipto Q. 36. 34. Why do you believe that electronic cigarettes are safer to smoke than regular cigarettes? 35. Do you believe that the medical evidence that ‘using electronic cigarettes is harmful’ is exaggerated? 36. Do you believe that Electronic Cigarettes are a useful quit-smoking aid? ____ Yes Continue to Q. 38. ____ No Skipto Q. 39. 37. Why do you believe that electronic cigarettes are a useful quit-smoking aid? 38. Do you believe that smoking electronic cigarettes is a habit, an addiction, neither or both? ____ Habit ____ Addiction ____ Neither ____ Both ____ I don’t know 39. Do you believe that smoking electronic cigarettes is as addictive as otherdrugs? ____ Yes Continue to Q. 41. ____ No Skipto Q. 42. 40. Why do you believe that smoking electronic cigarettes is as addictive as other drugs? Attitude Questions 41. Please indicate your level of agreement with: The FDA should regulate electronic cigarettes. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 42. Please indicate your level of agreement with: Smoking regular cigarettes is the same as using electronic cigarettes. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 43. Please indicate your level of agreement with: Electronic cigarettes are a less harmful alternative to smoking conventionalcigarettes. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 44. Please indicate your level of agreement with: Electronic cigarettes making quitting smoking easier. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree Advertisement Preferences 45. Have you ever heard anything negative about the dangers of using electronic cigarettes? ____ Yes Continue to Q. 47. ____ No Skipto Q. 49. 46. If you heard anything negative about the dangers of using electronic cigarettes, where did you hear it? 47. If you heard anything negative about the dangers of using electronic cigarettes, what specifically do you remember that was negative? 48. Have you seen any celebrities endorse e-cigarettes? 49. Have you noticed electronic cigarette promotions in stores or other locations? ____ Yes Continue to Q. 51. ____ No Skipto Q. 54. 50. Have you seen any messages lately that discourage tobacco use that have turned you off? Why? ____ Yes Continue to Q. 55. ____ No Skipto Q. 57. 51. Since you have seen a message(s) lately that discourages tobacco use that turned you off, why did it turn you off? 52. If you have seen any messages lately that discourage tobacco use that have turned you off, are you turned off by the smoking or the message?
38 53. Please tell me about a memorable advertisement for anything that you liked. 54. Please tell me why you liked the memorable advertisement you mentioned above. 55. In general, what style of ads do you like? 56. Please enter your contact information below: Email: _______________ Appendix X Preliminary Health Communication Campaign Materials Development First Round (Following Two-Part Questionnaire) Second Round (Edits suggestedby Primary Researcher, Dr. Jane Emmeree, and Dr. Juliette Christie)
39 Third Round (Following Content Review by Experts)
40 Final Round (Materials testedin Pre-Testing of Preliminary Materials Survey)
41
42 Appendix XI Pre-testing of Preliminary Campaign Materials (Same as Pre-testing of Revised Campaign Materials) Demographic Questions 1. Which best describes yourcurrent student statusat UF? ____ 1st year undergraduate ____ 2nd year undergraduate ____ 3rd year undergraduate ____ 4th year undergraduate ____ 5th year or more undergraduate ____ Graduate or professionalstudent ____ Prefer not to answer 2. What is your gender? ____ Female ____ Genderqueer ____ Male ____ Transgender ____ Identity not listed. Please indicate: _________________________ ____ Prefer not to answer 3. Are you Hispanic or Latino? ____ Yes ____ No ____ Prefer not to answer 4. How would you describe yourself (Select all that apply) ____ American Indian or Alaska Native ____ Asian ____ Black/African-American ____ Native Hawaiian/other Pacific Islander ____ White ____ Bi-racial/Multiracial ____ I prefer not to respond to this question ____ Other (Please specify): ________________________ ____ Prefer not to answer Please carefully look at and read the designs: 5. What is the “take-home” message from each individual design Design 1: _____________ Design 2: _____________ Design 3: _____________ 6. Please indicate your level of agreement or disagreement with the message from each individual design Design 1: _____________ ____ Strongly agree ____ Moderately agree ____ Undecided ____ Moderately disagree ____ Strongly disagee Design 2: _____________ ____ Strongly agree ____ Moderately agree ____ Undecided ____ Moderately disagree ____ Strongly disagree Design 3: _____________ ____ Strongly agree ____ Moderately agree ____ Undecided ____ Moderately disagree ____ Strongly disagree 7. Are any of the designs relatable to you personally in any way? If yes,please explain. (Select all that apply) ___None of the designs are relatable ___Yes, design 1 is relatable because _____________ ___Yes, design 2 is relatable because _____________ ___Yes, design 3 is relatable because _____________ 8. Is there any specific portion of a design (message, design, etc.) that is particularly “appealing” to you? If yes, please explain. (Select all that apply) ___None of the designs are appealing ___Yes, design 1 is appealing because _____________ ___Yes, design 2 is appealing because _____________ ___Yes, design 3 is appealing because _____________ 9. Fromthe designs provided, is there any specific portion of a design (message, design, etc.) that is particularly “confusing” to you? If yes, please explain. (Select all that apply) ___None of the designs are confusing ___Yes, design 1 is “confusing” because _____________ ___Yes, design 2 is “confusing” because _____________ ___Yes, design 3 is “confusing” because _____________ 10. Is there any specific portion of a design (message, design, etc.) that is particularly “unpleasant” or “distasteful”? If yes,please explain. (Select all that apply) ___None of the designs are “unpleasant” or “distasteful” ___Yes, design 1 is “unpleasant” or “distasteful” because _____________ ___Yes, design 2 is “unpleasant” or “distasteful” because _____________ ___Yes, design 3 is “unpleasant” or “distasteful” because _____________ a) Indicate whether each design conveys the following message: This message clearly communicates the negative health outcomes of electronic cigarette usage.
43 Strongly Agree Agree Neutral Disagree Strongly Disagree 1 2 b) Indicate whether each design conveys the following message: This message clearly shows that electronic cigarettes are not a healthy alternative to conventionalcigarettes. Strongly Agree Agree Neutral Disagree Strongly Disagree 1 2 11. How effective are these designs at supporting a message to dissuade students fromusing electronic cigarettes? Very Effective Effective Neutral Not Effective Very Ineffective 1 2 12. How effective are these designs at communicating the advantages ofnot using electronic cigarettes? (DOI Theory) Very Effective Effective Neutral Not Effective Very Ineffective 1 2 13. How consistent are the designs with yourvalues, experiences, and needs as a UF Student? Why? (DOI Theory) Very Consistent Consistent Neutral Inconsistent Very Inconsistent 1 2 14. Out of the two designs, which do you like best? Why? (Please only choose 1 design) ___ Design 1 because _____________ ___ Design 2 because _____________ ___ Design 3 because _____________ 15. Out of the two designs, which do you like the least? Why? (Please only choose 1 design) ___ Design 1 because _____________ ___ Design 2 because _____________ ___ Design 3 because _____________ 16. Please help us improve each design by providing specific suggestions:suggestions forimproving the designs? ____ Design 1____________ ____ Design 2____________ ____ Design 3____________ 17. Please enter your contact information below: Email: _______________
44 Appendix XII Health Communications Campaign Material Revisions Following Pre-Testing of Preliminary Materials (tested in Pre-Testing of RevisedMaterials Survey)
45 Appendix XIII Pre-testing of Revised Campaign Materials Final Message Designs (following in Pre-Testing of Revised Materials Survey- for campaign rollout)
46 Appendix XIV Study Flowchart Assessed for eligibility (n= 455) Excluded (n= 416) Did not meet inclusion criteria (n= 362) Did not complete Two-Part Questionnaire (n= 52) Other reasons (i.e.: missing emails) (n= 2) Formative Research Two-Part Questionnaire Sent Out Enrollment Eligible for enrollment (n= 39) Pre-Testing of Preliminary Materials Survey Pre-Testing of Revised Materials Survey Completed Pre-Testing Survey (n= 28) Completed Pre-Testing Survey (n= 38) Exited Study (n= 2) Revisions to Message Designs Final Revisions to Message Designs Message Designs Completed Follow-Up Analysis Analysis Follow-Up Excluded (n= 7) Completed the survey twice (n=2) Were not eligible as they had not completed stage 1 (n=5)
47 Appendix XV Electronic Cigarette Use Heat Map- Healthy Gators 2015 Survey Full Map of the University of Florida Campus 25% Zoom of Full Map of the University of Florida Campus
48 50% Zoom of Map of the University of Florida Campus- North 65% Zoom of Map of the University of Florida Campus- Northeast
49 65% Zoom of Map of the University of Florida Campus- Southeast Appendix XVI Pre-Testing Survey of Preliminary Materials Message Design Descriptive Matrix Appendix XVII Pre-Testing Survey of Revised Materials Message Design Descriptive Matrix Design Agreement Relatable Appeal Complex Unpleasant Comm Effect. Dissuasion Consistent Rank Pts D. 1 X X 3 D. 2 X X X 2 D. 3 X 2 D. 4 X X X 0 D. 5 X X -2 Design Agreement Relatable Appeal Complex Unpleasant Comm Effect. Dissuasion Consistent Rank Pts . D. 1 X X X X X 1 D. 2 X X X 1 D. 3 X X X X X 8
50 Appendix XVIII Cross Tabulations for Two-Part Questionnaire
51
52 Appendix XIV Frequency Tables for Two-Part Questionnaire 1. Which best describes your current student status at UF? Statistic Value Min Value 1 Max Value 6 Mean 4.30 Variance 3.14 Standard Deviation 1.77 Total Responses 40 2. Howold are you? (You must be 18 years or older to participate in this study) Statistic Value Min Value 2 Max Value 4 Mean 2.73 Variance 0.41 Standard Deviation 0.64 Total Responses 40 3. What is your gender?
53 Statistic Value Min Value 1 Max Value 3 Mean 2.65 Variance 0.59 Standard Deviation 0.77 Total Responses 40 4. Are you Hispanic or Latino? Statistic Value Min Value 1 Max Value 2 Mean 1.88 Variance 0.11 Standard Deviation 0.33 Total Responses 40 5. Howwould you describe yourself? (Select all that apply)
54 Statistic Value Min Value 1 Max Value 5 Total Responses 40 6. Have you ever heard ofan “e-cigarette” or electronic cigarette, a cigarette-looking electronic device that delivers nicotine aerosol when you puff it? (Other names for e-cigarettes include: “hookah pens”,“personal vaporizers”, and “smokelesscigarettes”) Statistic Value Min Value 1 Max Value 1 Mean 1.00 Variance 0.00 Standard Deviation 0.00 Total Responses 40 7. Have you tried an electronic cigarette, even one or two puffs?
55 Statistic Value Min Value 1 Max Value 4 Mean 2.28 Variance 1.23 Standard Deviation 1.11 Total Responses 40 8. Please indicate the level oflikelihood that you would participate in the behaviors below: Statistic You would try an electronic cigarette in the next 6 months, even ifoffered a puff from a friend or family member. You would start using an electronic cigarette regularly in the next 6 months. Min Value 4 4 Max Value 7 7 Mean 5.53 5.15 Variance 1.03 1.05 Standard Deviation 1.01 1.03 Total Responses 40 40 9. You indicated that you would possibly try electronic cigarettes,in which of the following situations would you be most likely to try them?
56 Statistic Value Min Value 1 Max Value 3 Mean 1.95 Variance 0.82 Standard Deviation 0.90 Total Responses 40 10. Do you have any close friends that currently use electronic cigarettes? Statistic Value Min Value 1 Max Value 2 Mean 1.58 Variance 0.25 Standard Deviation 0.50 Total Responses 40 11. Since you answered that some ofyour close friends currently use electronic cigarettes,have any ofthose friends that use electronic cigarettes attempted to convince you to use them as well?
57 Statistic Value Min Value 1 Max Value 2 Mean 1.18 Variance 0.15 Standard Deviation 0.39 Total Responses 17 12. Since you answered that some ofyour close friends currently use electronic cigarettes and they have attempted to convince you to use them as well, would you comply with that request? Statistic Value Min Value 1 Max Value 2 Mean 1.18 Variance 0.15 Standard Deviation 0.39 Total Responses 17 13. Which stage do you believe you are at in regards to your desire to use electronic cigarettes?
58 Statistic Value Min Value 2 Max Value 3 Mean 2.40 Variance 0.25 Standard Deviation 0.50 Total Responses 40 14. Do electronic cigarettescontain nicotine? Statistic Value Min Value 1 Max Value 2 Mean 1.18 Variance 0.15 Standard Deviation 0.38 Total Responses 40 15. More or less nicotine than regular cigarettes?
59 Statistic Value Min Value 1 Max Value 3 Mean 2.09 Variance 0.15 Standard Deviation 0.38 Total Responses 33 16. There are no harmful chemicals within what is exhaled from electronic cigarettes (the vapor). Statistic Value Min Value 1 Max Value 3 Mean 1.60 Variance 0.61 Standard Deviation 0.78 Total Responses 40 17. Please indicate your level ofagreement with the following statement:
60 Statistic Electronic cigarettesare not harmful. Min Value 1 Max Value 5 Mean 2.93 Variance 1.30 Standard Deviation 1.14 Total Responses 40 18. Do you believe there are some benefits ofnot using electronic cigarettes? Statistic Value Min Value 1 Max Value 2 Mean 1.58 Variance 0.25 Standard Deviation 0.50 Total Responses 40 19. Please indicate your level ofagreement with the following statement:
61 Statistic Electronic cigarette use among college students is very high. Min Value 1 Max Value 5 Mean 2.43 Variance 0.81 Standard Deviation 0.90 Total Responses 40 20. Please indicate your level ofagreement with the following statement: Statistic Electronic cigarette use among UF students is very high. Min Value 1 Max Value 5 Mean 2.75 Variance 1.12 Standard Deviation 1.06 Total Responses 40 21. Please indicate your level ofagreement with the following statement:
62 Statistic Electronic cigarette use among groups that I affiliate with is very high. Min Value 1 Max Value 5 Mean 2.93 Variance 1.15 Standard Deviation 1.07 Total Responses 40 22. Do you believe that electronic cigarettes are safer to smoke than regular cigarettes? Statistic Value Min Value 1 Max Value 2 Mean 1.33 Variance 0.23 Standard Deviation 0.47 Total Responses 40 23. Do you believe that Electronic Cigarettes are a useful quit-smoking aid?
63 Statistic Value Min Value 1 Max Value 2 Mean 1.25 Variance 0.19 Standard Deviation 0.44 Total Responses 40 24. Do you believe that smoking electronic cigarettesis a habit, an addiction, neither or both? Statistic Value Min Value 1 Max Value 4 Mean 2.38 Variance 1.30 Standard Deviation 1.14 Total Responses 39 25. Do you believe that smoking electronic cigarettesis as addictive as other drugs?
64 Statistic Value Min Value 1 Max Value 2 Mean 1.83 Variance 0.15 Standard Deviation 0.38 Total Responses 40 26. Please indicate your level ofagreement with: Statistic The FDA should regulate electronic cigarettes. Min Value 1 Max Value 4 Mean 1.78 Variance 0.59 Standard Deviation 0.77 Total Responses 40 27. Please indicate your level ofagreement with:
65 Statistic Smoking regular cigarettes is the same as using electronic cigarettes. Min Value 1 Max Value 5 Mean 3.20 Variance 1.50 Standard Deviation 1.22 Total Responses 40 28. Please indicate your level ofagreement with: Statistic Electronic cigarettesare a less harmful alternative to smoking conventional cigarettes. Min Value 1 Max Value 5 Mean 2.35 Variance 1.72 Standard Deviation 1.31 Total Responses 40 29. Please indicate your level ofagreement with:
66 Statistic Electronic cigarettesmaking quitting smoking easier. Min Value 1 Max Value 5 Mean 2.53 Variance 1.33 Standard Deviation 1.15 Total Responses 40 30. Have you ever heard anything negative about the dangers ofusing electronic cigarettes? Statistic Value Min Value 1 Max Value 2 Mean 1.78 Variance 0.18 Standard Deviation 0.42 Total Responses 40 31. Have you noticed electronic cigarette promotions in stores or other locations?
67 Statistic Value Min Value 1 Max Value 2 Mean 1.60 Variance 0.25 Standard Deviation 0.50 Total Responses 40 Appendix XV Frequency Tables for Pre-Testing of Preliminary Materials Survey 1. Please indicate your level ofagreement or disagreement with the message from each individual design. Statistic Design 1 Design 2 Design 3 Design 4 Design 5 Min Value 1 1 1 1 1 Max Value 5 5 5 4 5 Mean 1.86 1.75 1.96 1.96 2.21 Variance 1.24 1.23 1.00 0.55 1.06 Standard Deviation 1.11 1.11 1.00 0.74 1.03 Total Responses 28 28 28 28 28 2. Are any of the designs "relatable" to you personally in any way? If yes, please explain. (Select all that apply)
68 Statistic Value Min Value 1 Max Value 7 Total Responses 28 3. Is there any specific portion ofone ofthe designs (message,design, etc.) that is particularly “appealing” to you? If yes, please explain. (Select all that apply) Statistic Value Min Value 1 Max Value 7 Total Responses 28 4. From the designs provided, is there any specific portion of a design (message, design,etc.) that is particularly “confusing” to you? Ifyes, please explain. (Select all that apply)
69 Statistic Value Min Value 1 Max Value 7 Total Responses 28 5. Is there any specific portion ofa design (message, design, etc.) that is particularly “unpleasant” or “distasteful”? Ifyes,please explain. (Selectall that apply) Statistic Value Min Value 1 Max Value 7 Total Responses 28 6. Please indicate whether design 1 conveys the following message:
70 Statistic Design 1's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 5 Mean 2.21 Variance 0.69 Standard Deviation 0.83 Total Responses 28 7. Please indicate whether design 2 conveys the following message: Statistic Design 2's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 4 Mean 2.11 Variance 0.91 Standard Deviation 0.96 Total Responses 28 8. Please indicate whether design 3 conveys the following message:
71 Statistic Design 3's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 4 Mean 2.21 Variance 0.92 Standard Deviation 0.96 Total Responses 28 9. Please indicate whether design 4 conveys the following message: Statistic Design 4's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 4 Mean 1.86 Variance 0.65 Standard Deviation 0.80 Total Responses 28 10. Please indicate whether design 5 conveys the following message:
72 Statistic Design 5's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 4 Mean 2.14 Variance 0.87 Standard Deviation 0.93 Total Responses 28 11. Please indicate the level ofeffectivenessofdesign 1 for the following: Statistic Howeffective is Design 1 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 5 Mean 3.04 Variance 1.52 Standard Deviation 1.23 Total Responses 28 12. Please indicate the level ofeffectivenessofdesign 1 for the following:
73 Statistic Howeffective is Design 1 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 5 Mean 2.61 Variance 1.36 Standard Deviation 1.17 Total Responses 28 13. Please indicate the level ofeffectivenessofdesign 2 for the following: Statistic Howeffective is Design 2 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.64 Variance 1.35 Standard Deviation 1.16 Total Responses 28 14. Please indicate the level ofeffectivenessofdesign 2 for the following:
74 Statistic How effective is Design 2 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.61 Variance 1.36 Standard Deviation 1.17 Total Responses 28 15. Please indicate the level ofeffectivenessofdesign 3 for the following: Statistic Howeffective is Design 3 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.68 Variance 1.19 Standard Deviation 1.09 Total Responses 28 16. Please indicate the level ofeffectivenessofdesign 3 for the following:
75 Statistic Howeffective is Design 3 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.89 Variance 1.14 Standard Deviation 1.07 Total Responses 28 17. Please indicate the level ofeffectivenessofdesign 4 for the following: Statistic Howeffective is Design 4 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.04 Variance 1.67 Standard Deviation 1.29 Total Responses 28 18. Please indicate the level ofeffectivenessofdesign 4 for the following:
76 Statistic Howeffective is Design 4 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.86 Variance 1.53 Standard Deviation 1.24 Total Responses 28 19. Please indicate the level ofeffectivenessofdesign 5 for the following: Statistic Howeffective is Design 5 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.64 Variance 1.87 Standard Deviation 1.37 Total Responses 28 20. Please indicate the level ofeffectivenessofdesign 5 for the following:
77 Statistic Howeffective is Design 5 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.04 Variance 1.52 Standard Deviation 1.23 Total Responses 28 21. Out ofall of the designs,which do you like best? Why? (Please only choose 1 design) Statistic Value Min Value 1 Max Value 5 Mean 2.25 Variance 1.60 Standard Deviation 1.27 Total Responses 28 22. Please help us improve each design by providing specific suggestions: suggestions for improving the designs?
