Carla J. Berg, Ph.D. - US grants

DESCRIPTION (provided by applicant): Tobacco use is the leading cause of cancer deaths. Encouraging and assisting cessation early in life is critical given that quitting by age 30 dramatically reduces the risk of cancer death. Community college students are a priority population given their high rate of smoking compared to other young adults and lack of effective cessation programs targeting this group. A challenge facing tobacco control research is engaging high-risk populations in smoking cessation programs. This proposal addresses these issues using a novel approach. The long-term goal of this career development award is to develop Carla J. Berg, Ph.D. as an independent translational cancer control researcher, combining innovative approaches to cancer prevention including tobacco industry market segmentation research to inform smoking cessation messages, eHealth intervention strategies, and tailored messaging aimed at cancer prevention, specifically tobacco control among underserved, high-risk young adults. Her short-term career goals are to transition into independent cancer prevention research. Over the five-year award period, she will develop a knowledge base to will support development and implementation of an effective eHealth smoking cessation intervention targeting community college smokers. Career development activities include training in market segmentation research, eHealth intervention development, health behavior theory, cancer prevention, and biological bases of nicotine dependence. The tobacco industry has used market segmentation research (identification of groups with similar interests, goals, and values) to promote the uptake of smoking. We propose to apply these same tactics to promote smoking cessation and use of cessation services. We aim to develop and test the feasibility of using market segmentation to enhance tailoring as part of an eHealth cessation intervention. The plan involves 3 studies. Studies 1 (survey) and 2 (focus groups) aim to (1) identify market segments of community college smokers and quantitatively and qualitatively assess differences in smoking attitudes and behaviors; and (2) investigate preferred communication channels (internet, cell phone, etc.) for intervention delivery and appropriate messages for the intervention. In Study 3, we will conduct a 2-group randomized trial (n=95/group) comparing enhanced tailoring (based on market segment + smoking-related factors) vs. standard tailoring (smoking-related factors only) as part of an eHealth smoking cessation intervention. The primary outcome for this feasibility study will be website use over a 6-week intervention period. Secondary outcomes will include abstinence (both self-report and cotinine-validated) and message processing. This proposal is innovative and addresses important gaps in the literature, including adherence to online interventions and health risk behaviors among community college students (i.e., a high-risk, underserved group of young adults). These experiences will provide Dr. Berg with skills to launch an independent career as an eHealth cancer prevention researcher. The University of Minnesota is an excellent environment for this proposal given: (1) its standing as a national leader in tobacco and cancer research through its NCI-designated Comprehensive Cancer Center; (2) the School of Public Health and its well-established program in eHealth research; (3) the strength of the Carlson School of Management, which houses the Institute for Research in Marketing; and (4) its network of Minnesota colleges to support this work. The team of mentors, Drs. Jasjit Ahluwalia, Lawrence An, and Barbara Loken are leaders in tobacco control research and underserved populations, eHealth research among young adult smokers, and anti-tobacco marketing strategies, respectively. Thus, the candidate, the environment, and the mentorship team (in conjunction with a strong Scientific Advisory Board) are well matched to address this research and career development plan.

DESCRIPTION (provided by applicant): In recent years, emerging tobacco products, such as small cigars (i.e., little cigars, cigarillos), snuff, dissolvable tobacco products, and electronic nicotine delivery systems (ENDS; i.e., e-cigarettes), have been introduced to the US market, while water pipes or hookah have increased in popularity. The health risks associated with the utilization of these products include misperceptions of their relatively lower health risks, use as an alternative to smoking cessation, and potential appeal to youth, among other concerns. In June 2009, the Food and Drug Administration (FDA) acquired the authority to regulate the manufacture, marketing, and distribution of tobacco products. The current proposal primarily focuses on two main research priority areas established by the FDA, specifically to increase understanding of: 1) the impact of tobacco product marketing on use behaviors, perception, attitudes, and beliefs; and 2) how to effectively convey information regarding risks of tobacco product use and the regulation of tobacco products. The long-term goal of this research program is to better understand the epidemiology of tobacco product use, particularly alternative tobacco product use, and attitudes toward these tobacco products among young adults through the use of market research. Market research employs a novel approach to understanding individuals by defining market segments, individuals with similar psychographic profiles (defined by interests, lifestyles, goals, and values), which are predictive of consumer behavior. No research has employed market research to improve our predictive models of tobacco use in the context of longitudinal research. This study will examine whether psychographic profiles of market segments predict traditional and alternative tobacco product use and may elucidate valuable targets for health messaging to impact attitudes regarding these products among high-risk segments. Our specific aims are to: 1) identify market segments of young adults attending colleges and universities in Georgia based on their psychographic profiles using market research methodology; 2) examine the epidemiology of tobacco use among college student market segments over two years; and 3) investigate reasons for use of alternative tobacco products and how to best frame messages to alter attitudes about these products and regarding regulation of tobacco products. Aims 1 and 2 will be addressed through a longitudinal cohort study of 1,200 college students aged 18-25. Aim 3 will be addressed using semi- structured interviews of 60 tobacco product users from the cohort. This research will provide novel information regarding high-risk youth and how to best communicate health risks associated with using tobacco, particularly alternative tobacco products, as well as how to promote support for FDA's regulatory authority. Future research will develop and test messages to promote tobacco use prevention and cessation among high-risk young adults and will address a broader range of vulnerable populations using this approach.