78 Statistic Value Min Value 1 Max Value 7 Total Responses 28 Appendix XVI Frequency Tables for Pre-Testing of Revised Materials Survey 1. Please indicate your level ofagreement or disagreement with the message from each individual design. Statistic Design 1 Design 2 Design 3 Min Value 1 1 1 Max Value 3 3 3 Mean 1.79 1.58 1.18 Variance 0.33 0.30 0.21 Standard Deviation 0.58 0.55 0.46 Total Responses 38 38 38 2. Are any of the designs "relatable" to you personally in any way? If yes, please explain. (Select all that apply)
79 Statistic Value Min Value 1 Max Value 7 Total Responses 38 3. Is there any specific portion ofone ofthe designs (message,design, etc.) that is particularly “appealing” to you? If yes, please explain. (Select all that apply) Statistic Value Min Value 1 Max Value 7 Total Responses 38 4. From the designs provided, is there any specific portion ofa design (message, design,etc.) that is particularly “confusing” to you? Ifyes, please explain. (Select all that apply)
80 Statistic Value Min Value 3 Max Value 7 Total Responses 38 5. Is there any specific portion ofa design (message, design, etc.) that is particularly “unpleasant” or “distasteful”? Ifyes,please explain. (Selectall that apply) Statistic Value Min Value 7 Max Value 7 Total Responses 38 6. Please indicate whether design 1 conveys the following message:
81 Statistic Design 1's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 3 Mean 2.13 Variance 0.33 Standard Deviation 0.58 Total Responses 38 7. Please indicate whether design 2 conveys the following message: Statistic Design 2's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 3 Mean 2.13 Variance 0.23 Standard Deviation 0.47 Total Responses 38 8. Please indicate whether design 3 conveys the following message:
82 Statistic Design 3's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 3 Mean 1.24 Variance 0.29 Standard Deviation 0.54 Total Responses 38 9. Please indicate the level ofeffectiveness ofdesign 1 for the following: Statistic Howeffective is Design 1 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.53 Variance 1.07 Standard Deviation 1.03 Total Responses 38 10. Please indicate the level ofeffectivenessofdesign 1 for the following:
83 Statistic Howeffective is Design 1 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.03 Variance 1.16 Standard Deviation 1.08 Total Responses 38 11. Please indicate the level ofeffectivenessofdesign 2 for the following: Statistic Howeffective is Design 2 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.47 Variance 0.96 Standard Deviation 0.98 Total Responses 38 12. Please indicate the level ofeffectivenessof design 2 for the following:
84 Statistic Howeffective is Design 2 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.03 Variance 1.11 Standard Deviation 1.05 Total Responses 38 13. Please indicate the level ofeffectivenessofdesign 3 for the following: Statistic Howeffective is Design 3 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 1.63 Variance 1.54 Standard Deviation 1.24 Total Responses 38 14. Please indicate the level ofeffectivenessofdesign 3 for the following:
85 Statistic Howeffective is Design 3 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.50 Variance 2.31 Standard Deviation 1.52 Total Responses 38 15. Out ofall of the designs,which do you like best? Why? (Please only choose 1 design) Statistic Value Min Value 1 Max Value 3 Mean 2.82 Variance 0.32 Standard Deviation 0.56 Total Responses 38
86 References: 1. 10 Little-known Facts About E-cigarettes - HowStuffWorks. (n.d.). Retrieved May 20, 2015, from http://health.howstuffworks.com/wellness/smoking-cessation/10-facts-about-e-cigarettes3.htm 2. Adkison, S., O'Connor, R., Bansal-Travers, M., Hyland, A., Borland, R., Yong, H., . . . Fong, G. (2013). Electronic Nicotine Delivery Systems International Tobacco Control Four-Country Survey. American Journal of Preventative Medicine, 44(3), 207-215. 3. Ambrose, B., Rostron, B., Johnson, S., Portnoy, D., Apelberg, B., Kaufman, A., & Choiniere, C. (2014). Perceptions of the Relative Harm of Cigarettes and E-cigarettes Among U.S. Youth. American Journal of Preventive Medicine, 47(21), 53-60. 4. American Psychiatric Association. (2000). Practice guidelines for the treatment of patients with eating disorders (2nd ed.). Washington, DC: Author. 5. Bhatnagar, A., Whitsel, L., Ribisl, K., Bullen, C., Chaloupka, F., Piano, M., . . . Benowitz, N. (2014). Electronic Cigarettes: A Policy Statement From the American Heart Association. Circulation, 1418- 1436. 6. Breland, A., Spindle, T., Weaver, M., & Eissenberg, T. (2014). Science and Electronic Cigarettes: Current Data, Future Needs. American Society of Addiction Medicine, (8), 223-233. 7. Bunnell, R., Agaku, I., Arrazola, R., Apelberg, B., Caraballo, R., Corey, C., . . . King, B. (2014). Intentions to Smoke Cigarettes Among Never-Smoking US Middle and High School Electronic Cigarette Users: National Youth Tobacco Survey, 2011-2013. Nicotine & Tobacco Research, 228-235. 8. Cervellati, F., Muresan, X., Sticozzi, C., Gambari, R., Montagner, G., Forman, H., . . . Valacchi, G. (2014). Comparative effects between electronic and cigarette smoke in human 4 keratinocytes and epithelial lung cells. Toxiciology in Vitro. 9. Choi, K., & Forster, J. (2013). Characteristics Associated With Awareness, Perceptions, and Use of Electronic Nicotine Delivery Systems Among Young US Midwestern Adults. American Journal of Public Health, 103(3), 556-561. 10. Cobb, N., Byron, M., Abrams, D., & Shields, P. (2010). Novel Nicotine Delivery Systems and Public Health: The Rise of the “E-Cigarette”. American Journal of Public Health, 100(12), 2340-2342. 11. Coleman, B., Apelberg, B., Ambrose, B., Green, K., Choiniere, C., Bunnell, R., & King, B. (2014). Association Between Electronic Cigarette Use and Openness to Cigarette Smoking Among US Young Adults. Nicotine & Tobacco Research, 1-7. doi:doi:10.1093/ntr/ntu211 12. DrugFacts: Electronic Cigarettes. (n.d.). Retrieved May 20, 2015, from http://www.drugabuse.gov/publications/drugfacts/electronic-cigarettes-e-cigarettes 13. Duke, J., Lee, Y., Kim, A., Watson, K., Arnold, K., Nonnemaker, J., & Porter, L. (2014). Exposure to Electronic Cigarette Television Advertisements Among Youth and Young Adults. American Academy of Pediatrics, 134(1). doi:10.1542/peds.2014-0269 14. E-cigarettes Not Without Risk. (n.d.). Retrieved May 20, 2015, from http://www.medpagetoday.com/MeetingCoverage/ERS/41461 15. Electronic Cigarettes. (2014, September 22). Retrieved May 20, 2015, from http://www.cdc.gov/tobacco/basic_information/e-cigarettes/youth-intentions/index.htm 16. Enofe, N., Berg, C., & Nehl, E. (2014). Alternative Tobacco Use among College Students: Who is at Highest Risk? American Journal of Health Behavior, 180-189. Retrieved May 20, 2015, from http://www.ncbi.nlm.nih.gov/pubmed/24629547 17. Farsalinos, K., Romagna, G., Allifranchini, E., Ripamonti, E., Bocchietto, E., Todeschi, S., . . . Voudris, V. (2013). Comparison of the Cytotoxic Potential of Cigarette Smoke and Electronic Cigarette Vapour Extract on Cultured Myocardial Cells. International Journal of Environmental Research and Public Health, (10), 5146-5162. doi:10.3390/ijerph10105146 18. GatorWell Health Promotion Services. (2015). Healthy Gators E-Cigarette Survey. Gainesville, FL. Emmeree, J., Jarvis, B. 19. Lee, J., Ranney, L., & Goldstein, A. (2013). Cigarette butts near building entrances: What is the impact of smoke-free college campus policies? Tobacco Control, 22(2), 107-112. doi:10.1136/tobaccocontrol- 2011-050152
87 20. Lefebvre, RC (2000). In PN Bloom & GT Gundlach (Eds.), Handbook of Marketing and Society, Newbury Park, CA: Sage Publications. 21. Murphy-Hoefer, R., Hyland, A., & Rivard, C. (2010). The Influence of Tobacco Countermarketing Ads on College Students’ Knowledge, Attitudes, and Beliefs. Journal of American College Health, 58(4), 373-381. doi:10.1080/07448480903380276 22. Parts of an E-Cigarette and How They Work Together. (n.d.). Retrieved May 20, 2015, from http://www.learn.eversmoke.com/parts-of-an-e-cigarette.html 23. Saddleson, M., Kozlowski, L., Giovino, G., Hawk, L., Murphy, J., Maclean, M., . . . Mahoney, M. (2015). Risky behaviors, e-cigarette use and susceptibility of use among college students. Drug and Alcohol Dependence, 149, 25-30. 24. Saddleson, M.L., Kozlowski, L.T., Giovino, G.A., Hawk, L.W., JM, M., MacLean, M.G., Goniewicz, M.L., Homish, G.G., Wrotniak, B.H., Mahoney, M.C., (2015). Risky behaviors, e-cigarette use and susceptibility of use among college students, Drug and Alcohol Dependence. 25. Sutfin, E., Mccoy, T., Morrell, H., Hoeppner, B., & Wolfson, M. (2013). Electronic cigarette use by college students. Drug and Alcohol Dependence, 131(3), 214-221. doi:10.1016/j.drugalcdep.2013.05.001 26. Theory of planned behavior and smoking: Meta-analysis and SEM model. (n.d.). Retrieved May 20, 2015, from http://www.academia.edu/384590/Theory_of_planned_behavior_and_smoking_meta- analysis_and_SEM_model 27. Theory of planned behavior and smoking: Meta-analysis and SEM model. (n.d.). Retrieved May 20, 2015, from http://www.academia.edu/384590/Theory_of_planned_behavior_and_smoking_meta- analysis_and_SEM_model 28. Tobacco Cessation Among Users of Telephone and Web-Based Interventions — Four States, 2011– 2012. (2015, January 2). Retrieved May 20, 2015, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6351a1.htm?s_cid=mm6351a1_w 29. Tobacco Cessation Among Users of Telephone and Web-Based Interventions — Four States, 2011– 2012. (2015, January 2). Retrieved May 20, 2015, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6351a1.htm?s_cid=mm6351a1_w 30. Torjesen, I. (2014). E-cigarette vapour could damage health of non-smokers. BMJ. doi:10.1136/bmj.g6882 31. Trumbo, C., & Harper, R. (2013). Use and Perception of Electronic Cigarettes Among College Students. Journal of American College Health, 61(3), 149-155. doi:10.1080/07448481.2013.776052. 32. Trumbo, C., & Harper, R. (2015). Perceived Characteristics of E-cigarettes as an Innovation by Young Adults. Health Behavior and Policy Review, 2(2), 154-162. http://dx.doi.org/10.14485/HBPR.2.2.7 33. Trumbo, C., & Kim, S. (2015). The Effect of Electronic Cigarette Advertising on Intended Use Among College Students. Addictive Behavior, 46, 77-81. doi:10.1016/j.addbeh.2015.03.005 34. US Department of Health and Human Services. Physical Activity Evaluation Handbook. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2002, Appendix 3, pg. 43. Retrieved May 20, 2015, from http://www.cdc.gov/nccdphp/dnpa/physical/handbook/pdf/handbook.pdf 35. What's in Your E-Cigarette? (n.d.). Retrieved May 20, 2015, from http://www.webmd.com/smoking- cessation/news/20150218/e-cigarette-ingredients?page=3

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Final MPH Project Paper-1

  • 1. E-Cigs ≠ Safe: A Health Communication Campaign Dissuading First Time Users of Electronic Cigarettes Kiarash P. Rahmanian, B.S., MPH Candidate Department of Behavioral Sciences and Community Health College of Public Health and Health Professions University of Florida
  • 2. 2 E-Cigs ≠ Safe: A Health Communication Campaign Dissuading First Time Users of Electronic Cigarettes Kiarash P. Rahmanian Introduction Electronic cigarettes are devices that are powered by lithium batteries in which heat is applied to cartridges of flavored, liquid nicotine (along with other additives and chemicals) in order to deliver to the user in the form of an aerosol or ‘vapor’ ("DrugFacts: Electronic Cigarettes"). These ‘e-cigarettes’ are not lit, but produce the lit effect with an LED light when the user inhales the ‘vapor’ (Bhatnagar et. al. 2014). Often times, these electronic cigarette devices are made to look similar to tobacco products, particularly conventional cigarettes and cigars ("DrugFacts: Electronic Cigarettes"). Most e-cigarettes are comprised of five different components, which include the following ("DrugFacts: Electronic Cigarettes"): a.) A cartridge, b.) A heating device (an atomizer or vaporizer); c.) A power source (typically a lithium battery), d.) A sensor, and e.) A Smart Chip Microprocessor. The cartridge houses a built-in heating device (or atomizer) built in and comes prefilled with “nicotine juice”. The cartridges are attached onto one end of the lithium ion cell battery. The other end of includes the silicon mouthpiece. This holds the liquid solution, which contains the varying amounts of nicotine, flavorings, and other chemicals- such as nicotine, formaldehyde, acetaldehyde, propylene glycol, acrolein, glycerine‐based oils, flavorings and other chemicals (“Parts of an E-Cigarette and How They Work Together”). The heating device (an atomizer or vaporizer) is responsible for heating the liquid nicotine, which creates the nicotine-infused vapor that is inhaled (Bhatnagar et. al. 2014). This atomizer reacts to an electrical signal sent by the lithium ion cell battery. The power source (typically a lithium battery) is the most critical part of the Background: Data from the Healthy Gators survey of 2015, showed a staggering 84.54% of the students know what an electronic cigarette was; 40.9% stated that they had observed e-cigarette use on UF’s campus; 20.75% have tried an e-cigarette, 35.61% are unsure or do not think that e-cigarettes are harmful; 11.55% stated they would try an e-cigarette or start using regularly in the next 6 months; 3.2% of respondents used electronic cigarettes regularly in the past 30 days. The results of this survey show the rate of UF Students to be higher or equal to the national surveys for ever-use, attempted use, and awareness of electronic cigarettes. Objectives: The purpose of this study was to assess the knowledge, attitudes, and beliefs of students at the University of Florida that were defined as “at-risk” of becoming first-time users of electronic cigarettes in order to guide message designs for a health communication campaign to be rolled out in the Summer and Fall terms of 2015 that target the “at-risk” target population on campus by educating and promoting awareness of the negative health outcomes of electronic cigarettes. Methods: This study consists of 5 stages: 1) Recruitment; 2.) Two-Part Questionnaire of participants; 3.) Development of preliminary health communication products (based on findings from Two-Part Questionnaire); 4.) Pre-testing the first drafts of health communication products with the study participants; and 5.) Pre-testing the revised health communication products with the study participants. Results: 455 University of Florida students were recruited through convenience sampling, with 39 “at-risk” participants continuing in the study. Amongst the overall sample (n=455), 98% are aware of what e- cigarettes are, 57% have tried an e-cigarette (66% for “at-risk”), 53% are open to try an e-cigarette (83% for “at-risk”), 35% would become regular users of e-cigarettes (71.8% for “at-risk”), 57% are in the contemplation or preparation stage of becoming first-time users of e-cigarettes (59% for “at-risk” sample in the contemplation stage, and 40% in the preparation stage). Based on pre-testing results, design 1 (Only a hand with text), design 2 (aerosol spray can), and design 3 (Infographic) tested the most favorably amongst the “at-risk” target population. Conclusions: Design 1 (Only a hand with text), design 2 (aerosol spray can), and design 3 (Infographic) will be implemented and evaluated for effectiveness following GatorWell protocol in the Fall of 2015.
  • 3. 3 e-cigarette (“Parts of an E-Cigarette and How They Work Together”). A sensor inside the battery activates when a user begins inhaling or presses a button. This "Smart Chip Microprocessor" as it's known signals the e- cigarette to turn on, and sends a charge to the atomizer inside the cartridge. There are two settings- automatic and manual, which allow the user to just inhale (automatic), or press a button then inhale (manual). The sensor known as the “Operating Mode Sensor” or OMS triggers the smart chip, which signals the lithium ion cell battery to charge the atomizer upon inhalation (“Parts of an E-Cigarette and How They Work Together”). The Smart Chip Microprocessor is known as the “Microcomputer Smart Chip”. This component prompts the battery, through sending an electrical signal, which then employs the atomizer (“Parts of an E-Cigarette and How They Work Together”). In many e-cigarettes, puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The resulting aerosol or vapor is then inhaled (called "vaping"). Literature Review The cause for concern about e-cigarettes is plentiful but the primary concern lies in their potential ingredients being chemicals that are known to be toxic to humans. Because of the lack of regulation by the U.S. Food and Drug Administration (FDA), clinical studies about the safety of e-cigarettes have not been released to the public (“Electronic Cigarettes”, 2014, September 22). Users of e-cigarettes have no means of knowing: a.) Whether they are safe, b.) What chemicals they contain and at what dosages, and c.) How much nicotine the user is inhaling with each usage (Bhatnagar et. al. 2014). Atop these concerns are the concerns for those around e-cigarette users with secondhand smoke, nicotine digestion for children and pets, and the obvious long-term concerns about e-cigarettes. E-Cigarette Growth In the year 2014, the sales of electronic cigarettes have topped $1.7 million dollars (“Electronic Cigarettes”, 2014, September 22). According to Bhatnagar and colleagues (2014), electronic cigarette sales margins are predicted to grow to over $10 billion by 2017, which would surpass the sales of conventional cigarette sales margins. In addition, the 3 largest major tobacco companies have been purchasing independent e- cigarette companies and will potentially be sharing 75% of the profit pool from e-cigarette sales in the next 10 years (Bhatnagar et. al. 2014). The number of current electronic cigarette users stands at over 2.5 million. The awareness and use of electronic cigarettes is not as negligible as you may think. Currently, 4 out of 10 smokers or users of tobacco products use electronic cigarettes (“Electronic Cigarettes”, 2014, September 22). With the college student population, the largest cause for concern is that the number of never‐smokers who used electronic cigarettes rose. According to Bunnell (2014), that number rose from 79,000 to 263,000 between 2011 and 2013. Chemical Contents Some further concerns lie in the chemical contents (and solvents) of most e-cigarettes, the amount of nicotine intake per usage, the vapor of e-cigarettes, inequities of production / lack of quality control amongst all electronic cigarette products, and the gateway to conventional tobacco use. The solvents of most e-cigarettes in which nicotine and flavorings are dissolved in are contained as an aerosol and are also known as lung irritants that can transform into carbonyls ("DrugFacts: Electronic Cigarettes"). These carbonyls are cancer-causing chemicals- such as formaldehyde and acetaldehyde. In a study on E-cigarettes, toxic chemicals such as mercury, acrolein, aerosol, formaldehyde, diethylene glycol (found in antifreeze), acetaldehyde, propylene glycol (PG), glycerin, and various toxic metals- such as tin, nickel, cadmium, and lead, were found ("DrugFacts: Electronic Cigarettes"). A 2013 study notes that some of those toxic metals, such as nickel, are found in concentrations 2 to 100 times that of conventional cigarettes (“What's in Your E-Cigarette?”). Propylene glycol (PG) is used to make artificial smoke or fog that is used for stage pyrotechnics (Breland et. al., 2014). Glycerin is found in many food and prescription or over the counter (OTC) drugs and when heated becomes Acrolein, which can severely harm the lungs and can agitate heart conditions or disease in current or former smokers (“What's in Your E-Cigarette?”). Formaldehyde and acetaldehyde are
  • 4. 4 said to be potential carcinogens (Breland et. al., 2014). Aerosol is the state in which the chemicals above are contained. This state is a colloidal suspension of the metal and silicate particles dispersed in a gas. The natural flavoring that electronic cigarettes state they contain is even dangerous. There have been multiple cases of lipoid pneumonia reported that are cased by the recurrent exposure to the natural ingredient, glycerin-based oils, that is contained in electronic cigarette’s nicotine-based vapor (“What's in Your E-Cigarette?”). According to Farsalinos and colleagues (2013), the results of this study found from the “20 commercially-available EC liquids that were tested in vapour form, four were found to be cytotoxic on cultured cardiomyoblasts”. The results of the study further stated: “this study’s findings support the concept that ECs may be useful as tobacco harm reduction products, but the harm is still there and therefore, e-cigarettes should not be used because they are still harmful to human beings” (Farsalinos et. al., 2013). According to Torjesen, I. (2014), found that e- cigarette vapor could actually hurt non-smokers in the vicinity of those that use e-cigarettes and “although the data were preliminary, they provide evidence for a possible exposure risk to passive smokers in enclosed spaces with limited ventilation if all the emissions from e-cigarettes were exhaled”. This presents another consideration to be addressed in terms of e-cigarette regulation and use, since one of the primary arguments for using electronic cigarettes is their lack of harm to others around the users (Torjesen, I., 2014). Harm of E-Cigarettes Due to the 1st generation electronic cigarettes’ inability to deliver a similar powerful hit of nicotine that conventional tobacco products do, engineers and product developers worked on a 2nd generation electronic cigarettes that allows users to increase the device’s voltage, which increases the temperature to atomize substantially more nicotine per puff from the user (“Electronic Cigarettes”, 2014, September 22). This is a clear issue as the effect of nicotine could be worsened through further intake of nicotine. The lethality of nicotine does not change though, even a small dose of liquid nicotine is very lethal- less than one tablespoon of many of the “nicotine juices” currently available on the market is enough to kill an adult (“Electronic Cigarettes”, 2014, September 22). According to Cobb and colleagues (2010), a cigarette contains a “highly toxic dose of 10–15mg of nicotine” but serious poisoning is rare due to “pre-systemic metabolism and spontaneous vomiting limits the systemic absorption of nicotine in swallowed tobacco”, but these limits do not apply in the case of the high concentration of nicotine in “nicotine juice” and can “introduce a new set of risks similar to those in nicotine- based pesticides and not normally present in leaf tobacco products”. The nicotine poisoning has become such a large issue that the monthly poison control calls related to e-cigarettes (nationwide) increased from 1 in 2010 to 215 in 2014-- a rise from 0.3 percent to 41.7 percent of all emergency calls (Bunnell, 2014). Of those calls, 42% of them involved accidental poisoning of adults 20 or older (Bunnell, 2014). Overall, the U.S poison centers reported over 2,405 calls surrounding e-cigarette exposures from September 2010 to February 2014 (Bunnell, 2014). Another detail that is alarming is that the calls related to e-cigarettes were more likely than conventional cigarette calls to involve a report of a negative health effect following exposure (Cobb et. al., 2010). The potential effects of nicotine generally deal with the last segments of the brain to mature- the decision-making, and impulse control aspects. Particularly, the limbic system (otherwise known as the “reward system”) is affected, which regulates one’s responses to stimuli (including attention span) and dopamine production that deals with the feeling or pleasure and addiction (Breland et. al., 2014). Thusly, the level of harm of the potential nicotine exposure is very high and to be taken more seriously than conventional cigarettes. Research in the field of electronic cigarette usage is expanding rather rapidly with researchers who have already discovered that electronic cigarette users are experiencing diminished lung function, airway resistance and various negative cellular changes, regardless of whether they currently (or have ever) smoked conventional cigarettes or used other tobacco products (“E-cigarettes Not Without Risk”). These researchers exposed cells to e-cigarette vapor, which resulted in cells with similar unhealthy changes that occur to cells that are exposed to conventional cigarette smoke (“E-cigarettes Not Without Risk”). Those that use “nicotine-free electronic cigarettes” are not discounted from the side effects either. These users also experience inflammation of the cells in their lungs along with distinctive airway resistance (“E-cigarettes Not Without Risk”). The cause of the inflammation deals with the mass of the particles in the vapors of electronic cigarettes. The mass of these particles is about 3 milligrams per cubic meter of air (“E-cigarettes Not Without Risk”). This is approximately 100 times as greater than the Environmental Protection Agency’s (EPA) 24-hour exposure limit for the levels of
  • 5. 5 fine air particles, which is why 40% of these inhaled particles get deposited in the deepest and smallest airways of the lungs (“E-cigarettes Not Without Risk”). A study on pulmonary effects showed that 5 minutes of electronic cigarette usage led to a vast increase in peripheral airway flow resistance, impendence, and oxidative stress among health smokers (“E-cigarettes Not Without Risk”). Thus, these incredibly small particles are heavier than expected and are very harmful to the body, causing blood vessel damage, inflammation of the cells in the lungs, and other various negative effects on the nervous system. But, this does not discount former smokers that are using electronic cigarettes or current smokers who intend to use them for quit purposes. Considering all of the dangers of the chemical makeup of electronic cigarettes, the ingredient that stays uniform between conventional and electronic cigarettes is nicotine (“10 Little-known Facts About E-cigarettes – HowStuffWorks”). The FDA completed initial testing, which found that the cartridges for the e-cigarettes under the same manufacturing label release considerably different levels of nicotine (“10 Little-known Facts About E- cigarettes – HowStuffWorks”). These levels could range from 26.8 to 43.2 micrograms of nicotine per 100- milliliter puff (“10 Little-known Facts About E-cigarettes – HowStuffWorks”). Alongside this finding, the FDA’s lab tests indicate that those nicotine-free cartridges are still providing a low dose to users, notwithstanding the claims. Gateway to Conventional Cigarette Use The last and most disconcerting aspect to consider in terms of the need for a public health intervention and/ or education is that electronic cigarettes can prove to be a gateway to conventional tobacco product use, which is far worse and vastly proven through countless research studies showing all of the negative health effects both long-term and short-term. Studies have shown that those that identify as “never smokers” who went on to use an electronic cigarette were nearly twice as likely to smoke conventional cigarettes than those “never smokers” who had not used electronic cigarettes at all (Bunnell, 2014). According to Coleman and colleagues (2014), the “harm of e-cigarettes does not stop at the source, studies show that they can even serve as a gateway to using conventional cigarettes”. Based on the results of this study, “among young adults who had never established cigarette smoking behavior (unweighted 4,310), 7.9% reported having ever tried e-cigarettes—14.6% of whom reported current use of the product” (Coleman et. al., 2014). This “ever e-cigarette use was associated with being open to cigarette smoking (adjusted odds ratio = 2.4; 95% confidence interval = 1.7, 3.3), as was being male, aged 18–24, less educated, and having ever used hookah or experimented with conventional cigarettes” (Coleman et. al., 2014). In conclusion, this “ever use of e-cigarettes, as well as other tobacco products, was associated with being open to cigarette smoking”, and is therefore a rather large concern for those that use e- cigarettes (Coleman et. al., 2014). Concern for College Students Electronic cigarette (also called e-cigarettes or electronic nicotine delivery systems) usage is becoming a more frequent occurrence among college-aged students. According to Saddleson and colleagues (2015), “college students are involved with riskier behaviors than adults; and therefore are more susceptible to using e- cigarettes, alcohol, and drugs”. This statement aligns with the idea that though electronic cigarettes pose a threat and are harmful and considered “risky”, college-aged students are more prone to using them, which makes this target population “at-risk” and needing further study and education in order to effectively guide their decision- making process. This study went on to “evaluate susceptibility of future e-cigarette use among college students who have never used e-cigarettes” and discovered that the prevalence of those that will try or have tried e- cigarettes is very high (Saddleson et. al., 2015). According to Enofe and colleagues (2014), “never daily and nondaily smokers were 3 times as likely as former daily and non-daily smokers to use alternative nicotine products with a p < .001”. Adding to the risk of being a college-aged student, being a never-user of tobacco products also furthers the risk of the target population of concern. All of these factors melded together have and continue to create a high level of alarm among healthcare providers and public health professionals in the coming years. 2015 Health Gators Survey
  • 6. 6 With all of the concerns about electronic cigarettes circulating, there have been very minimal studies done dealing with the potentially “at-risk” population similar to the Healthy Gators Survey of 2015, but their results are invaluable in guiding this study. According to Sutfin and colleagues (2013), there is “limited data on e- cigarette use and correlations exist, and to our knowledge, no prevalence rates among U.S. college students have been reported”. This study in particular aimed to “estimate the prevalence of e-cigarette use and identify correlates of use among a large, multi-institution, random sample of college students” (Sutfin et. al., 2013). This was a fully web-based survey taken in the fall term of 2009 with 4,444 students from 8 colleges in North Carolina responding. The results of the survey stated: “ever use of e-cigarettes was reported by 4.9% of students, with 1.5% reporting past month use”, with the correlates of ever-use including “male gender, Hispanic or "Other race" (compared to non-Hispanic Whites), Greek affiliation, conventional cigarette smoking and e- cigarette harm perceptions” (Sutfin et. al., 2013). The interesting aspect of this study was that “although e- cigarette use was more common among conventional cigarette smokers, 12% of ever e-cigarette users had never smoked a conventional cigarette” and “e-cigarette use was negatively associated with lack of knowledge about e-cigarette harm” (Sutfin et. al., 2013). In conclusion, this study found that “unlike older, more established cigarette smokers, e-cigarette use by college students does not appear to be motivated by the desire to quit cigarette smoking” (Sutfin et. al., 2013). The other study that stood out as similar to the Healthy Gators survey of 2015 from UF is “Risky behaviors, e-cigarette use and susceptibility of use among college students” by Saddleson and colleagues published in 2015. This study used cross-sectional data from 2013 in order to examine prevalence, correlates and susceptibility to e-cigarettes among young adults using an Internet survey from a convenience sample of 1,437 respondents, 18-23 year olds that attended four colleges and/ or universities in the Upstate New York area (Saddleson, Kozlowski, et. al. 2015). According to Saddleson, Kozlowski, and colleagues (2015), “95.5% of respondents reported awareness of e-cigarettes; 29.9% were ever users and 14.9% were current users” with “never e-cigarette users, individuals involved in risky behaviors or, with lower harm perceptions for e-cigarettes” being more susceptible to electronic cigarette use in the near future. Both of these studies are very similar to the Healthy Gators survey of 2015, but their results are far less concerning than those of the Healthy Gator survey for the University of Florida’s campus and students. Following the Healthy Gators survey of February 2015, the electronic cigarette portion revealed a staggering 84.54% of the students surveyed responded that they are aware of what an electronic cigarette was (GatorWell Health Promotion Services, 2015). Though awareness is not indicative of use, 40.9% of respondents stated that they had observed e-cigarette use on UF’s campus- with 20.75% of respondents having tried an e- cigarette (GatorWell Health Promotion Services, 2015). Based off of these survey results, 35.61% of respondents are either unsure or they do not think that using e-cigarettes is harmful to one’s health (Gatorwell Health Promotion Services, 2015). The target of this study is based around those that are defined as “at-risk” for becoming first time users of e-cigarettes, which based on the survey results stands at 11.55% of respondents that stated they would try an e-cigarette in the next 6 months or start using an e-cigarette regularly in the next 6 months (GatorWell Health Promotion Services, 2015). The 30-day prevalence of use based off of item 61 of the Healthy Gators E-Cigarette survey indicated that 3.2% of respondents use electronic cigarettes regularly in the past 30 days. According to Adkison and colleagues (2013), “46.6% (of participants) were aware of ENDS (Electronic Nicotine Delivery Systems)- with the U.S. in the lead at 73; 7.6% had tried ENDS (or 16% of those aware of ENDS); and 2.9% were current users. In this study, awareness of ENDS was highest among “younger, non-minority smokers with higher income” and the “prevalence of trying ENDS was higher among younger, nondaily smokers with a high income and among those who perceived ENDS as less harmful than conventional cigarettes (79.8%)”. Need for Intervention The results of the Healthy Gators Electronic Cigarette Survey of 2015 are a large cause for concern for those that work in the healthcare and public health fields at the University of Florida with our campus statistics for ever-use, tried, and awareness being higher or equal to the national surveys, especially because current use of electronic cigarettes in 2013 was just 1.9% among adults, with ever-use being at 8.5% ("DrugFacts: Electronic Cigarettes").
  • 7. 7 The rising trend with Universities and colleges dealing with tobacco issues are indoor and outdoor tobacco- free campus policies. Despite the new policy changes, there is very little direct evidence that currently exists on the impact of these tobacco-free policies on the outcomes of tobacco use. According to (Lee et. al., 2013), “researchers collected cigarette butts (n=3427) at main building entrances (n=67) at baseline and follow-up on 19 community college campuses stratified by strength of campus outdoor tobacco policy (none, perimeter/designated area, 100% tobacco free)” and the “outcome measures included the number of butts per day at building entrances averaged to create a campus score”. The results of the study showed that “100% tobacco-free community college campuses had significantly fewer cigarette butts at doors than campuses with no outdoor restrictions” (Lee et. al., 2013). Therefore, this study provides “some of the first evidence on the impact of 100% tobacco-free outdoor policies on college campuses using an objective and reproducible measure” and the fact that “such policies likely provide a more healthful environment for students, staff, faculty and visitors” (Lee et. al., 2013). The University of Florida is among the list of universities that has already taken the first step toward tobacco product cessation back in 2010, with the UF Tobacco-Free Campus policy. According to Duke and colleagues (2014), the tobacco industry and e-cigarette industry’s marketing and advertisement campaigns pose a high risk to potential users “in the absence of evidence-based public health messaging” where “the current e-cigarette television advertising may be promoting beliefs and behaviors that pose harm to the public health”. This study states: “if current trends in e-cigarette television advertising continue, awareness and use of e-cigarettes are likely to increase among youth and young adults” (Duke et. al. 2014). According to Trumbo, and Kim (2015), the e-cigarettes market’s advertisement tactics to college students and young adults in particular in the U.S. is geared around being “less harmful”, “only water vapor”, and “not addictive due to the lack of nicotine”. This study’s results state that there is a “positive reaction to the ads and holding the belief that e-cigarettes are not as addictive were both independently associated with intention” alongside the change in attitudes and norms, which “were also associated but were controlled by inclusion of the other variables” (Trumbo, and Kim. 2015). This perception shift of e-cigarettes could be creating an “at-risk” user population that this study will be addressing. This “at-risk” college-aged population is basically created by these pro-electronic cigarette advertisements (Trumbo, and Kim. 2015). These articles very much encourage counter-marketing campaigns against electronic cigarettes. Thus, with a clear understanding that there is a dire need for anti-electronic cigarette marketing and campaigns, a creation of a health communication campaign was pursued in this study through a strong basis in literature and theoretical frameworks. Purpose The next stage involves educating and increasing awareness of the dangers of tobacco products in the college-age population through health communication campaigns and social marketing campaigns. According to Choi and Forster (2013), “69.9% of respondents were aware of e-cigarettes, 7.0% had ever used e-cigarettes, and 1.2% had used e-cigarettes in the past 30 days”. These numbers are far lower than the number presented in the Healthy Gators Survey of 2015. Therefore, this study showed that those young college-aged adults perceive e-cigarettes as “less harmful and less addictive than cigarettes, despite the lack of scientific evidence related to e-cigarettes” (Choi and Forster, 2013). This low perceived severity of e-cigarette usage is prevalent amongst all research studies and adds weight to this study’s intentions to create a strategic health communication campaign in order to intervene with young adults who are “at-risk” of becoming first time users of electronic cigarettes (Choi and Forster, 2013). According to Choi and Forster (2013), “strategic health communication interventions to communicate to the public that evidence to support these perceptions is lacking and strengthening tobacco control regulations to include e-cigarettes could potentially reduce the prevalence of e-cigarette use among young adults”. Thusly, this study will undertake the first two stages of a health communication campaign targeting University of Florida students who identify as “at-risk” (based on survey items in the Two-Part Questionnaire) to explore the characteristics (e.g., knowledge, attitudes, beliefs) and preferences for health communication material targeted college-age students at risk for becoming first-time users of electronic cigarettes. Exploratory data from this study will be used to guide message designs for a larger health communication campaign targeting the “at-risk” target population on campus in the Summer and Fall terms of 2015. The overall purpose of the larger campaign sponsored by GatorWell at the University of Florida (UF) is
  • 8. 8 to educate and promote awareness of the negative health outcomes of electronic cigarettes among UF college students. Research questions and specific aims that guided this pilot study listed below: Objectives and Specific Aims The research questions that the primary researcher looked at were the following:  Research Question 1: What are the perceptions of knowledge that the members of the “at-risk” population possess about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects?  Research Question 2: In general, what is attitude of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects?  Research Question 3: In general, what are the beliefs of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects?  Research Question 4: How can this health communication campaign increase the perceived susceptibility and severity of the negative health outcomes of using electronic cigarettes of the members of the at-risk target population to decrease campus-wide usage of electronic cigarettes at UF?  Research Question 5: What are some of the preferred communication campaign design characteristics (e.g., color, graphic, text, rhetoric, etc.) among college-age students at risk for e-cig use?  Research Question 6: Are college-aged students who have attempted to use in the past (ever use) more likely to have close friends that use electronic cigarettes? The objectives or specific aims of the study were to:  Objective 1: To describe perceptions of knowledge that the members of the “at-risk” population possess about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects.  Objective 2: To explore the general attitude of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects.  Objective 3: To examine general beliefs of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects.  Objective 4: To distinguish how a health communication campaign can be executed effectively in order to increase the perceived susceptibility and severity of the negative health outcomes of using electronic cigarettes of the members of the at-risk target population to decrease campus-wide usage of electronic cigarettes at UF.  Objective 5: To distinguish the design preferences (color, graphic, text, rhetoric, etc.) of this “at-risk” target audience in regards to a health communication campaign geared toward the dissuasion of electronic cigarette use (learner verification).  Objective 6: To explore the association between using electronic cigarettes and reporting close friends who currently use electronic cigarettes. Hypotheses Based on the vast literature review and the Healthy Gators Survey of 2015, I have hypothesized that majority of participants that fall into the “at-risk” population recruited from the Two-Part questionnaire will be White Males, as there is already data that displays this in the literature review above. The large majority of data collected from this study is intended primarily for exploratory purposes. Due to the nature of this campaign’s intention being dissuasion of use, the perceived benefits by the study participants (based on each message design) will be geared toward their effectiveness in creating behavioral intention to not use electronic cigarettes using the negative health aspects (toxic chemicals, vapor instead of aerosol, etc.). Thus, it can be predicted that
  • 9. 9 the message designs that best conveys the various negative aspects (toxic chemicals, vapor instead of aerosol, etc.) will parallel the greatest intention of not using electronic cigarettes in the future. This study’s hypotheses are as follows:  Hypothesis 1: Baseline, or Time 1 (T1), knowledge of the harms of electronic cigarettes (toxic chemicals, vapor instead of aerosol, etc.) will be low.  Hypothesis 2: General attitudes towards electronic cigarettes will be positive at T1.  Hypothesis 3: Beliefs of the harm (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes will be negative at T1.  Hypothesis 4: The perceptions of the harm and negative health effects of electronic cigarettes will be low at T1.  Hypothesis 5: Participants with low levels of knowledge will have lower understanding of the harm of electronic cigarettes at T1.  Hypothesis 6: Participants that have tried (ever-use) electronic cigarettes in the past have several close friends that currently use electronic cigarettes.  Hypothesis 7: Participants with positive attitudes and beliefs will have a lower understanding of the harm of electronic cigarettes at T1. Theoretical Framework This study examines the knowledge, attitudes, and beliefs of college-age students “at-risk” for e-cig use, as well as design preferences for color, graphics, textual content, rhetoric, etc. Thusly, this study will be using the following theoretical frameworks to aid in the objectives and goals of the study: the health belief model, the stages of change (the Transtheoretical Model or TTM), the information processing paradigm, the theory of reasoned action (TRA), and the Diffusion of Innovation theory (or DOI) (Lefebvre, 2000). The Health Belief Model The Health Belief model consists of constructs that delve into a person’s regard for their own safety and their likelihood of susceptibility to the disease or harm, which are effected heavily by their barriers to change or benefits to the change. This theory later gained the construct of self-efficacy, which can be defined as the power to create or sustain that behavior change. For the Health Belief Model, this study’s campaign materials will work to increase the “at-risk” population’s perceived severity, the perceived benefits of action of not using them (or quitting for those outside of the “at-risk” population) all while addressing their perceived barriers to action through creating more cues to action. Primarily for this study, the campaign materials will be working to increase the “at-risk” population’s perceived severity and perceived benefits of action through providing varying cues to action throughout campus in the form of health communication messages and designs. The perceived severity of electronic cigarettes will be increased through messaging that includes the harmfulness of using them and their toxic contents, while the perceived benefits of action will be addressed simply through understanding that not using electronic cigarettes brings an overall healthier life. The components of this theory can be found in Appendix I. According to Ambrose and colleagues (2014), the perceived susceptibility of the college-aged population as a whole is rather low and contributes to creating college students with low perceived susceptibility and severity, which in turn adds to the current problem of the “at-risk” users that this study plans to address. Basically, this article shows that “many youth perceive tobacco use on a continuum of harm”, stating that “youth who perceive gradations in harm—both by frequency and intensity of cigarette use and by type of product—may be particularly susceptible to e-cigarette use” (Ambrose et. al., 2014). The basis of using a health communication campaign is further supported by literature in regards to tobacco counter-marketing ads and their effects on college students in regard to their level of knowledge, their attitudes, and their general beliefs. According to Murphy-Hoefer and colleagues (2010), “health consequences ads significantly increased overall knowledge and negative attitudes and beliefs”. Using surveys “before and after viewing four 30-second anti- tobacco advertisements in 1 of 3 theme categories-social norms, health consequences, or tobacco industry manipulation”, the students were to determine their answers based on their “knowledge, attitudes, and beliefs”