? DESCRIPTION (provided by applicant): Perhaps the broad interest in and the importance placed on social media by industry, policymakers, researchers, and others is based on the assumption that social media activity must impact individual behavior, or at least be a reflection of behavior. However, there is little or no empirical research explicitly examining whether or not this is true - does social media impact individual consumer behavior (or at least reflect it)? The topic of this proposal - electronic cigarettes (or e-cigarettes) - is ideal for addressing this question. These battery-powered nicotine delivery devices have emerged in the U.S. market in the past five years and have had a strong online presence, including within social media. Within the context of varied levels of tobacco control across states and a range of e-cigarette advertising, there were a dramatic increases in awareness (40.9% in 2010 to 75.4% in 2012) and use of e-cigarettes (3.3% ever use in 2010 to 8.1% in 2012). Drawing from the Socio Ecological Model and Diffusion of Innovation, contextual factors such as social influence, advertising, and public policy play an important role in tobacco use and rate of adoption. Using this foundation, we will examine specific tobacco control policies (per the American Lung Association's State of Tobacco Control) and e-cigarette advertising (per Competitrack Advertising Data) in relation to social media activity, specifically Twitter activity (volume, sentiment, and source from Gnip). We will also examine these greater contextual factors (tobacco control activity, e-cigarette advertising, Twitter activity) in relation to e-cigarette purchases, per the Nielsen Consumer Panel data, which records household purchases at the Universal Product Code (UPC) level among over 60,000 panelists beginning in 2004. We will triangulate these data sets through ZIP codes and use data from January 2011 to December 2013. Our specific aims are to: 1) examine the association between e-cigarette Twitter activity (volume, sentiment, source) and e-cigarette purchasing behavior (volume) per the Nielsen Consumer Panel data; 2) examine tobacco control policies (prevention, cessation, tax, smoke- free policy) and e-cigarette advertising (traditional, new media) in relation to e-cigarette Twitte activity; and 3) model e-cigarette purchasing through tobacco control policies, e-cigarette advertising, and e-cigarette Twitter activity over time and across states. The unique triangulation of these multilevel data will yield timely and important information given the emergence of e-cigarettes; the increased use of new and social media to promote e-cigarettes, other tobacco products, and substance use more broadly; and the need to understand the impact of policy and advertising on social media activity and ultimately the use of e-cigarettes. Examining the aforementioned aims of this R21 will establish whether these associations exist and provide data for a larger study including online sales of e-cigarettes, a larger range of advertising effors, and tobacco control activities within counties or cities to further extrapolate and contextualize the impact of social media on e- cigarette use. This may provide a basis for examination of similar factors related to use of other substances.