  • 10. 10 (Murphy-Hoefer et. al., 2010). With further fervor of support from the literature, it can be stated that a health communication campaign was the correct choice in regard to this “at-risk” population of college-aged students. The Stages of Change theory (the Transtheoretical Model or TTM) In regard to tobacco prevention or tobacco cessation processes, people generally are said to progress through five varying levels of readiness to change—pre-contemplation, contemplation, preparation, action, and maintenance. At each of these stages, various tactics can be used in order to help students to progress to the next stage and get closer to the action or maintenance stage. Within this study, this theory will be used in reverse through asking what stage the participant believes himself or herself to be in regarding their willingness to use an electronic cigarette. This will later be used as part of the data analysis and cleaning of the data in order to only be targeting those that are deemed “at-risk” based on being in either the contemplation or preparation stages of this model. This won’t necessarily be used to guide message campaigns, but rather for surveying the “at-risk” target population. The components of this theory can be found in Appendix II. The Information Processing Paradigm This paradigm, often used to look at the ways in which people process information from health communication campaigns, was used to look at the impact of the persuasive communication, through the three phases of message processing—attention to the message, comprehension of the content, and acceptance of the content. Some of the concepts from this theory that this study will look at are: exposure to information, perception of the information presented, comprehension of what is perceived, and agreement with what is presented. The later half of this health communication campaign will look at retention of what is accepted, and acting on the basis of the decision. The message designs will be evaluated following the pre-testing survey of preliminary materials based on these components. The components of this theory can be found in Appendix III. The Theory of Reasoned Action If a person has control over their own behaviors, their behavioral intentions can be predicted through their actual behavior. These behavioral intentions are determined by two factors—attitude toward the behavior and beliefs regarding others people’s support of the behavior. The concepts of this theory are: attitude toward that behavior, outcome expectations, normative beliefs, subjective norms, the beliefs and evaluations of others, and desire to comply with others (or motivation to copy). All of these components together determine that individual’s behavioral intention, which then predicts their actual behavior. This theory was used to determine the at-risk target population’s reasoning behind their action and aid in the pre-testing campaign materials. The components of this theory can be found in Appendix IV. According to Trumbo and Harper (2013), “an important goal of this project is to examine behavioral intention to try e-cigarettes”. In order for the researchers in this study to do so, they used the Theory of Reasoned Action (TRA), with its’ parsimonious form- behavior that is under volitional control is best predicted by behavioral intention, which in turn is best predicted by the individual’s attitude toward the act and the individual’s perception of social norms involving the act (Trumbo, C., and Harper, R., 2013). The authors state that they used the TRA because “it is widely acknowledged that tobacco use is socially embedded and the inclusion of normative effects addresses this condition” (Trumbo, C., and Harper, R., 2013). Also, this study measures attitudes, which in their measurement “included three items with 5-point responses (strongly agree to strongly disagree): use of e-cigarettes should be legal for adults, e-cigarettes are a big step forward, and belief that e-cigarettes are a more modern way of using tobacco. This study also looks at individual norms, which are “consisted of three pairs of items: it would be acceptable to my closest friends (most people I know, closest family members) if I used e-cigarettes; when it comes to things like e-cigarettes it is important for me to follow the wishes of my closest friends” (Trumbo, C., and Harper, R., 2013). In conclusion, this study guided a lot of the design of the Two-Part Questionnaire with questions similar to those used within this study’s survey methods. The Diffusion of Innovation Theory (DOI)
  • 11. 11 Any new idea, product, or behavior is adopted at varying rates. This rate is affected by the concepts within the Diffusion of Innovation theory. The concepts that this study looks at are: relative advantage, compatibility, complexity, trialability, and observability (Lefebvre, 2000). This theory was used in order to determine the aspects of electronic cigarettes that the “at-risk” population likened to and their reasoning. Thus, using their logic and reasoning, this theory and the survey items were used to guide campaign messaging and countering their reasoning and unsound logic. The components of this theory can be found in Appendix V. According to Trumbo, and Harper (2015), the results of this study show that “television ranked first for exposure to e-cigarette information” and that “the most positive innovation attributes were observability and relative advantage”. These two factors from the Diffusion of Innovation theory showed that “information exposure and favorable perception of an innovation predicted use” and therefore the “high degree of e-cigarette awareness combined with depiction of the devices as a favorable innovation may contribute to their wider adoption and may argue for regulation of e-cigarette advertising” (Trumbo, and Harper, 2015). This study led the preliminary design of the messages along with the data analysis of the Two-Part Questionnaire items that dealt with the DOI theory concepts. Methods Using the above theoretical frameworks, this study has worked to marry the various components (relative advantage, compatibility, complexity, trialability, and observability of the Diffusion of Innovation Theory; attitude toward behavior, outcome expectations, normative beliefs, subjective norms, the beliefs and evaluations of others, and desire to comply with others of the Theory of Reasoned Action; attention to the message, comprehension of the content, and acceptance of the content of the Information Processing Paradigm; perceived severity, perceived benefits of action, perceived barriers to action, and cues to action of the Health Belief Model; and the stage in which our target population is in regard to their level of readiness to use electronic cigarettes—contemplation and preparation of the Stages of Change or Transtheoretical Model) of each theory in order to build a strong synergy of message design and content for the health communication campaign. Inclusion Criteria The “at-risk” first-time users of electronic cigarettes will be defined through a Two-Part Questionnaire that includes 4 items from the 2015 Healthy Gators survey (Q.29, 57, 59, and 60) to determine risk level of participants. These items include: 1.) Have you ever heard of an “e-cigarette” or electronic cigarette, a cigarette- looking electronic device that delivers nicotine aerosol when you puff it (Other names for e-cigarettes include: “hookah pens”, “personal vaporizers”, and “smokeless cigarettes”); 2.) Have you ever tried an e-cigarette, even one or two puffs; 3.) How likely do you think that you would try an e-cigarette in the next 6 months, even if offered a puff from a friend or family member; and 4.) How likely do you think that you would start (or continue) using an e-cigarette regularly in the next 6 months. If the participant did not answer the questions in a particular manner to be included in this study, they did not progress to the second part of the initial questionnaire. They were thanked for their participation at that point and exited the questionnaire. Study Design As part of a larger study, this pilot study completed stages 1 and 2 of a health communication process model (cite appendix). Data from this study will help plan for the next two stages (Stage 3 and 4) of the health communication campaign design and testing. Stage 1 of the health communication campaign is the “Planning and Strategy Development” stage. Stage 2 of the health communication campaign is the “Developing and Pretesting Concepts, Messages, and Materials” stage. Following the completion of this study, the GatorWell Design Team will make the final revisions and follow the created action plan and timeline to rollout the health communication campaign for the Summer B and Fall 2015 terms. A flowchart of this study’s process is available in Appendix XIV. This study’s recruitment channels disseminated recruitment materials to a maximum of 51,000 participants, who are 18 years and older. Informed Consent Process
  • 12. 12 For each stage of the research study (questionnaire, pre-testing survey of preliminary materials, and post-testing survey of revised materials), consent was requested at the beginning of the Qualtrics survey. The informed consents were online and consisted of a checkbox (Appendix VII) that will not allow the participant to progress without selecting ‘I Do Consent for consent. If consent was not given, the participant was exited from the survey automatically using a programmed Qualtrics command. Stage 1: Planning and Strategy Development In the “Planning and Strategy Development” stage of the health communication campaign, the primary researcher: 1.) Completed a full literature review, and 2.) Completed all formative research based on data, collaborators, and other resources. Stage 2: Developing and Pretesting Concepts, Messages, and Materials Upon Institutional Review Board approval, during the “Developing and Pretesting Concepts, Messages, and Materials” stage of the health communication campaign, the primary researcher: 1.) Completed recruitment, 2.) Disseminated the two-part questionnaire, 3.) Developed the preliminary health communication campaign materials, 4.) Pre-tested the preliminary materials, 5.) Revised the preliminary materials based on pre-test results, 6.) Pre-tested the revised materials, and 7.) Made final revisions to materials. Recruitment (Appendix VIII) Participants for this study were recruited through email solicitation (over various listservs), social media websites (Facebook), and the Gator Times (a weekly E-Newsletter that is sent out to all UF students). Two-Part Questionnaire (Appendix IX) The Two-Part Questionnaire (T.1 in the process), in the form of an online survey through the Qualtrics program, was part of the formative research process. This survey provided insight to the at-risk students’ knowledge, attitudes and beliefs about using electronic cigarettes. Upon completion of data collection, the primary researcher completed a comprehensive data analysis (themed and coded qualitative data, SPSS for the Quantitative data) defined the potential “at-risk” first-time users of electronic cigarettes. These chosen “eligible” participants were then sent an email to await a follow-up email to continue in this study by aiding in the conceptualization and guiding of message designs for this health communication campaign. Preliminary Health Communication Campaign Materials Development (Appendix X) The findings from the Two-Part Questionnaire informed health communication product development. Following data analysis, the primary researcher attended message design meetings with the GatorWell Junior Designer for the preliminary campaign materials, resulting in the 1st mock-ups of the preliminary campaign materials. The message designs included 2 designs in different variations accounting for inclusivity of demographic backgrounds and color / text variations and one infographic with 2 variations. Upon completion of designs, these designs and their variations were pilot tested with peer groups, public health professionals with experience on the health topic of tobacco and electronic cigarettes. These content reviewers included: Dr. Jane Emmerée, Ph.D., CHES; Health Promotion Specialist for GatorWell Health Promotion Services; Dr. Kathy Nichols, MS, CHES; Associate Director of Area Health Education Center Program (AHEC); John-Michal Gonzales, MPH, MA; Health Communication Consultant at Tobacco Free Alachua; and Joi Alexander, MA, CHES, RHEd, Health Promotion Specialist for GatorWell Health Promotion Services. Pre-testing of Preliminary Campaign Materials (Appendix XI) After finalizing the campaign materials, an email was sent to all participants from the Two-Part Questionnaire that were deemed as “eligible” to complete the Pre-testing Survey of Preliminary Materials through an online Qualtrics survey (T.2 in the process), requesting their feedback on message designs. The products were tested for clarity, appeal, and applicability of the message content of the health communication designs. Upon completion of data collection, the primary researcher completed a comprehensive data analysis
  • 13. 13 (themed and coded qualitative data, SPSS for the Quantitative data) of the potential “at-risk” first-time users in regard to their feedback of the preliminary campaign messages. Health Communications Campaign Material Revisions (Appendix XII) The findings from the Pre-testing of Preliminary Products Survey informed health communication product development. Following data analysis, the primary researcher attended message design meetings with the GatorWell Junior Designer for the preliminary campaign materials, resulting in the final revised campaign materials. Pre-testing of Revised Campaign Materials (Appendix XIII) After finalizing the revised campaign materials, an email was sent to all participants from the Two-Part Questionnaire that were deemed as “eligible” to complete the Pre-testing Survey of Revised Materials (T.3 in the process), through an online Qualtrics survey, requesting their feedback on message designs. The products were tested for clarity, appeal, and applicability of the message content of the health communication designs. Upon completion of data collection, the primary researcher completed a comprehensive data analysis (themed and coded qualitative data, SPSS for the Quantitative data) of the potential “at-risk” first-time users in regard to their feedback of the revised campaign messages. Dr. Jane Emmeree and the GatorWell Junior Designer then revised the health communication products based on these findings for final products, to be implemented in the future. Incentives After sifting through all 455 surveys, only 39 participants were deemed “at-risk” and eligible for enrollment in this study. Each participant who completed the Two-Part Questionnaire and was deemed eligible based on the inclusion criteria was provided with a $5 Amazon gift card for the 1st stage of the study completed. Following this stage, every participant who completed the 2nd and 3rd survey or exited was awarded a $5 Amazon gift card for each one of the surveys. Plans for Analysis All statistical analyses within this study were performed using IBM SPSS, Version 22.0 (2013). Descriptive analysis was completed at each stage of data collection within the study (Two-Part Questionnaire, Pre-test of Preliminary Materials Survey, and the Pre-test of Revised Materials Survey). Descriptive statistics include demographic backgrounds for each data collection point as well as a fundamental Qualtrics data analysis based on frequency of answers. Qualtrics provided multivariate analysis measures through a Chi- Squared Test for Independence providing p-value comparisons (significance levels of p < 0.05) in order to take two categorical variables from the target sample and determine if there is a significant association between the two of them. Qualitative data analysis was completed for all qualitative items through coding, theming and quantifying through frequency of responses under each theme. Cross tabulations were completed for various questions from the Two-Part Questionnaire and the Pre-test of Revised Materials Survey. These cross tabulations were to explore potential associations. Due to the nature of this project and the shorten timeline, the participants’ selection of their favorite visual design and message content for each message design were collected for exploratory purposes and in order to determine the message designs to be implemented following the completion of this internship. Frequency tables were used in order to evaluate the differences between designs and the major themes that resulted from qualitative items following each quantitative question intended to provide a richer dataset to interpret from. The last three items on the pre-testing surveys provided options to participants through open-ended items requesting suggestions to improve upon the next round of message designs. The major themes are discussed throughout the results section. Continuation of Health Communication Campaign Process
  • 14. 14 Stage 3 and 4 were not completed by the primary researcher but instead will be completed by GatorWell staff and the preceptor. A cyclical flowchart of this study’s four stages is available in Appendix VI. These stages are: Stage 3: Implementing the Program, and Stage 4: Assessing Effectiveness and Making Refinements. Stage 3 will involve the roll out of the program through all the marketing channels from this study and the implementation plan that was formulated from this study. Stage 4 will involve evaluating the effectiveness of the campaign through surveying students at the University of Florida about the health communication campaign message designs and their content. An action plan was formed for stages 3 and 4 based on this study’s results and further collaboration with project partners, other professionals researchers in the public health field, as well as Dr. Jane Emmeree at the University of Florida’s GatorWell Health Promotion Services office. Stakeholder Involvement For this study, the stakeholders that were engaged were all UF Students (both graduate and undergraduate) in order to develop messages that are tailored toward the “at-risk” of use target population. The stakeholders were first recruited for the Two-Part Questionnaire, and then re-requested for feedback on messages designed based on their initial questionnaire results. Throughout the process, these stakeholders supported or opposed choices offered to them in order to influence the implementation of this campaign’s decisions. The purpose of collecting and using the demographic questions from the Two-Part Questionnaire are for screening and sampling purposes. This information was used to be informative and to “describe the group as a whole,” in order to test hypotheses about any gender differences. It was vital for this study to be able to understand the views of the stakeholder based on their community and identifying factors. Overall, this study’s stakeholder engagement provided GatorWell opportunities to further align their practices with the UF community’s needs and expectations, in order to help drive long-term solutions to health issues on the UF campus. Justification of Methods The methods used for this study were justified in the allotted timeline and deemed as valuable to GatorWell for further review and study. The idea of a health communication campaign geared toward UF students who are deemed as “at-risk” of becoming first-time users of electronic cigarettes was novel. There was no current running campaign that GatorWell had created around the topic area of electronic cigarettes, yet alone “at-risk” users. The need for an intervention, combined with a shortened timeline created vast justification for creating a novel health communication campaign around this target population within the health topic of electronic cigarette use. Results Two-Part Questionnaire Data- Descriptive Statistics Four hundred and fifty five University of Florida students were recruited through convenience sampling through social media solicitation, listserv mailings (Gator Times, Honors Daily), and emails to University of Florida professors to pass along to their students. The overall response rate was 89%; with the average time it took participants to complete the survey being 9 minutes. Amongst this group, awareness of E-Cigarettes was very high with 98% (n=455) stating that they know what an e-cigarette is. Attempted use amongst this sample sat at 57% of respondents who have tried an e-cigarette before (16%- “Yes, more than a year ago, but not in the past year”, 20%- “Yes, within the past year, but more than a month ago”, and 21%- “Yes, within the past month”). From this sample, only 179 have not tried an e-cigarette in their lifetime. In regards to future use, 53% stated they would try an electronic cigarette in the next 6 months, even if offered a puff from a friend or family member (12%- “Maybe yes, maybe no”, 15.4%- “Likely”, 13.7%- “Very likely”, and 11.8%- “Absolutely yes”). Regular use amongst this sample was 35% with respondents stating “You would start using an electronic cigarette regularly in the next 6 months” (6.7%- “Maybe yes, maybe no”, 10.4%- “Likely”, 10.6%- “Very likely”, 7.23%- “Absolutely yes”). Using the Stages of Change Model (or the Transtheoretical Model or TTM)
  • 15. 15 to look at the priority of risk, 57% stated they are in the contemplation or preparation stage of becoming first- time users of electronic cigarettes. Amongst the 403 completed surveys, 110 (or 27.3%) completed the entire survey (all questions- after meeting inclusion for being in the “at-risk” target population) with an average time of 18 minutes. Of the 110 potential “at-risk” users, 39 (or 35.5% of completed surveys for potential “at-risk” users or 8.8% of the original sample) were determined to not be using electronic cigarettes currently and be the true “at-risk” for use population and are representative of 0.08% of the Student Body. The students in this sample were 15.4% (n = 6) female, 84.6% (n = 33) male. There were 0 persons who identified as transgender or genderqueer who participated in this study. This target population consisted of 22 Undergraduate students (or 55%) and 17 Graduate / Professional students (or 44%). The undergraduate student makeup consisted of three 1st year undergraduate students (8%), five 2nd year undergraduate students (13%), six 3rd year undergraduate students (15%), seven 4th year undergraduate students (18%), one 5th year undergraduate student (3%), and seventeen Graduate or Professional students (44%). Participants ranged in age from 18-44 years old, with 38% in the 18- 24 range, 52% in the 25-34 range, and 10% in the 35-44 range. The demographic breakdown by race and ethnicity was 84% White (n=33), 13% Hispanic / Latino (n=5), 8% Asian (n=3), 5% Black or African- American (n=2), 3% American Indian / Alaskan Native (n=1), 0% Multi-race (n=0), 0% Unknown (n=0), and 0% Native Hawaiian / Pacific Islander (n=0). This is in comparison to the UF student population demographics of 49,878 students total (33,168 Undergraduates or 66.5% and 16,710 Graduate / Professional students or 33.5%) consisting of 18,189 female students and 14,979 male students (54.8% Female and 45.2% Male respectively) who are 59.1% White, 19.2% Hispanic / Latino, 7.6% Asian, 7.5% Black or African-American, 2.8% Multi-race, 2.8% Unknown, 0.7% Native Hawaiian / Pacific Islander, 0.3% American Indian / Alaskan Native (CollegeData.com, 2014). Two-Part Questionnaire Data- Background Attempted use amongst the “at-risk” sample sat at 66% of respondents who have tried an e-cigarette before (18%- “Yes, more than a year ago, but not in the past year”, 31%- “Yes, within the past year, but more than a month ago”, and 15%- “Yes, within the past month”). In regards to future use, 83% stated they would try an electronic cigarette in the next 6 months, even if offered a puff from a friend or family member (22.5%- “Absolutely yes”, 22.5%- “Very likely”, 40%- “Likely”, and 15%- “Maybe yes, maybe no”). Regular use amongst this sample was 71.8% with respondents stating “You would start using an electronic cigarette regularly in the next 6 months” (18%-“Absolutely yes”, 7.7%- “Very likely”, 46.2%- “Likely”, and 28.2%- “Maybe yes, maybe no”). Using the Stages of Change Model (or the Transtheoretical Model or TTM) to look at the priority of risk, 59% stated they are in the contemplation and 40% are in the preparation stage of becoming first-time users of electronic cigarettes. The qualitative portion of this question discovered that 42.5% (n=14) stated that they “needed more information before trying them”, 30.3% (n=10) stated that they “just want to try them”, 15.2% (n=5) stated that they “are concerned about the health consequences”, and 6.1% (n=2) stated that they “were concerned about the cost”. Two-Part Questionnaire Data- Social Norms Delving deeper into the data collected from the Two-Part Questionnaire, the situations in which participants would most likely try e-cigarettes were “when you are with friends” (43%, n=17), “in a social setting (a bar, restaurant, etc.)” (38%, n=15), and “when you are with family members” (20%, n=8). The social norms of this “at-risk” target population include that 43% (n=17) of the participants’ close friends or social groups currently use e-cigarettes with 82.5% citing a positive aspect to using electronic cigarettes (47.1%- “e- cigarettes are healthier than conventional cigarettes”, 35.4%- “electronic cigarettes are easy to use, cause no harm, and are low cost”, and 17.7%- “prefer electronic cigarettes”). The area of concern dealing with peer groups is that of close friend persuasion. 35% (n=14) of participants stated that their close friends who use electronic cigarettes have attempted to convince them to use them as well and they would comply with that request. Two-Part Questionnaire Data- Attitudes and Beliefs
  • 16. 16 The next segment of the Two-Part Questionnaire included questions about the participants’ attitudes and beliefs. Regarding the safety of electronic cigarettes versus conventional cigarettes, 68% (or 27 of 40 respondents) believe that electronic cigarettes are safer to smoke than regular cigarettes because “they are less harmful” (43%), “they have less nicotine” (36%), “they are not lit like a conventional cigarette” (14.3%), and because “they contain no tobacco” (4%). 56% (n=22) believe that using electronic cigarettes is either a habit or an addiction with 23% (n=9) believing it is both a habit and an addiction, and 21% (n=8) believing that it is neither a habit nor an addiction. 83% (n=33) believe that using electronic cigarettes is not as addictive as using other drugs. 85% (n=34) believe that the FDA should regulate electronic cigarettes. One item addressed the idea of the medical evidence that is being compiled against electronic cigarettes, through which 52% (n=19) stated they either believe the medical evidence about electronic cigarettes is exaggerated or they are unsure. In regard to the target audience’s perception of harm, 78% (n=31) have not heard anything negative about the dangers of using electronic cigarettes with 60% (n=3) having heard the negative statements about the dangers of using electronic cigarettes from “the Internet”, 20% (n=1) from “the News”, and 20% (n=1) from “Television commercials”. From these sources, 38% (n=3) stated that the negative statements about the dangers of using electronic cigarettes that they have heard through different media were about the “toxic chemicals in the vapor”, 25% (n=2) were about “incidents where electronic cigarettes burst while being used”, 25% (n=2) were about the “potential of causing various diseases”, and 12.5% (n=1) were about their “addictiveness”. 68% (n=27) believe that the electronic cigarettes are a less harmful alternative to smoking conventional cigarettes. 53% (n=21) believe that electronic cigarettes are not harmful. 43% (n=17) believe there are some benefits of not using electronic cigarettes. Of those, 65% (n=11) stated the biggest benefit to never using electronic cigarettes is “you would have better overall health”. Other reasons include “never being addicted to nicotine” (24%), “saving money rather than spending it on e-cigs” (6%), and “you would appear more classy” (6%). 57% (n=23) believe there are no benefits of not using electronic cigarettes. 27% (n=12) stated that the primary reason they would never use electronic cigarettes is because “of the health concerns”, with 18% (n=8) citing “the cost and price of electronic cigarettes”, 13% (n=6) citing “what others will think about me”, 13% (n=6) citing the “chance of the battery exploding or hurting me”, and 11% (n=5) citing “the possibility of addiction of presence of nicotine”. Other reasons that were cited for not using e-cigarettes were “the difference in the taste” (9%), “of the concern of my family members and friends” (7%), “of the law on UF’s campus” (2%). The final item addressed the participants’ thoughts on the use of electronic cigarettes by others. 32% (n=15) stated that their thoughts on others using electronic cigarettes is that they are “healthier than conventional cigarettes anyways”, 22% (n=10) “support their decision”, 19% (n=9) “don’t mind or care at all”, 15% (n=7) believe “it is that person’s choice”, and 13% (n=6) “don’t support their decision”. Two-Part Questionnaire Data- Knowledge The next segment of the Two-Part Questionnaire included questions about the participants’ knowledge in order to determine baseline knowledge on the topic of electronic cigarettes and their negative health aspects (toxic chemicals, aerosol instead of vapor, etc.). 77% (n=30) think that electronic cigarettes use among college students is very high. 52% (n=20) think that electronic cigarettes use among UF students is very high. 47% (n=18) think that electronic cigarettes use among their friend group is very high. Regarding the nicotine content of e-cigarettes, 20% (n=7) think that electronic cigarettes do not contain nicotine, and 15% (n=5) think that electronic cigarettes contain more nicotine than regular cigarettes or they are unsure. The reasons given for thinking e-cigarettes contain less nicotine than conventional cigarettes range from “they are unsure what else they contain” (60%), and “their purpose is not to be used as a quit aid, rather a continuation of tobacco use” (20%), to “they don’t use traditional tobacco” (17%). The item that addresses the chemical content of e- cigarettes discovered that 77% (n=30) are either unsure or believe that there are no harmful chemicals within what is exhaled from electronic cigarettes (the “vapor”). Instead, 60% (n=3) believe that e-cigarettes contain “filtrates” instead of nicotine, and 40% (n=2) believe they contain “vegetable juice”. The depth of this target population’s knowledge was uncovered through the final item in this segment. 53% (n=23) have heard that the chemicals in electronic cigarettes are “not harmful” with 21% (n=9) having heard that “there is not much known about the chemicals in electronic cigarettes”. Other responses regarding the chemicals in e-cigarettes include: “they contain nicotine” (16%), “they contain acetone” (5%), and “they contain formaldehyde” (5%).
  • 17. 17 Two-Part Questionnaire Data- Advertising Preferences For the final segment of the Two-Part Questionnaire, items were asked to gauge message style preferences and to guide the development of the message designs for this health communication campaign. 18% (n=7) have noticed various messages lately that discourage tobacco use that have turned them off. Among those that have noticed various messages lately that discourage tobacco use that have turned them off, 43% (n=3) were turned off by both the message and smoking, and 57% (n=4) were more turned off by the message than the smoking. Specifically, 72% (n=5) stated that what turned them off about the messages that they have seen lately is that they “used a scare tactic” and 29% (n=2) stated that what turned them off was “the gruesomeness of the message”. Regarding memorable advertisements, 33% (n=7) stated a memorable advertisement that they have seen recently was “geared toward their particular brand”, 14.3% (n=3) stated it was “very specifically based on the product”, and 14.3% (n=3) stated it was “one with a celebrity involved or endorsing the brand and product”. Other memorable advertisements that the respondents mentioned that they liked were from: Corona, Diet Coke, Airheads, various Car companies, White Owl, Petsmart, and Dove. The reasons that this target population gave for their preferences were “brand loyalty” (30%), “they looked modern” (23%), “they were clever” (17%), “it made them fearful” (9%), and “it was simple and bright” (9%). Other reasons that were mentioned were: “women were involved”, “variety of choices”, and the “involvement of a celebrity or endorsement by a celebrity”. As far as this target audience’s preference in terms of types of advertising, 54% (n=21) stated that their preference in regard to advertising styles is “a modern look”, “one that includes a lot of knowledge or is like a PSA”, and or is “clever or different”, and 16% (n=6) stated that their preference in regard to advertising styles is “clear-cut and to the point”. Other preferences included styles that are “flashy”, “contain a storyline”, “humorous”, and or “that create fear”. Pre-Testing Survey of Preliminary Materials Data- Descriptive Statistics Following the completion of the design phase of this study, thirty-five University of Florida students consented to participate in the Pre-Testing Survey of Preliminary Materials. Out of this initial 35, 28 surveys were determined to be from the Stage 1 survey (2 participants completed the survey twice, and 5 participants were not eligible as they had not completed Stage 1 of this study). The overall response rate was 72% completion based on the eligible Stage 1 “at-risk” participants, with the average time it took participants to complete the survey being 19 minutes. This pre-test survey tested 6 various designs for: clarity, appeal, and relatability of the message content of the health communication designs (see Appendix X). Design 1 was of a hand holding an e-cigarette with no face on a white background and the word “Deets” used instead of “Facts” at the bottom of the message following the campaign slogan “E-Cigs =/= Safe”. Design 2 was of a darker skin tone hand holding an e- cigarette with a darker tone face on a white background and the word “Deets” used instead of “Facts” at the bottom of the message following the campaign slogan “E-Cigs =/= Safe”. Design 3 was of a light skin tone hand holding an e-cigarette with a light tone face on a dark background and the word “Facts” used instead of “Deets” at the bottom of the message following the campaign slogan “E-Cigs =/= Safe”. Design 4 was of an aerosol can spraying a fog containing the toxic chemical words in e-cigarettes, the slogan, and some facts on a dark background. Design 5 was of an aerosol can spraying a fog containing the toxic chemical words in e- cigarettes, the slogan, and some facts on a turquoise background. Pre-Testing Survey of Preliminary Materials Data- Favorite Design Following a comprehensive data analysis of all survey results, each design was scored on the following categories: 1.) Agreement with message; 2.) Relatability; 3.) Appeal; 4.) Complexity; 5.) Unpleasantness or distastefulness; 6.) Effectiveness in communicating the negative health effects; 7.) Dissuasion effectiveness; 8.) Consistency with personal values; and 9.) The participant’s favorite design amongst the five choices. According to participants, design 2 (White background, e-cig, dark face, “Deets”) was the most agreeable at 86% (n=24), while design 5 (Aerosol Spray, colorful background) was the least agreeable at 68% (n=19). Design 2 (White background, e-cig, dark face, “Deets”) was the most relatable at 36% (n=10), while design 5 (Aerosol Spray, colorful background) was the least relatable at 7% (n=2). Design 3 (Dark background,
  • 18. 18 e-cig, light face, “Facts”) was the most appealing at 21% (or 6 responses), while design 4 (Aerosol Spray, dark background) was the least appealing at 7% (or 2 responses). Design 1 (White background, e-cig, no face, “Deets”) was the most confusing at 14% (or 4 response), while design 2 (White background, e-cig, dark face, “Deets”) was the least confusing at 4% (or 1 responses). Design 2 (White background, e-cig, dark face, “Deets”) and Design 3 (Dark background, e-cig, light face, “Facts”) were tied for being the most unpleasant or distasteful at 7% (or 2 responses), while design 4 (Aerosol Spray, dark background) and Design 5 (Aerosol Spray, colorful background) were tied for being the least unpleasant or distasteful at 4% (or 1 responses). Design 4 (Aerosol Spray, dark background) was the best at communicating negative health effects at 82% (or 23 responses), while design 2 (White background, e-cig, dark face, “Deets”) was the worst at communicating negative health effects at 11% (or 3 responses). Design 4 (Aerosol Spray, dark background) was the most effective at dissuading students from using e-cigarettes at 82% (or 23 responses), while design 1 (White background, e-cig, no face, “Deets”) and design 2 (White background, e-cig, dark face, “Deets”) were tied for being the least effective at dissuading students from using e-cigarettes at 11% (or 3 responses). Design 5 (Aerosol Spray, colorful background) was the most effective at communicating the advantages of not using electronic cigarettes at 75% (or 21 responses), while design 3 (Dark background, e-cig, light face, “Facts”) was the least effective at communicating the advantages of not using electronic cigarettes at 32% (or 9 responses). Lastly, design 1 (White background, e-cig, no face, “Deets”) was the most consistent with their values at 79% (or 22 responses). All of the descriptive statistics of each design can be found in Appendix XVI. In terms of the participants’ favorite design, design 1 (White background, e-cig, no face, “Deets”) was the frontrunner at 39% (n=11). In second place was design 2 (White background, e-cig, dark face, “Deets”) at 21% (n=6). Third place was design 3 (Dark background, e-cig, light face, “Facts”) at 18% (n=5). The second to last ranking was design 4 (Aerosol Spray, dark background) at 18% (n=5). In last place was design 5 (Aerosol Spray, colorful background) at 4% (n=1). Using all of the above descriptive statistics, a point system was created to rank the message designs in order to proceed to the final pre-testing survey. The scoring system that was used in this study either added a positive point for being the highest ranking in each one of the 9 categories or a negative point for being the lowest ranking in each one of the 9 categories (agreement with message, relatability, appeal, complexity, unpleasantness or distastefulness, effectiveness in communicating the negative health effects, dissuasion effectiveness, consistency with personal values; and the participant’s favorite design amongst the five). The total point valuation for design 1 (White background, e-cig, no face, “Deets”) was three points. The total point valuation for design 2 (White background, e-cig, dark face, “Deets”) was two points. The total point valuation for design 3 (Dark background, e-cig, light face, “Facts”) was two points. The total point valuation for design 4 (Aerosol Spray, dark background) was zero points. The total point valuation for design 5 (Aerosol Spray, colorful background) was negative two points. Overall, design 1 (White background, e-cig, no face, “Deets”) and design 3 (Dark background, e-cig, light face, “Facts”) were chosen to continue (with revisions) to the final Pre-Testing Survey of Revised Materials. Based on this scoring, design 1 and 3 were chosen to continue as the primary message designs in this health communication campaign. The revisions for the message designs that were suggested (based on qualitative items in the survey) were in the areas of: 1.) Color / Layout; 2.) Image content; and 3.) Content. For the area of color and layout, the suggestion that resonated the most from participants was “you may want to use brighter colors to attract attention”. For the area of image content, the suggestions that resonated the most from participants were: "get rid of the beard. I don’t know any guys with a beard”, “get rid of the man”, and “get rid of the woman”. For the area of content, the suggestions that resonated the most from participants were: “mention more about the side effects”, “provide the laymen’s terms for the chemicals”, and "it would help better if there were tiny footnotes on how each of these chemicals are harmful”. Due to a shortage of time and the amount of time an infographic takes, the infographic for this study was not pre-tested in the first round of pre-testing. Instead, the infographic was revised based on content experts that aided in the content and design revisions for the message designs prior to being pre-tested. The edits that were suggested for the infographic were in the areas of: 1.) Color / Layout; and 2.) Content. For the area of color and layout, the suggestion that resonated the most from participants were: “it looks a bit cluttered”, “one of the best things about infographics is that, since they are usually designed for the web, they are free to break from typical size/dimensions. This looks like it would fit on an 8.5 by 11 sheet of paper
  • 19. 19 but (unless you DO want to print it) it doesn’t have to”, and “maybe space it out a bit or give some sections a lighter brown background to separate it visually”. For the area of content, the suggestions that resonated the most from participants were: “under “Concerns about e-cigs”, there ARE ways of knowing these things, we just don’t know yet. Your major premise is that they are not safe, so saying ” there is no way of knowing if they are safe” doesn’t connect”, “maybe “Toxic Chemicals” could use a statement underneath about e-cigs. Or at least call it “Toxic Chemical in E-cig vapor”, “for the “5 minutes of e-cig use” fact: consider rephrasing to something about making it harder to breath – which is basically what I guess that “peripheral airflow resistance and oxidative stress” means. But I don’t really know what it means”, “put quotes around “nicotine-free” in the FDA fact”, and “for the final fact: Don’t start with “it has been found that” Use more active language like “E- cigarette vapor has more than twice the concentration of harmful heavy metals as cigarette smoke – sometimes as much as 100 times more”. Pre-Testing Survey of Revised Materials Data- Descriptive Statistics Following the completion of the revisions of the preliminary message designs, forty-two University of Florida students consented to participate in the Pre-Testing Survey of Revised Materials. Out of this initial 38, 38 surveys were determined to be from the Stage 1 survey (4 participants completed the survey twice). The overall response rate was 97.4% completion based on the eligible Stage 1 “at-risk” participants, with the average time it took participants to complete the survey being 17 minutes. This pre-test survey tested 3 various designs for: clarity, appeal, and relatability of the message content of the health communication designs (see Appendix X). Design 1 was of a hand holding an e-cigarette with no face on a turquoise background and the word “Facts” used instead of “Deets” at the bottom of the message following the campaign slogan “E-Cigs =/= Safe”. Design 2 was of an aerosol can spraying a fog containing the toxic chemical words in e-cigarettes, the slogan, and some facts on a turquoise background. Design 3 was an infographic containing an e-cigarette in the middle with facts on both sides on a turquoise background. Pre-Testing Survey of Revised Materials Data- Favorite Design Following a comprehensive data analysis of all survey results, each design was scored on the following categories: 1.) Agreement with message; 2.) Relatability; 3.) Appeal; 4.) Complexity; 5.) Unpleasantness or distastefulness; 6.) Effectiveness in communicating the negative health effects; 7.) Dissuasion effectiveness; 8.) Consistency with personal values; and 9.) The participant’s favorite design amongst the five choices. According to participants, design 2 (Aerosol spray) and 3 (infographic) were the most agreeable at 97.4% (n=37), while design 1 (Turquoise background, e-cig, no face, “Facts”) was the least agreeable at 92.1% (n=35). This was a 10.1% increase for design 1, and a 29.4% increase for design 2. Design 1 (Turquoise background, e-cig, no face, “Facts”) was the most relatable at 11% (n=4), while design 3 (Infographic) was the least relatable at 8% (n=3). Design 1 (Turquoise background, e-cig, no face, “Facts”) was the most appealing at 11% (n=4), while design 2 (Aerosol spray) was the least appealing at 5% (n=2). This was a 4% increase for design 2. Design 3 (Infographic) was the most confusing at 8% (n=3), while design 1 (Turquoise background, e- cig, no face, “Facts”) and design 2 (Aerosol spray) was the least confusing at 0% (n=0). This was a 14% decrease in confusion for design 1, and an 11% decrease in confusion for design 2. No Designs were the most unpleasant or distasteful, while all Designs were tied for being the least unpleasant or distasteful. This was a 7% decrease in unpleasantness for design 1, and a 4% decrease in unpleasantness for design 2. Design 3 (Infographic) was the best at communicating negative health effects at 94.8% (n=36), while design 1 (Turquoise background, e-cig, no face, “Facts”) was the worst at communicating negative health effects at 76.3% (n=29). This was a 3% increase for design 1. Design 3 (Infographic) was the most effective at dissuading students from using e-cigarettes at 100% (n=38), while no Designs were the least effective at dissuading students from using e-cigarettes. Design 3 (Infographic) was the most effective at communicating the advantages of not using electronic cigarettes at 100% (n=38), while design 1 (Turquoise background, e-cig, no face, “Facts”) was the least effective at communicating the advantages of not using electronic cigarettes at 2.6% (n=1). Lastly, Design 1 (Turquoise background, e-cig, no face, “Facts”) was the most consistent with their values at 86.9% (n=33). This was a 7% increase for design 1. All of the descriptive statistics of each design can be found in Appendix XVII.
  • 20. 20 In terms of the participants’ favorite design, design 3 (Infographic) was the frontrunner at 89% (n=34). In second place was design 1 (Turquoise background, e-cig, no face, “Facts”) at 3% (n=1). In last place was de design 2 (Aerosol spray) at 8% (n=3). Using all of the above descriptive statistics, a point system was created to rank the message designs in order to proceed to the final pre-testing survey. The scoring system that was used in this study either added a positive point for being the highest ranking in each one of the 9 categories or a negative point for being the lowest ranking in each one of the 9 categories (agreement with message, relatability, appeal, complexity, unpleasantness or distastefulness, effectiveness in communicating the negative health effects, dissuasion effectiveness, consistency with personal values; and the participant’s favorite design amongst the five). The total point valuation for design 1 (Turquoise background, e- cig, no face, “Facts”) was one point. The total point valuation for design 2 (Aerosol spray) was one point. The total point valuation for design 3 (Infographic) was eight points. Overall, all three designs tested positively with the target population and will be implemented following this study. The revisions for the message designs that were suggested (based on qualitative items in the survey) were in the areas of: 1.) Color / Layout; and 2.) Content. For the area of color and layout, the suggestion that resonated the most from participants was “if you make the slogan bolder and a bright color, it will stand out better against the background” - on the aerosol message, “the title looks good bold, but it doesn’t stand out” - on the infographic, and “make key points stand out by pictures clearly- text with hand. Based on the suggested edits, the following actions were taken: to make the slogan red on the aerosol message, make the word “Harmful” red on the infographic, and to make some of the chemicals different colors to stand out on the text with hand message. For the area of content, the suggestions that resonated the most from participants were: "add more attractive content”- hand with text, “needs a slogan”- Text with hand, and "reduce the text and add more graphical content”- Infographic. Based on the suggested edits, the following action was taken: use “Less harmful doesn’t mean safe” on the text with hand message design. Exploratory Analysis Completing data analysis through Qualtrics provided multivariate analysis measures through Chi- Squared Tests for Independence providing p-value comparisons (significance levels of p < 0.05) in order to take two categorical variables from the target sample to determine if there is a significant association between the two of them. From the Two-Part Questionnaire, the variables that were compared through cross tabulation were: 1.) Perception of harm of chemical contents and future use; 2.) Close friend use and future use; 3.) Age and gender; 4.) Gender and ever use; 5.) Ever use and close friend use; 6.) Awareness and future use; 7.) Stage of TTM and future use; 8.) Nicotine contents and future use; 9.) Amount of nicotine and future use; 10.) Perceptions of harm and future use; and 11.) Comparative harm (conventional cigarettes versus e-cigarettes) and future use. After a detailed analysis, the variables that may be associated are: 1.) Perception of harm of chemical contents and future use (p=0.40); 2.) Nicotine contents and future use (p-value=0.34); and 3.) Comparative harm (conventional cigarettes versus e-cigarettes) and future use (p-value=0.60). But due to the rather small sample size of 39 participants these variables were not associated to each other. Only one variable comparison showed significance, ever use and close friend use. For the comparison of participants’ ever use cross tabulation showed a p-value of 0.02 in regard to close friend use. Therefore, because the cross tabulation showed a p-value less than the significance level (0.05), therefore there was relationship between the two variables of ever use (use in the past at any point in time) and future use (within the next 6 months- regular use or attempted use). For each of the remaining comparisons, cross tabulation showed a p- value greater than the significance level (0.05), therefore there was no relationship between any of the remaining compared variables. These cross tabulations can be found in Appendix XVIII. Frequency tables were used in order to evaluate the differences between designs and the major themes that resulted from qualitative items following each quantitative question intended to provide a richer dataset to interpret from. These frequency tables, graphs, and charts can be found in Appendix XIV (for the Two-Part Questionnaire), XV (for the Pre-Testing of Preliminary Materials Survey), and XVI (for the Pre-Testing of Revised Materials Survey).