SUMMARY/ABSTRACT Public health efforts in low- and middle-income countries (LMICs) could be catalyzed by bolstering ways to optimally leverage local talents and resources, such as civil society. Developing effective models for aligning civil society and governmental public health at the local level in LMICs has the potential to impact a range of chronic diseases and risk factors, including tobacco. Local coalitions have been a dominant strategy in tobacco control in the US, with well-documented success in establishing smoke-free policies specifically. However, this approach has not been widely leveraged or well-studied in LMICs or those with less democratic traditions than the US. Instead, in many LMICs, smoke-free policy progress is largely initiated at the national level. Parallel civil society movements at the local level may be needed to build support for and compliance with policies. Given their sociopolitical histories and high tobacco use and secondhand smoke exposure (SHSe) rates, Georgia (GE) and Armenia (AM) are two strategic settings for the proposed work. The smoking prevalence is 57.7% and 52.3% in men (6th and 11th highest in the world) and 5.7% and 1.5% in women, respectively. Moreover, our findings indicate extremely high rates of SHSe. However, we also documented high receptivity to public smoke-free policies despite high use rates, particularly in worksites and restaurants. This proposal is a well-justified extension of the literature and our prior work. We will build the capacity of GE and AM researchers to conduct high-quality mixed methods tobacco research and test the Community Coalition Action Theory as a framework for impacting local community-driven policy change. Researchers from the GE National Center for Disease Control (NCDC) and AM National Institute of Health (NIH) will collaborate with Emory to execute the proposed research, train tobacco control researchers within their organizations and partnering universities, and train practitioners within local communities to build local coalitions for tobacco control policy. We aim to: 1) conduct a matched-pair community randomized controlled trial in 28 municipalities in GE and AM to examine the impact of local coalitions promoting the adoption of smoke-free policies in worksites and restaurants, with the primary outcome of changes in SHSe over time; 2) assess how community context and coalition factors influence adoption of organizational and municipal smoke-free policies to provide an evidence- base for public health practice; 3) disseminate research findings regarding both the effectiveness and the process of establishing and maintaining coalitions, and consequently increasing smoke-free policies and reducing SHSe, to key stakeholders in GE and AM; and 4) capitalize on the proposed research and dissemination opportunities to build tobacco control research capacity within the GE NCDC, AM NIH, and partnering universities, as well as practice capacity within local public health centers and their civil society partners. Ultimately, the activities outlined in this proposal will serve as a catalyst for future action-oriented science and evidence-based practice to support tobacco control progress in this region more broadly.

PROJECT SUMMARY/ABSTRACT Electronic nicotine delivery systems (ENDS) have emerged in the US market, with use and awareness rapidly increasing in recent years, particularly in young adults. While ENDS may facilitate harm reduction in smokers, ENDS represent significant health risks, including addiction in the nicotine-naïve (e.g., young adults). From a socioecologic perspective, the literature regarding tobacco retail indicates that place characteristics such as neighborhood demography and policy context influence retailer location and marketing, and these factors impact individual tobacco use. However, this literature is in its infancy in regard to ENDS and particularly to vape shops, which are stores exclusively devoted to ENDS sales. Vape shops have proliferated in the US and are unique in their product offerings, marketing, and overall retail environment (e.g., tasting bars). Vape shops, as well as the 2nd and 3rd generation ENDS they sell, have particular appeal to young adults. A particularly important and timely macro-level factor that may impact ENDS use and distribution channels is the impending FDA Deeming Regulation on ENDS and other tobacco products. The Deeming Regulation involves a range of policies implemented in the next 3 years (e.g., mandatory age verification and prohibiting free samples beginning in Aug 2016, mandatory health warning labels effective Aug 2018, manufacturers required to submit a new tobacco product application by Aug 2018, etc.). These regulations are likely to impact vape shop survival as well as their marketing and the overall vape shop experience, given young adults are the biggest segment of vape shop clientele (who will require ID), the social experience of tasting bars (which will no longer be allowed), and the history of ENDS being promoted as safe and for cessation or harm reduction (with products and ads requiring health warnings). A well-integrated program of research is needed to examine the multilevel impact of regulation on ENDS retailers, as well as on ENDS marketing, specifically among vape shops, given that they are a unique retail settings that have a particular impact on young adult ENDS use. Leveraging a Socioecological Framework, we will draw data from 6 metropolitan statistical areas (MSAs) representing the CDC-defined regions and the gradient of tobacco control in order to address 3 inter-related aims: 1) examine density and survival of vape shops over time and across contexts in relation to FDA regulation, local policies, and other sociocontextual factors (e.g., neighborhood context, density/proximity of convenience stores); 2) examine vape shop marketing and POS practices (e.g., age verification, free sampling, health warnings) over time and across contexts in relation to FDA regulation, local policies, and other sociocontextual factors (e.g., neighborhood context, density/proximity of convenience stores); and 3) examine young adult ENDS use over time and across contexts in relation to spatial access to vape shops and convenience stores, ENDS advertising exposure, local policies, and sociocontextual factors. This research will document the impact of regulation on this industry and provide an evidence base for legislation regarding zoning and vape shop marketing/POS practices to protect high-risk populations. We will disseminate findings with an explicit focus on informing public health policy and practice regarding ENDS, as well as future research.