  • 21. 21 Relationship of Findings to Objectives, Aims, or Hypotheses Based on the findings of this study, majority of the objectives were met and exceeded. This study: 1.) Described perceptions of knowledge that the members of the “at-risk” population possess about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects; 2.) Explored the general attitude of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects; 3.) Examined general beliefs of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects; 4.) Distinguished how a health communication campaign can be executed effectively in order to increase the perceived susceptibility and severity of the negative health outcomes of using electronic cigarettes of the members of the at-risk target population to decrease campus-wide usage of electronic cigarettes at UF; 5.) Distinguished the design preferences (color, graphic, text, rhetoric, etc.) of this “at-risk” target audience in regards to a health communication campaign geared toward the dissuasion of electronic cigarette use (learner verification); and 6.) Explored the association between using electronic cigarettes and reporting close friends who currently use electronic cigarettes. Out of all seven hypotheses, the data were consistent with four hypotheses and inconsistent with three hypotheses. Baseline knowledge of the harms of electronic cigarettes (toxic chemicals, vapor instead of aerosol, etc.) was impartial (neutral) at T1. This was inconsistent with the hypothesis, based on this study’s findings. This study’s findings resulted in 2 out of 4 items being answered incorrectly (2 correct- 83% knew of nicotine content and 85% knew of less nicotine than conventional cigarettes; and 2 incorrect- 76% didn’t know about toxic chemicals and 90% chemicals were not harmful). The general attitude towards electronic cigarettes was more positive at T1. This was consistent with the hypothesis, based on this study’s findings. This study’s findings resulted in 3 out of 4 items being answered in the positive direction in regard to attitude (3 positives- 54% medical evidence exaggerated, 53% not harmful, 87% don’t care if others use; and 1 positive- 85% want FDA regulation). The beliefs of the harm (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes were more negative at T1. This was consistent with the hypothesis, based on this study’s findings. This study’s findings resulted in 7 out of 8 items being answered in the negative direction in regard to beliefs of the harms of e-cigarettes (1 positive- 68% safe; and 7 negative- 78% not heard of dangers, 60% believe not the same as conventional cigarettes, 48% doesn’t cause stroke, 45% doesn’t cause heart attacks, 43% doesn’t cause lung cancer, 57% no benefit of not using, 83% not as addictive). The perceptions of the harm and negative health effects of electronic cigarettes will be low at T1. This was consistent with the hypothesis, based on this study’s findings. This study’s findings resulted in 12 out of 14 items being answered in the negative direction in perception of the harms of e-cigarettes. The hypothesis associating low levels of knowledge to lower perception of harm was unproven, through cross tabulation and therefore was inconsistent with the hypothesis, based on this study’s findings. Participants’ ever use cross tabulation showed a p-value of 0.02 (a p-value less than the significance level 0.05) in regard to close friend use and therefore a relationship between the two variables of ever use (use in the past at any point in time) and future use (within the next 6 months- regular use or attempted use) exists, which is consistent with this study’s hypothesis. The hypothesis associating positive levels o f attitudes and beliefs to a lower perception of harm was unproven, through cross tabulation and therefore was inconsistent with the hypothesis, based on this study’s findings. Regarding the research questions, all of the research questions of this study were answered through findings as well. The level of knowledge that the members of the “at-risk” population possess about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects was neutral. The attitude of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects was more positive. The beliefs of the members of the “at-risk” population about the various aspects (toxic chemicals, vapor instead of aerosol, etc.) of electronic cigarettes and their negative health effects were more negative. There was an association between ever use (attempted use in the past) to having close friends that use electronic cigarettes. This study discovered various communication campaign design preferences (color, graphic, text, rhetoric, etc.) for the at-risk participants for electronic cigarettes such as: being more colorful, including facts about electronic cigarettes, being clear-cut and to the point, providing valuable knowledge, being less wordy, being flashy to
  • 22. 22 catch attention, using a more modern look, creating an overarching brand for the campaign, and using clever rhetoric and text. The aspects that this sample did not like in regards to messaging were: using fear tactics, being humorous, using gruesome imaging, and being dull-colored or boring. Interpretation of Findings This study’s health communication campaign discovered tactics to increase the perceived susceptibility and severity of the negative health outcomes of using electronic cigarettes of the members of the at-risk target population to decrease campus-wide usage of electronic cigarettes through speaking about the harm of electronic cigarettes to educate more on the toxic chemicals, secondhand aerosol, long term effects, and facts to not normalize use amongst the college student group nationwide. These tactics could potentially aid in generating a negative attitude toward electronic cigarettes, bolstering baseline knowledge, and creating negative beliefs about e-cigarettes. With design 1 (text with hand) and design 2 (aerosol spray can) testing the highest among pre-tested message designs through providing appealing characteristics (based on design preferences) and educating on the harms of electronic cigarettes, these message designs convey all the desired aspects from GatorWell’s standpoint and will be received the best from the “at-risk” target audience (to be determined by GatorWell through evaluation protocol). Discussion Relationship of Findings to Literature The harm of electronic cigarettes starts with the lack of health communication messaging that provides accurate depictions of the harms of electronic cigarettes. According to Duke and colleagues (2014), the tobacco industry and e-cigarette industry’s marketing and advertisement campaigns pose a high risk to potential users “in the absence of evidence-based public health messaging” where “the current e-cigarette television advertising may be promoting beliefs and behaviors that pose harm to the public health”. This study states: “if current trends in e-cigarette television advertising continue, awareness and use of e-cigarettes are likely to increase among youth and young adults” (Duke et. al. 2014). According to Trumbo, and Kim (2015), the e-cigarettes market’s advertisement tactics to college students and young adults in particular in the U.S. is geared around being “less harmful”, “only water vapor”, and “not addictive due to the lack of nicotine”. This study’s results stated that there is a “positive reaction to the ads and holding the belief that e-cigarettes are not as addictive were both independently associated with intention” alongside the change in attitudes and norms, which “were also associated but were controlled by inclusion of the other variables” (Trumbo, and Kim. 2015). This perception shift of e-cigarettes is creating an “at-risk” user population that this study will be addressing. This “at-risk” college-aged population is basically created by these pro-electronic cigarette advertisements (Trumbo, and Kim. 2015). According to Choi and Forster (2013), “strategic health communication interventions to communicate to the public that evidence to support these perceptions is lacking and strengthening tobacco control regulations to include e-cigarettes could potentially reduce the prevalence of e-cigarette use among young adults”. According to Enofe and colleagues (2014), “never daily and nondaily smokers were 3 times as likely as former daily and non-daily smokers to use alternative nicotine products with a p < .001”. Adding to the risk of being a college-aged student, being a never-user of tobacco products also furthers the risk of the target population of concern. These articles from the literature review very much encourage counter-marketing campaigns against electronic cigarettes and stoically support the need for health communication messaging. The comprehensive literature revels a multitude of negative aspects (toxic chemicals, secondhand aerosol, aerosol state of contents, nicotine content, etc.) and health effects (causing blood vessel damage, inflammation of the cells in the lungs, and other various negative effects on the nervous system) of electronic cigarette use. With the Sutfin and colleagues (2013) study discovering that “unlike older, more established cigarette smokers, e-cigarette use by college students does not appear to be motivated by the desire to quit cigarette smoking”, using such tactics geared toward heightening harm perception of the “at-risk” target population allowed for effective message, in addition to using facts from the literature surrounding toxic chemicals (toxic chemicals such as mercury, acrolein, aerosol, formaldehyde, diethylene glycol found in antifreeze, acetaldehyde, propylene glycol, glycerin, and various toxic metals- such as tin, nickel, cadmium, and
  • 23. 23 lead, were found- "DrugFacts: Electronic Cigarettes") and nicotine poisoning (U.S poison centers reported over 2,405 calls surrounding e-cigarette exposures from September 2010 to February 2014- Bunnell, 2014). Relating the comprehensive literature review to this study shows that the UF students stand at 98% awareness of e-cigarettes (versus 84.54% aware of what an electronic cigarette was- GatorWell Health Promotion Services, 2015), 57% ever use (versus 20.75% ever use- GatorWell Health Promotion Services, 2015), and 53% have a low perception of their harm (versus 35.61% are unsure or do not think using e- cigarettes is harmful- GatorWell Health Promotion Services, 2015). The findings of this study align with the comprehensive literature review from this study and support the need for an intervention and the knowledge, attitudes, and beliefs being a large driving force for creating effective health communication messaging geared toward dissuading University of Florida students from becoming first time users of electronic cigarettes. Limitations As far as limitations for this study, the major limitation was the process of gaining IRB approval. The first submission was on April 2nd, and final approval was not given until May 6th. An added issue with IRB was the lack of notification until eight days following the approval on May 14th. This limitation created a bit of a time crunch, though nothing was impacted to a differing point. There could be a possibility of gaining more UF students who are truly “at-risk” of becoming first time users of electronic cigarettes. Another issue was the lack of parallel design in terms of all three surveys in order to gain an understanding of the effectiveness of message content in increasing the knowledge of participants, and promoting a negative attitude about e-cigarettes. A counter-argument for this limitation could be the potential of historical confounding that could arise between T1 and T2 testing. Generalizability Due to the fact that this study’s participants were recruited through convenience sampling, this target population might not necessarily be reflective of the whole University of Florida student population. Whites, Asians, and American Indian / Alaskan Natives were over-represented and Hispanics and Black or African- Americans were underrepresented when compared to the currently enrolled overall UF student population. The race / ethnicities that were not represented at all were Multi-race, Unknown, and Native Hawaiian / Pacific Islander. As far as genders, Males were over-represented (84.6%) and Females were underrepresented (15.4%) when compared to the currently enrolled overall UF student population. In addition, the demographics of this study’s target population did not include any members of the LGBTQ+ community (transgender or genderqueer) to provide a representative sample representative of the UF student population. Looking at the age representation, 25-34 year olds were over-represented (52%). The skew of the status of students was also skewed right with the largest population being Graduate / Professional students at 44%. Furthermore, participants were recruited through social media and other various electronic routes. This could add further availability of electronic research sources in order to add to the possibility of historical confounding through research between T1 and T2 in the study. Due to the target population of this study being UF students who are “at-risk” of becoming first time users of electronic cigarettes, the findings from this study are potentially less generalizable to the UF Student population. The intention of this campaign is to promote awareness of electronic cigarettes and their negative aspects in order to dissuade “at-risk” UF students from using them. Therefore, this study may not accurately reflect those of other campuses, as well as other types of users from varying subpopulations at the University of Florida. Next Steps Following final edits to the message designs, implementation will include release through a designated timeline developed by the Preceptor, Dr. Jane Emmeree and the intern. For the week of September 28th, all three designs (text with hand, aerosol spray, and the infographic) will be released through the following channels: 1.) The A-frame around campus; 2.) The Little Hall Bulletin Board; 3.) Flat Screen TV Image for GW Main Office (start this week); 4.) Tabling at Satellites; 5.) GatorWell Website under “The Basics- E-Cigarettes”; 6.) An
  • 24. 24 email to Eta Sigma Gamma to disseminate through their social media, website, and membership listservs; 7.) An email to Alpha Epsilon Delta to disseminate through their social media, website, and membership listservs; 8.) An email to Health Science Student Organization to disseminate through their social media, website, and membership listservs; and 9.) An email to Public Health Student Association to disseminate through their social media, website, and membership listservs. For this week, only the “text with the hand” and “aerosol spray” will be released through the following channels: 1.) As a GatorWell website banner; 2.) As a flat screen TV Image for Housing TV Channel 8; 3.) As a flat screen TV Image for SHCC TV; 4.) The Gator Dining Table Tents; 5.) This method will be continued for the weeks of October 5th until the week of October 26th, when the following channels will be added (in addition to the previous weeks’ channels): 1.) A Facebook status update (the 1st post on Facebook) of the “text with the hand” message design; 2.) An Alligator Ad of the “text with the hand” message design; 3.) An Odyssey Ad of the “text with the hand” message design; and 4.) The SHCC Bulletin Boards with the “text with the hand” message design. Starting the week of November 2nd running until the 9th, the following channels will be added (in addition to the previous weeks’ channels): 1.) A Facebook status update (the 2nd post on Facebook) with the “aerosol spray” message; 2.) A Facebook status update (the final post on Facebook) with the infographic message; and 3.) Tabling for “Great American Smokeout” on November 9th with all three designs. For the Spring 2015 Semester, starting on the week of March 7th running until March 28th, the tabling for “Kick Butts Day” will be used as a channel for dissemination of all three messages. For the final stage (Stage 4: Assessing Effectiveness and Making Refinements) of the health communication campaign process, the evaluation methods of this health communication campaign will be completed as per GatorWell’s protocol and determined by Dr. Jane Emmeree. Implications The majority of current college students are aware of electronic cigarettes, but only a small amount of students currently use them. Those that currently use have a direct association with a lower level of knowledge of the harms of electronic cigarettes. With the University of Florida’s campus, the rates are higher for ever-use for students and therefore seen as an area of need for public health interventions. This approach in targeting the at-risk users through health communication methods aimed to take a perspective on increasing the perceived severity and susceptibility while breaking down the benefits to using electronic cigarettes as a safe nicotine delivery system, particularly for first time users. This campaign highlights specific aspects of electronic cigarettes (toxic chemicals, secondhand aerosol, and overall harm) that are relevant and potential risks for first time users of electronic cigarettes, who have never used tobacco products in the past, that are relevant and appealing to the University of Florida population based on formative research. If this health communication campaign is successful in dissuading students from becoming first time users of electronic cigarettes, GatorWell health education specialists should fervently consider researching the effectiveness of persuasive messaging in dissuading students from becoming conventional cigarette users as well. This could highly impact the larger number of students that could potentially be considering conventional cigarette or tobacco product use. Future studies should look to create associations in the data derived from this study in order to more effectively target the students who are potentially “at-risk” of becoming first time users of electronic cigarettes. Using the data from this overall study, future studies can also create associations in electronic cigarette use with the overall student population of current users to develop and implement a whole different health communication campaign or public health intervention. Another area of strong need is a public health intervention in the form of harm reduction, which works to persuade and convert users of conventional cigarettes to becoming users of electronic cigarettes in order to prevent a large majority of long term and short term health effects of using conventional cigarettes or tobacco products. In addition, it would be highly beneficial in future studies to create a brand for the health communication campaign and create a multi-faceted approach to intervening with students on campus. This might include campaign materials to aid in primary interventions, and even educational presentations for students to become more aware of the risks and not just the product and what the e-cigarette companies market and advertise to them as their primary target audience. Relationship of Project to Internship Experience
  • 25. 25 The internship with Dr. Jane Emmeree at GatorWell Health Promotion Services involved the development and implementation of a variety of programmatic efforts in the health topics of tobacco, interpersonal violence prevention, sexual health, and sleep. This section will review the key contributions of the intern to Gatorwell through the various different programs and health areas. Three of the major events conducted by the intern were: 1.) A project of engaging men with interpersonal violence prevention and sexual assault education through STRIVE, 2.) Developing and implementing a health communication on sleep for students to develop better habits in order to have better sleep hygiene, and 3.) Creating and presenting a presentation based on the Healthy Gators 2015 E-cigarette survey results. Upon reviewing internship expectations of the University of Florida’s Master of Public Health program, the areas of learning and development that are expected to be fostered are: 1.) SBS Planning Activities, 2.) Conducting Research, Community Assessments, and Evaluations, 3.) Data Management, Analysis, and Interpretation, and 4.) Communication. For the project of engaging men with interpersonal violence prevention and sexual assault education through STRIVE, the intern worked in the areas of: 1.) Identification of community priority concerns (negotiating with stakeholders and community participants); 2.) Literature reviews of relevant studies on theory, methods, and content issues; 3.) Study, intervention, and evaluation design review and selection; 4.) Data collection (observation, committee meetings); 5.) Developing and sustaining communication with stakeholder groups; 6.) Working productively as a member of a team (community partners in committee); 7.) Data analysis (qualitative), 8.) Creating tables, graphs, charts of analyses; 9.) Routine professional communication with team members and stakeholders; 10.) Written reports and findings for different stakeholders; 11.) Graphics, slides, or the aids in communicating results; 12.) Two oral presentations; and 13.) Disseminating results. For the project of developing and implementing a health communication on sleep for students to develop better habits in order to have better sleep hygiene, the intern worked in the areas of: 1.) Identification of community priority concerns (negotiating with stakeholders and community participants); 2.) Literature reviews of relevant studies on theory, methods, and content issues; 3.) Study, intervention, and evaluation design review and selection; 4.) Designing, testing, and adapting data collection methods; 5.) Data collection (interviews and surveys); 6.) Developing and sustaining communication with stakeholder groups; 7.) Working productively as a member of a team (research group and community partners); 8.) Designing data entry systems; 9.) Data analysis (qualitative and quantitative); 10.) Writing data methods; 11.) Routine professional communication with team members; 12.) Graphics, slides, or the aids in communicating results; and 13.) Three oral presentations. For the creating and presenting a presentation based on the Healthy Gators 2015 E-cigarette survey results, the intern worked in the areas of: 1.) Identification of community priority concerns; 2.) Study design review and selection, 3.) Data collection (Surveys); 4.) Working with data entry systems (Survey Monkey); 5.) Working productively as a member of a team (research group, community partners, Tobacco Free Taskforce Committee); 6.) Database tasks (data cleaning, programming, variable classification and coding); 7.) Data analysis (qualitative and quantitative); 8.) Creating tables, graphs, charts of analyses; 9.) Writing data methods; 10.) Routine professional communication with team members and stakeholders; 11.) Written reports and findings for different stakeholders; 12.) Graphics, slides, or the aids in communicating results; and 13.) Two oral presentations. For the actual internship special project, the intern worked in the areas of: 1.) Identification of community priority concerns (negotiating with stakeholders and community participants); 2.) Literature reviews of relevant studies on theory, methods, and content issues; 3.) Study, intervention, and evaluation design review and selection; 4.) IRB preparation and submission; 5.) Designing, testing, and adapting data collection methods; 6.) Data collection (online surveys); 7.) Working with data entry systems (Qualtrics); 8.) Developing and sustaining communication with stakeholder groups; 9.) Working productively as a member of a team (GatorWell, and Faculty Advisor); 10.) Database tasks (data cleaning, programming, skip logic, variable classification and coding); 11.) Data analysis (qualitative and quantitative); 12.) Creating tables, graphs, charts of analyses; 13.) Writing data methods; 14.) Routine professional communication with team members and stakeholders (content reviewers, participants, Faculty Advisor, and Preceptor); 15.) Graphics, slides, or the aids in communicating results (poster presentation); and 16.) One oral presentation.
  • 26. 26 The only area that the intern did not receive further development in was that of grant writing. The strongest areas of development were the study design, literature review, and communication areas. MPH Competencies Strengthened The culmination of the internship with GatorWell Health Promotion Services in conjunction with the other various programmatic efforts during the duration, aided in the furthered development, fostering, and strengthening of a number of the Public Health core and concentration competences as defined by the University of Florida’s Master of Public Health program. Core Competencies Monitoring health status to identify and solve community health problems. The internship special project looked at the at-risk population of potential first time electronic cigarette users. Alongside this project, the STRIVE project involved identifying how to target and engage men about interpersonal violence prevention and sexual assault. The intern worked diligently on both projects to identify the UF and Gainesville community’s problems under the three health topics of interpersonal violence, sexual assault and tobacco. Diagnosing and investigating health problems and health hazards in the community using an ecological framework. GatorWell Health Promotion Services uses the socio-ecological framework for all programmatic efforts. The Socio-Ecological framework looks at the various health factors through the relationships between each level of an individual’s interaction with their environment. Particularly, the intern engaged with students at the individual level for the STRIVE project, and the community level with the internship special project, where the use of electronic cigarette leading to further negative health outcomes and health hazards for the University of Florida community was brought up. The policy level was discussed during the STRIVE project’s advisory committee meetings in order to change University and Gainesville policies for more effective education about interpersonal violence and sexual assault. Informing, educating, and empowering people about health issues. The intern created and presented over five different presentations (on sleep, electronic cigarette use, Interpersonal Violence Prevention, and Sexual Assault) to various community partners, GatorWell Staff, and committee members over the duration of the internship. These presentations all included an educational, empowerment, and informative portion dealing within their particular health topic. Mobilizing community partnerships and action to identify and solve health problems. The intern worked diligently to create community partnerships for the formation of the STRIVE project’s advisory committee on the focus to engage UF males in Interpersonal Violence prevention on campus. This included a brain storming session, and introductory committee meeting to define the purpose, goals, and objectives of the advisory committee and each member’s role. Developing policies and plans that support individual and community health efforts. The intern worked closely with the UF Tobacco-Free Taskforce, created an advisory committee for the STRIVE project geared toward strategies of engaging men with sexual assault and interpersonal violence prevention education. Applying laws and regulations that protect health and ensure safety. The intern worked closely with the UF Tobacco-Free Taskforce, in order to further the research process and add weight to the argument of including electronic cigarettes in the University of Florida’s campus Tobacco-Free Policy. Alongside this, the intern looked for policy measures that could be implemented on the community level at UF for sexual assault education and interpersonal violence prevention.