SUMMARY/ABSTRACT The global market has increasingly included heated tobacco products (HTPs). Philip Morris International (PMI) submitted a Premarket Tobacco Application for IQOS, the global HTP leader, and is pursuing Modified Risk Tobacco Product categorization for this product. Given the impending introduction of IQOS into the US market, it is critical to leverage marketing data from other contexts to inform and advance regulatory efforts regarding IQOS. This proposal leverages a scientific premise and a conceptual framework based on a Socioecological Framework, indicating the importance of regulatory contexts and implications for marketing, and Diffusion of Innovation Theory, accounting for marketing strategies and channels, as well as impact on consumer behavior and perceptions. At the policy level, while there are several countries in which IQOS has a presence in the market, Israel is unique in that it represents 3 distinct regulatory contexts: 1) during IQOS?s initial emergence in Israel, it was not categorized as a tobacco product (Dec 2016-Apr 2017); 2) it was classified as a tobacco product in a relatively weak regulatory context (Apr 2017- 2019); and 3) it will be regulated as a tobacco product within new progressive legislation (going into effect beginning 2019). Our study team has been collecting and analyzing IQOS marketing data in Israel since 2016; thus, we are strategically positioned to compare real-world marketing strategies used by PMI in these different regulatory contexts and to examine consumer reactions to this marketing content in both Israel and the US. PMI?s IQOS website suggests targeting at least 4 consumer market segments (business & current events; art, culture & fashion; nature & hiking; innovation & technology). Thus, their marketing content and distribution channels likely reflect these groups. However, these segments may be differentially prioritized by PMI marketing and may be distinct in their likely IQOS use and perceptions. In summary, the Israeli regulatory context and our prior research offers an opportunity to advance US readiness to regulate IQOS marketing. This will be critical, given that independent research is needed, particularly using real-world marketing and borrowing from the industry?s own methods, in order to truly estimate population impact of such products and their marketing. The overall goal of this line of work is to inform tobacco regulatory efforts to minimize population harm of tobacco use. To this end, the immediate objective is to examine IQOS marketing strategies used in Israel during 3 regulatory periods and examine their impact on segments of the Israel and US population. We propose 2 inter-related specific aims: 1) examine IQOS marketing strategies in Israel from its emergence in the Israel market; and 2) examine market segments of Israeli and US adults in relation to IQOS use and/or likelihood of future use. This proposal is responsive to RFA-OD-18-002, focusing on marketing influences and behavior, and involves innovative applications of rigorous methodology. By examining PMI?s IQOS marketing strategies used in the 3 different regulatory periods in Israel and understanding the impact of these strategies on different segments of consumers and the extent to which they generalize to US consumers, findings will provide information to better estimate the potential impact of IQOS and its marketing in the US.

SUMMARY/ABSTRACT Globally, 7 million deaths are attributable to the joint effects of indoor and ambient air pollution annually, with ~94% occurring in low- and middle-income countries (LMICs). In addition, secondhand smoke (SHS) is a major global health problem, causing ~600,000 deaths (1% of mortality) annually, with women and children being disproportionately affected by SHS. LMICs are also disproportionately impacted by SHS and related morbidity and mortality. The Republic of Georgia (GE) is notably impacted by air pollution and SHS. Adverse environmental exposures cause 21% of disease burden and 25% of deaths, including 30% of disease burden and 14% of deaths among children. Moreover, GE?s mortality index attributed to ambient and indoor air pollution is the 3rd highest in the world. Additionally, the smoking prevalence in GE is 58% in men (6th highest in the world) and 6% in women, implying significant impact of SHS in GE. Indeed, 42% of GE adults report daily SHS exposure. Underscoring the impact of these statistics, GE?s 2017-2021 National Environment and Health Action Plan indicates that addressing air pollution is among the most prominent public health priorities in GE. However, there is limited in-country capacity to conduct research regarding the impact of such environmental hazards on health. This application, the Emory-Georgia Clean Air Research and Education (EG-CARE) program, coincides with increased prioritization of research and policy to reduce air pollution and address NCDs in GE, and represents a uniquely strategic collaboration among Emory University, the GE National Center for Disease Control and Public Health (NCDC), the GE National Environmental Agency (NEA), and Tbilisi State Medical University (TSMU). Various existing collaborations and ongoing efforts will be leveraged, including Fogarty-funded grants to promote smoke-free air policies in GE (an R01) and to enhance TB research capacity in GE (a D43), as well as an NIEHS-funded center grant called HERCULES (a P30) and an NIEHS-funded T32 training program at Emory. Key leaders of these efforts and across these institutions will collaborate to implement this training program, with the long-term goal of enhancing capacity in GE to conduct research related to NCDs and environmental health (EH) and ultimately inform policy and practice to reduce NCDs. The overall objective of this application is to develop and implement a training program involving training, mentorship, and applied research opportunities to ultimately reach the long-term goal. Thematically, EG-CARE will focus on the intersection between NCDs and EH, particularly air pollution, and aim to: 1) enhance formal NCD and EH training opportunities and institutional infrastructure to support ongoing research training; 2) provide mentored NCD- and EH- related research opportunities spanning from the molecular to the population level, with a particular focus on air quality and pollution, to candidates with outstanding potential; and 3) emphasize research dissemination and knowledge translation to inform policy and practice. Leveraging the aforementioned ongoing efforts, this proposal addresses a timely, high-priority public health concern in GE, underscoring its potential impact. The program team is uniquely positioned to address these aims and enhance research capacity related to NCDs and EH in the next 5 years and in the long term.

SUMMARY/ABSTRACT The past decade in the US marked pivotal changes in the policy and retail environments regarding marijuana (MJ), the most commonly used federally illicit drug, particularly prevalent in young adults and racial and sexual/gender minorities (SGM). Despite controversy regarding recreational MJ, further legalization is likely, and states will continue to struggle with how to implement legislation. Thus, states with legalized recreational MJ provide an opportunity and a need to monitor recreational MJ retail and impact on various subpopulations, as regulatory frameworks for MJ are in their infancy and require additional research given the nuances of MJ retail (e.g., specialty stores, uniquely diverse products, progressive promotional strategies). The overall goal of this research is to inform regulatory efforts to minimize MJ use in vulnerable populations, in states with legalized recreational MJ and those that subsequently legalize it. The immediate objective of this proposal is to examine the recreational MJ market, MJ use, and related perceptions in consumer segments of vulnerable populations, particularly diverse young adults. Our scientific premise builds on literature that indicates that licit drug retail marketing ? both brick-and-mortar and online ? target vulnerable populations (e.g., racial/ethnic minorities, SGM, young adults) and the consequences of such marketing on substance use in these groups. The MJ retail has largely lacked standardized industry marketing surveillance tools, which have been critical in establishing the impact of tobacco and alcohol retail marketing and informing regulation. This proposal leverages our team?s prior work; we developed surveillance tools to characterize point-of-sale practices (e.g., age verification), product availability, promotional strategies, and product pricing at brick-and-mortar shops and online. Findings indicated several issues with policy compliance (e.g., inconsistent age verification), promotional strategies appealing to young people and minorities, various health claims, and minimal health warnings. In addition, our team has demonstrated the utility of identifying young adults at high-risk for substance use and likely exposure to related marketing by using industry market segmentation based on psychographics (e.g., values, attitudes, lifestyle); the extent to which psychographics vs. sociodemographics inform industry marketing strategies, particularly among vulnerable populations, is not well known. Using a Socioecologic Framework, we aim to: 1) determine whether neighborhood demography is associated with marketing and point-of-sale practices among recreational MJ retailers over time, accounting for policy context; and 2) compare young adult market segments defined by age and minority status vs. psychographics in relation to MJ use, perceptions, access, and advertising exposure in states with differing MJ policy contexts (recreational, medicinal, no legalized MJ policy) over time. This proposal a) is responsive to PA-17-135, addressing a timely public health issue; b) is supported by a strong scientific premise and rationale; c) is highly integrative across aims/data sources; d) leverages robust, replicable methods yet integrates innovative, novel applications; e) prioritizes dissemination and translation to impact public health and regulation; and f) will be executed by uniquely-poised research team and stakeholder advisors.