  • 27. 27 Linking people to needed personal health services and assure the provision of health care when otherwise unavailable. All of GatorWell’s resources disseminated by the student intern included campus partners who specialized in various health services related to all health issues and wellness. These include, but are not limited to medical care, legal services, and counseling. Evaluating effectiveness, accessibility, and quality of personal and population-based health services. The intern evaluated the effectiveness of population-based health services for electronic cigarette users for the special project, as well as evaluating the health services provided around sleep for the Sleep Health Communication Campaign. Conducting research for new insights and innovative solutions to health problems. The intern conducted research about electronic cigarettes in order to gain further insight to solutions for the cessation and prevention of using electronic cigarettes for University of Florida students. The same process was followed for the Sleep Health Communication campaign as well as the STRIVE project’s formation of the “Engaging Men in Interpersonal Violence Prevention and Sexual Assault” advisory committee. Communicating effectively with public health constituencies in oral and written forms. Consistent communication was up kept with all parties and constituents from the Sleep Health Communication campaign, and the special project, but particularly the STRIVE project’s “Engaging Men in Interpersonal Violence Prevention and Sexual Assault” advisory committee. Following the special project, the intern released all final and draft designs and results to GatorWell for further use and research. None of the University of Florida’s Master of Public Health program’s core competencies were unmet throughout the duration of the intern’s internship with GatorWell Health Promotion Services. Social and Behavioral Science Competencies Critically describe and evaluate the state of public health social and behavioral science research and literature. The intern conducted a comprehensive literature review to inform the development of a health communication campaign for the topic of electronic cigarettes within the college student population (and overall) as well as for the topic area of engaging men with interpersonal violence prevention, and aiding college-aged students to develop and keep better sleep habits. Apply social and behavioral science theories and concepts to public health problems. The intern developed a theory based health communication campaign for both electronic cigarettes and the health topic of sleep, using several theories such as the health belief model, the diffusion of innovation, and the theory of reasoned action. Also, social and behavioral science theories were applied to the interpersonal violence prevention committee in order to formulate various ideas and strategies for engaging men on campus. Describe and apply the social ecological framework to public health problems. The intern worked in the development of various programs (including the creation of an advisory committee for STRIVE in the area of Engaging Men with IVP, the Sleep study health communication campaign, and the Health Gators Secondary data analysis future recommendations / PH interventions) directed at the various intrapersonal, interpersonal, and community levels. Understand and apply the principles of community participation in public health research and interventions. The intern worked closely with campus and community stakeholders throughout all four of the various projects (including the internship special project). This was done in order to gain a deeper insight into the target population, advisory aid, and steering of projects.
  • 28. 28 Demonstrate the knowledge and skills necessary to conduct social and behavioral science research. The intern conducted a comprehensive literature review for the health communication campaign on electronic cigarettes, sleep (improving sleep for an at-risk population of students who are receiving less than 4 days of sleep and believe that sleep is important), and pre-testing for sexual assault bystander intervention “It’s On Us” health communication campaign, as well as e-cigarette campaign). Demonstrate an understanding of health disparities in the US and the underlying role of power differentials to disparities. According to the CDC, the use of tobacco can cause very detrimental health effects to users alongside various forms of disease and untimely death in all varying demographic populations. The “disparity” lies with the college students that use tobacco and tobacco products, in unequal amounts to other age groups. Particularly with e-cigarettes, the populations that are the highest users are those who “are male, Hispanic or Other race, and Greek affiliated” according to Sutfin and colleagues (2013). Therefore, this disparaging inequality of health in the area of electronic use is a population that the intern worked closely with. Demonstrate knowledge and skills needed to design and implement a public health information campaign. The intern completed the first two stages of a health communication campaign on dissuading UF students from becoming first time users of electronic cigarettes and another health communication campaign on promoting cues to action for more rested sleep for UF students. Stage 3 and 4 were planned out by the intern and will be implemented by GatorWell in the Fall of 2015 and Spring of 2016. Demonstrate communication skills key to public health workforce participation and advocacy. The intern worked closely with the members the research team and GatorWell staff on various projects including the e-cigarette health communication campaign, the sleep health communication campaign, and the STRIVE Advisory Committee. Outside resources were also collaborated with, such as Brantley Jarvis, a doctoral candidate at the University of Florida. None of the University of Florida’s Master of Public Health program’s Social and Behavioral Sciences (SBS) competencies were unmet throughout the duration of the intern’s internship with GatorWell Health Promotion Services. Lessons Learned and Future Internship Recommendations Upon completing the duration of the MPH special project, the intern completed a final set of health communication campaign materials based on dissuading UF students from becoming first time users of electronic cigarettes. This health communication campaign will be released in Fall of 2015. The creation of the health communication messages from this study determined the area of focus for messaging based on the two- part questionnaire. The remaining stages of this study should focus on stage 3 and 4 of the hea lth communication campaign process. Another area of focus for this study should be determining the areas that this campaign did not address with the at-risk target population in order to reach those segmented audiences as well. The intern that will complete this project should focus on an implementation plan and evaluative measures for the message designs and their effectiveness in communication and persuasion. Future needs for this project require a post-test to be applied in order to compare to the pre-test (Two-Part Questionnaire) based on UF students’ knowledge, attitudes, and beliefs to compare following the launch of this health communication campaign. Understanding that a properly completed health communication campaign requires several months of planning and development in order to be effective and impactful, the largest lesson to be learned from this project was that a health communication campaign development requires a large amount of time. The limitation on time for the MPH internship did not allow for a proper needs assessment in order to directly evaluate students’ perceived barriers and benefits to electronic cigarette use. Though the Two-Part questionnaire was effective, the ideal timeline for a project would allow for the qualitative method of focus groups, which would have proven to provide a wider array of answers and data to guide this research project.
  • 29. 29 The chief recommendation to future interns working on any other health communication campaigns geared toward the use of electronic cigarettes (whether a primary or a secondary intervention) would be to spend a larger amount of time on the formative research and needs assessment portion of the health communication framework in order to develop the most effective and impactful campaign messaging tailored to that particular target population. Another chief recommendation to future interns working on health communication campaigns is to have an idea and most of their supplemental research done for their creative brief for campaign messaging in the different areas of focus. The largest quantity of time that was taken up was due to message design, at no fault of the graphic designer. Completing a plethora of the project ahead of time will save a lot of work and time toward the end of the study. A final recommendation would be to submit IRB a lot sooner than the MPH program’s deadline, as issues can arise along the way that might hinder a student from beginning their project. Overall, being conscience of the timeline, sticking to a fluid plan of action, and remembering the intention of this project are what will drive the study to successful completion.
  • 30. 30 Appendix I. The Health Belief Model Appendix II. The Stages of Change Model (Transtheoretical Model or TTM)
  • 31. 31 Appendix III. The Information Processing Paradigm
  • 32. 32 Appendix IV. The Theory of Reasoned Action
  • 33. 33 Appendix V. The Diffusion of Innovation Theory Appendix VI. The Health Communication Program Cycle Appendix VII. Informed Consent Process
  • 34. 34 Researchers in the Department of Behavioral Science and Community Health at UF, in collaboration with GatorWell, are recruiting UF students to develop a health communication campaign on electronic cigarettes. Interested students will complete a 30-minute survey to assess their knowledge, beliefs, and attitudes about electronic cigarettes, and to assess their eligibility for the study. Upon completion of this 30-minute survey, you will be eligible for a $5 Amazon gift card. If selected for further participation as described below, you can receive an additional $5 Amazon gift card for each section of this study (for a total of $15 in Amazon Gift cards): 1. Pre-testing of Preliminary Products (Upon Completion, you will receive a $5 Amazon Gift card): The preliminary products will be tested with the same participants, using a 10-minute online Qualtrics survey. The products will be tested for clarity, appeal, and relatability of the message content of the health communication designs. 2. Pre-testing of Revised Products (Upon Completion, you will receive a $5 Amazon Gift card): The health communication products will be revised based on the findings of the pre-test and the participants will complete another 10-minute survey in Qualtrics to provide feedback on the revisions. Your participation in this two-part questionnaire is voluntary and you maintain the right to withdrawal at any time without penalty. If you choose to withdraw, you must contact the study coordinator to receive your $5 Amazon gift card for participating in the first stage of this study. Your name will not be associated with your responses and will never be used in any report on project materials. Your responses will be used to determine if they are to be included in the subsequent phases; after that decision has been made, responses will be decoupled from their names, and so anonymous from then on. Your responses will be kept confidential by all those associated with this research project. Based on the results of this two-part questionnaire, you will be selected to participate in this study. This two-part questionnaire will last approximately 30-minutes. If you are selected to participate in the rest of this study following the results from this two-part questionnaire, you will be asked to complete two other online surveys lasting 10-minutes each. Upon completion of all three online surveys, you will receive a $15 gift card. Following this survey, the study coordinator will contact you for the next stage of this study. You will not directly benefit from participating in this study. However, your participation will allow GatorWell Health Promotion Services to create and enhance health messages for UF students. There is a minimal risk that security of any online data may be breached, but our survey host (QUALTRICS) uses strong encryption and other data security methods to protect your information. Only the researchers will have access to your information on the Qualtrics server. Whom to contact if you have questions about the study: Dr. Jane Emmeree, PhD, CHES, Health Promotion Specialist, 273-4450, emmeree@ufl.edu or Kiarash P. Rahmanian, BS, (863) 368-1526, rahmanian@ufl.edu. Whom to contact about your rights as a research participant in the study: UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611-2250; 392-0433 Statement of Consent: I have read the above information, have received answers to any questions I have asked, and I am at least 18 years of age. I consent to take part in this study. ______ I consent ______ I do not consent Appendix VIII Recruitment E-Cigarette Health Communication Campaign– Gator Times Announcement
  • 35. 35 Title: E-Cigarette Research Study. Participants receive $15 Amazon gift card! Researchers in the Department of Behavioral Science and Community Health at UF, in collaboration with GatorWell, are recruiting UF students to develop a health communication campaign on electronic cigarettes. Interested students will complete a brief survey to assess eligibility for the study, and will be compensated with a $15 Amazon gift card for further participation, if eligible. Please contact Kiarash P. Rahmanian at rahmanian@ufl.edu for more information or begin the two-part questionnaire now: https://ufl.qualtrics.com/SE/?SID=SV_6RRwdU3mjzRGzqt E-cigarette Health Communication Campaign– Social Media Announcement Researchers in the Department of Behavioral Science and Community Health at UF, in collaboration with GatorWell, are recruiting UF students to develop a health communication campaign on electronic cigarettes. Interested students will complete a brief survey to assess eligibility for the study, and will be compensated with a $15 Amazon gift card for further participation, if eligible. Please contact Kiarash P. Rahmanian at rahmanian@ufl.edu for more information or begin the two-part questionnaire now: https://ufl.qualtrics.com/SE/?SID=SV_6RRwdU3mjzRGzqt E-Cigarette Health Communication Campaign– Listserv Solicitation Hello, Researchers in the Department of Behavioral Science and Community Health at UF, in collaboration with GatorWell, are recruiting UF students to develop a health communication campaign on electronic cigarettes. Interested students will begin by completing a brief survey to assess eligibility for the study. If selected, participants will be compensated with a $5 Amazon gift card for completion of each portion of the study- up to $15 for completion of the entire study. Please contact Kiarash P. Rahmanian at rahmanian@ufl.edu for more information or begin the two-part questionnaire now: https://ufl.qualtrics.com/SE/?SID=SV_6RRwdU3mjzRGzqt Respectfully, Kiarash P. Rahmanian, B.S GatorWell Graduate Student Intern Appendix IX Two-Part Questionnaire Demographic Questions 1. Which best describes your current student status at UF? ____ 1st year undergraduate ____ 2nd year undergraduate ____ 3rd year undergraduate ____ 4th year undergraduate ____ 5th year or more undergraduate ____ Graduate or professionalstudent Other: ________________________ ____ Prefer not to answer 2. How old are you? (You must be 18 years or older to participate in this study) _________________________ ____ Prefer not to answer 3. What is your gender? ____ Female ____ Genderqueer ____ Male ____ Transgender ____ Identity not listed ____ Please indicate: _________________ ____ Prefer not to answer 4. Are you Hispanic or Latino? ____ Yes ____ No ____ Prefer not to answer 5. How would you describe yourself (Select all that apply) ____ American Indian or Alaska Native ____ Asian ____ Black/African-American ____ Native Hawaiian/other Pacific Islander ____ White ____ Bi-racial/Multiracial ____ I prefer not to respond to this question ____ Other (Please specify): ________________________ ____ Prefer not to answer Background Questions (Inclusion Criteria) 6. Have you ever heard of an “e- cigarette” or electronic cigarette, a cigarette-looking electronic device that delivers nicotine aerosol when you puff it? (Other names for e-cigarettes include:
  • 36. 36 “hookah pens”, “personal vaporizers”, and “smokeless cigarettes”) ____ Yes ____ No 7. Have you tried an electronic cigarette, even one or two puffs? ____ No ____ Yes, more than a year ago, but not in the past year ____ Yes, within the past year, but more than a month ago ____ Yes, within the past month 8. How likely do you think that you would try an electronic cigarette in the next 6 months, even if offered a puff from a friend or family member? ____ Absolutely Not ____ Very Unlikely ____ Unlikely ____ Maybe Yes, Maybe No ____ Likely ____ Very Likely ____ Absolutely Yes 9. How likely do you think that you would start using an electronic cigarette regularly in the next 6 months? ____ Absolutely Not ____ Very Unlikely ____ Unlikely ____ Maybe Yes, Maybe No ____ Likely ____ Very Likely ____ Absolutely Yes Background Questions 10. You indicated that you would possibly try electronic cigarettes, in which of the following situations would you be most likely to try them? (Please check only one) ____ When you are with friends ____ When you are with family members ____ In a social setting ____Other: ____________________ 11. Do you have any close friends that currently use electronic cigarettes? ____ Yes Continue to Q. 12. ____ No Skipto Q. 15. 12. Since you answered that some of your close friends currently use electronic cigarettes, have you heard them say anything about electronic cigarettes? 13. Since you answered that some of your close friends currently use electronic cigarettes, have any of those friends that use electronic cigarettes attempted to convince you to use them as well? ____ Yes Continue to Q. 14. ____ No Skipto Q. 15. 14. Since you answered that some of your close friends currently use electronic cigarettes and they have attempted to convince you to use them as well, would you comply with that request? ____ Yes ____ No 15. Which stage do you believe you are at in regards to your desire to use electronic cigarettes? ____ Pre-Contemplation (I’m not thinking about using electronic cigarettes) ____ Contemplation (I’m thinking about using electronic cigarettes) ____ Preparation (I’m planning to use electronic cigarettes) ____ Action (I’m using electronic cigarettes) ____ Maintenance (I have already been using electronic cigarettes for more than 6 months) 16. In the previous question, you were asked what stage you believe that you are in regards to your desire to use electronic cigarettes. Why did you indicate that particular stage in the model for behavior change? Knowledge Questions 17. Tell me a little bit about your perceptions of the harm of electronic cigarettes. 18. Does smoking electronic cigarettes cause the following: Stroke (blood clots in the brain that may cause paralysis)? ____ Yes ____ No ____ Unsure Heart attack? ____ Yes ____ No ____ Unsure Lung cancer? ____ Yes ____ No ____ Unsure 19. Do electronic cigarettes contain nicotine? ____ Yes Continue to Q. 20. ____ No Skipto Q. 21. 20. More or less nicotine than regular cigarettes? 21. Why do you think that electronic cigarettes do not contain Nicotine? 22. What do electronic cigarettes contain instead of nicotine? 23. There are no harmful chemicals within what is exhaled from electronic cigarettes (the vapor). ____ Yes ____ No ____ Unsure 24. What have you heard about the chemicals that are exhaled from electronic cigarettes? Belief Questions 25. Please indicate your level of agreement with the following statement: Electronic cigarettes are not harmful. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 26. Do you believe there are some benefits of not using electronic cigarettes? ____ Yes Continue to Q. 27.
  • 37. 37 ____ No Skipto Q. 28. 27. What do you think are those benefits of not using electronic cigarettes? 28. What would stop you from using electronic cigarettes? 29. Please indicate your level of agreement with the following statement: Electronic cigarette use among college students is very high. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 30. Please indicate your level of agreement with the following statement: Electronic cigarette use among UF students is very high. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 31. Please indicate your level of agreement with the following statement: Electronic cigarette use among groups that I affiliate with is very high. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 32. What do you think of other people’s decision to use electronic cigarettes? 33. Do you believe that electronic cigarettes are safer to smoke than regular cigarettes? ____ Yes Continue to Q. 35. ____ No Skipto Q. 36. 34. Why do you believe that electronic cigarettes are safer to smoke than regular cigarettes? 35. Do you believe that the medical evidence that ‘using electronic cigarettes is harmful’ is exaggerated? 36. Do you believe that Electronic Cigarettes are a useful quit-smoking aid? ____ Yes Continue to Q. 38. ____ No Skipto Q. 39. 37. Why do you believe that electronic cigarettes are a useful quit-smoking aid? 38. Do you believe that smoking electronic cigarettes is a habit, an addiction, neither or both? ____ Habit ____ Addiction ____ Neither ____ Both ____ I don’t know 39. Do you believe that smoking electronic cigarettes is as addictive as otherdrugs? ____ Yes Continue to Q. 41. ____ No Skipto Q. 42. 40. Why do you believe that smoking electronic cigarettes is as addictive as other drugs? Attitude Questions 41. Please indicate your level of agreement with: The FDA should regulate electronic cigarettes. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 42. Please indicate your level of agreement with: Smoking regular cigarettes is the same as using electronic cigarettes. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 43. Please indicate your level of agreement with: Electronic cigarettes are a less harmful alternative to smoking conventionalcigarettes. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree 44. Please indicate your level of agreement with: Electronic cigarettes making quitting smoking easier. ____ Strongly agree ____ Somewhat agree ____ Neither agree nor disagree ____ Somewhat disagree ____ Strongly disagree Advertisement Preferences 45. Have you ever heard anything negative about the dangers of using electronic cigarettes? ____ Yes Continue to Q. 47. ____ No Skipto Q. 49. 46. If you heard anything negative about the dangers of using electronic cigarettes, where did you hear it? 47. If you heard anything negative about the dangers of using electronic cigarettes, what specifically do you remember that was negative? 48. Have you seen any celebrities endorse e-cigarettes? 49. Have you noticed electronic cigarette promotions in stores or other locations? ____ Yes Continue to Q. 51. ____ No Skipto Q. 54. 50. Have you seen any messages lately that discourage tobacco use that have turned you off? Why? ____ Yes Continue to Q. 55. ____ No Skipto Q. 57. 51. Since you have seen a message(s) lately that discourages tobacco use that turned you off, why did it turn you off? 52. If you have seen any messages lately that discourage tobacco use that have turned you off, are you turned off by the smoking or the message?
  • 38. 38 53. Please tell me about a memorable advertisement for anything that you liked. 54. Please tell me why you liked the memorable advertisement you mentioned above. 55. In general, what style of ads do you like? 56. Please enter your contact information below: Email: _______________ Appendix X Preliminary Health Communication Campaign Materials Development First Round (Following Two-Part Questionnaire) Second Round (Edits suggestedby Primary Researcher, Dr. Jane Emmeree, and Dr. Juliette Christie)
  • 39. 39 Third Round (Following Content Review by Experts)
  • 40. 40 Final Round (Materials testedin Pre-Testing of Preliminary Materials Survey)
  • 41. 41
  • 42. 42 Appendix XI Pre-testing of Preliminary Campaign Materials (Same as Pre-testing of Revised Campaign Materials) Demographic Questions 1. Which best describes yourcurrent student statusat UF? ____ 1st year undergraduate ____ 2nd year undergraduate ____ 3rd year undergraduate ____ 4th year undergraduate ____ 5th year or more undergraduate ____ Graduate or professionalstudent ____ Prefer not to answer 2. What is your gender? ____ Female ____ Genderqueer ____ Male ____ Transgender ____ Identity not listed. Please indicate: _________________________ ____ Prefer not to answer 3. Are you Hispanic or Latino? ____ Yes ____ No ____ Prefer not to answer 4. How would you describe yourself (Select all that apply) ____ American Indian or Alaska Native ____ Asian ____ Black/African-American ____ Native Hawaiian/other Pacific Islander ____ White ____ Bi-racial/Multiracial ____ I prefer not to respond to this question ____ Other (Please specify): ________________________ ____ Prefer not to answer Please carefully look at and read the designs: 5. What is the “take-home” message from each individual design Design 1: _____________ Design 2: _____________ Design 3: _____________ 6. Please indicate your level of agreement or disagreement with the message from each individual design Design 1: _____________ ____ Strongly agree ____ Moderately agree ____ Undecided ____ Moderately disagree ____ Strongly disagee Design 2: _____________ ____ Strongly agree ____ Moderately agree ____ Undecided ____ Moderately disagree ____ Strongly disagree Design 3: _____________ ____ Strongly agree ____ Moderately agree ____ Undecided ____ Moderately disagree ____ Strongly disagree 7. Are any of the designs relatable to you personally in any way? If yes,please explain. (Select all that apply) ___None of the designs are relatable ___Yes, design 1 is relatable because _____________ ___Yes, design 2 is relatable because _____________ ___Yes, design 3 is relatable because _____________ 8. Is there any specific portion of a design (message, design, etc.) that is particularly “appealing” to you? If yes, please explain. (Select all that apply) ___None of the designs are appealing ___Yes, design 1 is appealing because _____________ ___Yes, design 2 is appealing because _____________ ___Yes, design 3 is appealing because _____________ 9. Fromthe designs provided, is there any specific portion of a design (message, design, etc.) that is particularly “confusing” to you? If yes, please explain. (Select all that apply) ___None of the designs are confusing ___Yes, design 1 is “confusing” because _____________ ___Yes, design 2 is “confusing” because _____________ ___Yes, design 3 is “confusing” because _____________ 10. Is there any specific portion of a design (message, design, etc.) that is particularly “unpleasant” or “distasteful”? If yes,please explain. (Select all that apply) ___None of the designs are “unpleasant” or “distasteful” ___Yes, design 1 is “unpleasant” or “distasteful” because _____________ ___Yes, design 2 is “unpleasant” or “distasteful” because _____________ ___Yes, design 3 is “unpleasant” or “distasteful” because _____________ a) Indicate whether each design conveys the following message: This message clearly communicates the negative health outcomes of electronic cigarette usage.
  • 43. 43 Strongly Agree Agree Neutral Disagree Strongly Disagree 1 2 b) Indicate whether each design conveys the following message: This message clearly shows that electronic cigarettes are not a healthy alternative to conventionalcigarettes. Strongly Agree Agree Neutral Disagree Strongly Disagree 1 2 11. How effective are these designs at supporting a message to dissuade students fromusing electronic cigarettes? Very Effective Effective Neutral Not Effective Very Ineffective 1 2 12. How effective are these designs at communicating the advantages ofnot using electronic cigarettes? (DOI Theory) Very Effective Effective Neutral Not Effective Very Ineffective 1 2 13. How consistent are the designs with yourvalues, experiences, and needs as a UF Student? Why? (DOI Theory) Very Consistent Consistent Neutral Inconsistent Very Inconsistent 1 2 14. Out of the two designs, which do you like best? Why? (Please only choose 1 design) ___ Design 1 because _____________ ___ Design 2 because _____________ ___ Design 3 because _____________ 15. Out of the two designs, which do you like the least? Why? (Please only choose 1 design) ___ Design 1 because _____________ ___ Design 2 because _____________ ___ Design 3 because _____________ 16. Please help us improve each design by providing specific suggestions:suggestions forimproving the designs? ____ Design 1____________ ____ Design 2____________ ____ Design 3____________ 17. Please enter your contact information below: Email: _______________
  • 44. 44 Appendix XII Health Communications Campaign Material Revisions Following Pre-Testing of Preliminary Materials (tested in Pre-Testing of RevisedMaterials Survey)
  • 45. 45 Appendix XIII Pre-testing of Revised Campaign Materials Final Message Designs (following in Pre-Testing of Revised Materials Survey- for campaign rollout)
  • 46. 46 Appendix XIV Study Flowchart Assessed for eligibility (n= 455) Excluded (n= 416) Did not meet inclusion criteria (n= 362) Did not complete Two-Part Questionnaire (n= 52) Other reasons (i.e.: missing emails) (n= 2) Formative Research Two-Part Questionnaire Sent Out Enrollment Eligible for enrollment (n= 39) Pre-Testing of Preliminary Materials Survey Pre-Testing of Revised Materials Survey Completed Pre-Testing Survey (n= 28) Completed Pre-Testing Survey (n= 38) Exited Study (n= 2) Revisions to Message Designs Final Revisions to Message Designs Message Designs Completed Follow-Up Analysis Analysis Follow-Up Excluded (n= 7) Completed the survey twice (n=2) Were not eligible as they had not completed stage 1 (n=5)
  • 47. 47 Appendix XV Electronic Cigarette Use Heat Map- Healthy Gators 2015 Survey Full Map of the University of Florida Campus 25% Zoom of Full Map of the University of Florida Campus
  • 48. 48 50% Zoom of Map of the University of Florida Campus- North 65% Zoom of Map of the University of Florida Campus- Northeast
  • 49. 49 65% Zoom of Map of the University of Florida Campus- Southeast Appendix XVI Pre-Testing Survey of Preliminary Materials Message Design Descriptive Matrix Appendix XVII Pre-Testing Survey of Revised Materials Message Design Descriptive Matrix Design Agreement Relatable Appeal Complex Unpleasant Comm Effect. Dissuasion Consistent Rank Pts D. 1 X X 3 D. 2 X X X 2 D. 3 X 2 D. 4 X X X 0 D. 5 X X -2 Design Agreement Relatable Appeal Complex Unpleasant Comm Effect. Dissuasion Consistent Rank Pts . D. 1 X X X X X 1 D. 2 X X X 1 D. 3 X X X X X 8
  • 50. 50 Appendix XVIII Cross Tabulations for Two-Part Questionnaire
  • 51. 51
  • 52. 52 Appendix XIV Frequency Tables for Two-Part Questionnaire 1. Which best describes your current student status at UF? Statistic Value Min Value 1 Max Value 6 Mean 4.30 Variance 3.14 Standard Deviation 1.77 Total Responses 40 2. Howold are you? (You must be 18 years or older to participate in this study) Statistic Value Min Value 2 Max Value 4 Mean 2.73 Variance 0.41 Standard Deviation 0.64 Total Responses 40 3. What is your gender?
  • 53. 53 Statistic Value Min Value 1 Max Value 3 Mean 2.65 Variance 0.59 Standard Deviation 0.77 Total Responses 40 4. Are you Hispanic or Latino? Statistic Value Min Value 1 Max Value 2 Mean 1.88 Variance 0.11 Standard Deviation 0.33 Total Responses 40 5. Howwould you describe yourself? (Select all that apply)
  • 54. 54 Statistic Value Min Value 1 Max Value 5 Total Responses 40 6. Have you ever heard ofan “e-cigarette” or electronic cigarette, a cigarette-looking electronic device that delivers nicotine aerosol when you puff it? (Other names for e-cigarettes include: “hookah pens”,“personal vaporizers”, and “smokelesscigarettes”) Statistic Value Min Value 1 Max Value 1 Mean 1.00 Variance 0.00 Standard Deviation 0.00 Total Responses 40 7. Have you tried an electronic cigarette, even one or two puffs?
  • 55. 55 Statistic Value Min Value 1 Max Value 4 Mean 2.28 Variance 1.23 Standard Deviation 1.11 Total Responses 40 8. Please indicate the level oflikelihood that you would participate in the behaviors below: Statistic You would try an electronic cigarette in the next 6 months, even ifoffered a puff from a friend or family member. You would start using an electronic cigarette regularly in the next 6 months. Min Value 4 4 Max Value 7 7 Mean 5.53 5.15 Variance 1.03 1.05 Standard Deviation 1.01 1.03 Total Responses 40 40 9. You indicated that you would possibly try electronic cigarettes,in which of the following situations would you be most likely to try them?
  • 56. 56 Statistic Value Min Value 1 Max Value 3 Mean 1.95 Variance 0.82 Standard Deviation 0.90 Total Responses 40 10. Do you have any close friends that currently use electronic cigarettes? Statistic Value Min Value 1 Max Value 2 Mean 1.58 Variance 0.25 Standard Deviation 0.50 Total Responses 40 11. Since you answered that some ofyour close friends currently use electronic cigarettes,have any ofthose friends that use electronic cigarettes attempted to convince you to use them as well?
  • 57. 57 Statistic Value Min Value 1 Max Value 2 Mean 1.18 Variance 0.15 Standard Deviation 0.39 Total Responses 17 12. Since you answered that some ofyour close friends currently use electronic cigarettes and they have attempted to convince you to use them as well, would you comply with that request? Statistic Value Min Value 1 Max Value 2 Mean 1.18 Variance 0.15 Standard Deviation 0.39 Total Responses 17 13. Which stage do you believe you are at in regards to your desire to use electronic cigarettes?
  • 58. 58 Statistic Value Min Value 2 Max Value 3 Mean 2.40 Variance 0.25 Standard Deviation 0.50 Total Responses 40 14. Do electronic cigarettescontain nicotine? Statistic Value Min Value 1 Max Value 2 Mean 1.18 Variance 0.15 Standard Deviation 0.38 Total Responses 40 15. More or less nicotine than regular cigarettes?
  • 59. 59 Statistic Value Min Value 1 Max Value 3 Mean 2.09 Variance 0.15 Standard Deviation 0.38 Total Responses 33 16. There are no harmful chemicals within what is exhaled from electronic cigarettes (the vapor). Statistic Value Min Value 1 Max Value 3 Mean 1.60 Variance 0.61 Standard Deviation 0.78 Total Responses 40 17. Please indicate your level ofagreement with the following statement:
  • 60. 60 Statistic Electronic cigarettesare not harmful. Min Value 1 Max Value 5 Mean 2.93 Variance 1.30 Standard Deviation 1.14 Total Responses 40 18. Do you believe there are some benefits ofnot using electronic cigarettes? Statistic Value Min Value 1 Max Value 2 Mean 1.58 Variance 0.25 Standard Deviation 0.50 Total Responses 40 19. Please indicate your level ofagreement with the following statement:
  • 61. 61 Statistic Electronic cigarette use among college students is very high. Min Value 1 Max Value 5 Mean 2.43 Variance 0.81 Standard Deviation 0.90 Total Responses 40 20. Please indicate your level ofagreement with the following statement: Statistic Electronic cigarette use among UF students is very high. Min Value 1 Max Value 5 Mean 2.75 Variance 1.12 Standard Deviation 1.06 Total Responses 40 21. Please indicate your level ofagreement with the following statement:
  • 62. 62 Statistic Electronic cigarette use among groups that I affiliate with is very high. Min Value 1 Max Value 5 Mean 2.93 Variance 1.15 Standard Deviation 1.07 Total Responses 40 22. Do you believe that electronic cigarettes are safer to smoke than regular cigarettes? Statistic Value Min Value 1 Max Value 2 Mean 1.33 Variance 0.23 Standard Deviation 0.47 Total Responses 40 23. Do you believe that Electronic Cigarettes are a useful quit-smoking aid?
  • 63. 63 Statistic Value Min Value 1 Max Value 2 Mean 1.25 Variance 0.19 Standard Deviation 0.44 Total Responses 40 24. Do you believe that smoking electronic cigarettesis a habit, an addiction, neither or both? Statistic Value Min Value 1 Max Value 4 Mean 2.38 Variance 1.30 Standard Deviation 1.14 Total Responses 39 25. Do you believe that smoking electronic cigarettesis as addictive as other drugs?
  • 64. 64 Statistic Value Min Value 1 Max Value 2 Mean 1.83 Variance 0.15 Standard Deviation 0.38 Total Responses 40 26. Please indicate your level ofagreement with: Statistic The FDA should regulate electronic cigarettes. Min Value 1 Max Value 4 Mean 1.78 Variance 0.59 Standard Deviation 0.77 Total Responses 40 27. Please indicate your level ofagreement with:
  • 65. 65 Statistic Smoking regular cigarettes is the same as using electronic cigarettes. Min Value 1 Max Value 5 Mean 3.20 Variance 1.50 Standard Deviation 1.22 Total Responses 40 28. Please indicate your level ofagreement with: Statistic Electronic cigarettesare a less harmful alternative to smoking conventional cigarettes. Min Value 1 Max Value 5 Mean 2.35 Variance 1.72 Standard Deviation 1.31 Total Responses 40 29. Please indicate your level ofagreement with:
  • 66. 66 Statistic Electronic cigarettesmaking quitting smoking easier. Min Value 1 Max Value 5 Mean 2.53 Variance 1.33 Standard Deviation 1.15 Total Responses 40 30. Have you ever heard anything negative about the dangers ofusing electronic cigarettes? Statistic Value Min Value 1 Max Value 2 Mean 1.78 Variance 0.18 Standard Deviation 0.42 Total Responses 40 31. Have you noticed electronic cigarette promotions in stores or other locations?
  • 67. 67 Statistic Value Min Value 1 Max Value 2 Mean 1.60 Variance 0.25 Standard Deviation 0.50 Total Responses 40 Appendix XV Frequency Tables for Pre-Testing of Preliminary Materials Survey 1. Please indicate your level ofagreement or disagreement with the message from each individual design. Statistic Design 1 Design 2 Design 3 Design 4 Design 5 Min Value 1 1 1 1 1 Max Value 5 5 5 4 5 Mean 1.86 1.75 1.96 1.96 2.21 Variance 1.24 1.23 1.00 0.55 1.06 Standard Deviation 1.11 1.11 1.00 0.74 1.03 Total Responses 28 28 28 28 28 2. Are any of the designs "relatable" to you personally in any way? If yes, please explain. (Select all that apply)
  • 68. 68 Statistic Value Min Value 1 Max Value 7 Total Responses 28 3. Is there any specific portion ofone ofthe designs (message,design, etc.) that is particularly “appealing” to you? If yes, please explain. (Select all that apply) Statistic Value Min Value 1 Max Value 7 Total Responses 28 4. From the designs provided, is there any specific portion of a design (message, design,etc.) that is particularly “confusing” to you? Ifyes, please explain. (Select all that apply)
  • 69. 69 Statistic Value Min Value 1 Max Value 7 Total Responses 28 5. Is there any specific portion ofa design (message, design, etc.) that is particularly “unpleasant” or “distasteful”? Ifyes,please explain. (Selectall that apply) Statistic Value Min Value 1 Max Value 7 Total Responses 28 6. Please indicate whether design 1 conveys the following message:
  • 70. 70 Statistic Design 1's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 5 Mean 2.21 Variance 0.69 Standard Deviation 0.83 Total Responses 28 7. Please indicate whether design 2 conveys the following message: Statistic Design 2's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 4 Mean 2.11 Variance 0.91 Standard Deviation 0.96 Total Responses 28 8. Please indicate whether design 3 conveys the following message:
  • 71. 71 Statistic Design 3's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 4 Mean 2.21 Variance 0.92 Standard Deviation 0.96 Total Responses 28 9. Please indicate whether design 4 conveys the following message: Statistic Design 4's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 4 Mean 1.86 Variance 0.65 Standard Deviation 0.80 Total Responses 28 10. Please indicate whether design 5 conveys the following message:
  • 72. 72 Statistic Design 5's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 4 Mean 2.14 Variance 0.87 Standard Deviation 0.93 Total Responses 28 11. Please indicate the level ofeffectivenessofdesign 1 for the following: Statistic Howeffective is Design 1 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 5 Mean 3.04 Variance 1.52 Standard Deviation 1.23 Total Responses 28 12. Please indicate the level ofeffectivenessofdesign 1 for the following:
  • 73. 73 Statistic Howeffective is Design 1 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 5 Mean 2.61 Variance 1.36 Standard Deviation 1.17 Total Responses 28 13. Please indicate the level ofeffectivenessofdesign 2 for the following: Statistic Howeffective is Design 2 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.64 Variance 1.35 Standard Deviation 1.16 Total Responses 28 14. Please indicate the level ofeffectivenessofdesign 2 for the following:
  • 74. 74 Statistic How effective is Design 2 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.61 Variance 1.36 Standard Deviation 1.17 Total Responses 28 15. Please indicate the level ofeffectivenessofdesign 3 for the following: Statistic Howeffective is Design 3 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.68 Variance 1.19 Standard Deviation 1.09 Total Responses 28 16. Please indicate the level ofeffectivenessofdesign 3 for the following:
  • 75. 75 Statistic Howeffective is Design 3 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.89 Variance 1.14 Standard Deviation 1.07 Total Responses 28 17. Please indicate the level ofeffectivenessofdesign 4 for the following: Statistic Howeffective is Design 4 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.04 Variance 1.67 Standard Deviation 1.29 Total Responses 28 18. Please indicate the level ofeffectivenessofdesign 4 for the following:
  • 76. 76 Statistic Howeffective is Design 4 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.86 Variance 1.53 Standard Deviation 1.24 Total Responses 28 19. Please indicate the level ofeffectivenessofdesign 5 for the following: Statistic Howeffective is Design 5 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.64 Variance 1.87 Standard Deviation 1.37 Total Responses 28 20. Please indicate the level ofeffectivenessofdesign 5 for the following:
  • 77. 77 Statistic Howeffective is Design 5 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.04 Variance 1.52 Standard Deviation 1.23 Total Responses 28 21. Out ofall of the designs,which do you like best? Why? (Please only choose 1 design) Statistic Value Min Value 1 Max Value 5 Mean 2.25 Variance 1.60 Standard Deviation 1.27 Total Responses 28 22. Please help us improve each design by providing specific suggestions: suggestions for improving the designs?
  • 78. 78 Statistic Value Min Value 1 Max Value 7 Total Responses 28 Appendix XVI Frequency Tables for Pre-Testing of Revised Materials Survey 1. Please indicate your level ofagreement or disagreement with the message from each individual design. Statistic Design 1 Design 2 Design 3 Min Value 1 1 1 Max Value 3 3 3 Mean 1.79 1.58 1.18 Variance 0.33 0.30 0.21 Standard Deviation 0.58 0.55 0.46 Total Responses 38 38 38 2. Are any of the designs "relatable" to you personally in any way? If yes, please explain. (Select all that apply)
  • 79. 79 Statistic Value Min Value 1 Max Value 7 Total Responses 38 3. Is there any specific portion ofone ofthe designs (message,design, etc.) that is particularly “appealing” to you? If yes, please explain. (Select all that apply) Statistic Value Min Value 1 Max Value 7 Total Responses 38 4. From the designs provided, is there any specific portion ofa design (message, design,etc.) that is particularly “confusing” to you? Ifyes, please explain. (Select all that apply)
  • 80. 80 Statistic Value Min Value 3 Max Value 7 Total Responses 38 5. Is there any specific portion ofa design (message, design, etc.) that is particularly “unpleasant” or “distasteful”? Ifyes,please explain. (Selectall that apply) Statistic Value Min Value 7 Max Value 7 Total Responses 38 6. Please indicate whether design 1 conveys the following message:
  • 81. 81 Statistic Design 1's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 3 Mean 2.13 Variance 0.33 Standard Deviation 0.58 Total Responses 38 7. Please indicate whether design 2 conveys the following message: Statistic Design 2's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 3 Mean 2.13 Variance 0.23 Standard Deviation 0.47 Total Responses 38 8. Please indicate whether design 3 conveys the following message:
  • 82. 82 Statistic Design 3's message clearly communicates the negative health outcomesofelectronic cigarette usage. Min Value 1 Max Value 3 Mean 1.24 Variance 0.29 Standard Deviation 0.54 Total Responses 38 9. Please indicate the level ofeffectiveness ofdesign 1 for the following: Statistic Howeffective is Design 1 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.53 Variance 1.07 Standard Deviation 1.03 Total Responses 38 10. Please indicate the level ofeffectivenessofdesign 1 for the following:
  • 83. 83 Statistic Howeffective is Design 1 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.03 Variance 1.16 Standard Deviation 1.08 Total Responses 38 11. Please indicate the level ofeffectivenessofdesign 2 for the following: Statistic Howeffective is Design 2 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.47 Variance 0.96 Standard Deviation 0.98 Total Responses 38 12. Please indicate the level ofeffectivenessof design 2 for the following:
  • 84. 84 Statistic Howeffective is Design 2 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 3.03 Variance 1.11 Standard Deviation 1.05 Total Responses 38 13. Please indicate the level ofeffectivenessofdesign 3 for the following: Statistic Howeffective is Design 3 at supporting a message to dissuade students from using electronic cigarettes? Min Value 1 Max Value 4 Mean 1.63 Variance 1.54 Standard Deviation 1.24 Total Responses 38 14. Please indicate the level ofeffectivenessofdesign 3 for the following:
  • 85. 85 Statistic Howeffective is Design 3 at communicating the advantages ofnot using electronic cigarettes? Min Value 1 Max Value 4 Mean 2.50 Variance 2.31 Standard Deviation 1.52 Total Responses 38 15. Out ofall of the designs,which do you like best? Why? (Please only choose 1 design) Statistic Value Min Value 1 Max Value 3 Mean 2.82 Variance 0.32 Standard Deviation 0.56 Total Responses 38
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