Developing Tobacco Risk Communications for Young Adults Susceptible to Dual Use of Combustible Cigarettes and Nicotine Vapes: Mixed Methods Study.

Background: Dual use of combustible cigarettes and nicotine vapes is disproportionately high among lesbian, gay, bisexual, transgender, and queer (LGBTQ+) young adults. Mass-reach health communications may be effective at curbing dual use. Current research is exploring whether comparative risk messaging, which presents nicotine vapes as less harmful than cigarettes, reduces dual use. Objective: This formative message testing study focused on communicating the health risks of cigarette smoking and nicotine vaping use to young adults susceptible to dual use of these products, including LGBTQ+ young adults. Methods: Online focus groups were conducted with young adults to develop candidate messages (N=12). Interviews (N=13) qualitatively explored thematic content. An online rating survey (N=286) quantitatively assessed perceived message effectiveness (PME) of and reactance to candidate messages applying standard and comparative risk message framing, compared to adapted regulatory warnings used by the US Food and Drug Administration. Results: Qualitatively, interview and focus group participants found messages featuring novel information, including toxic constituents and physical harms (eg, hypertension), most effective. "Known" harms (eg, cancer) were described as effective by LGBTQ+ young adults due to the "shock value" of fear appeals. However, participants recommended pairing "known" harms with novel information; for example, addiction messaging was best received when described in the context of social or occasional use. Comparative messaging was appealing for harm reduction (ie, encouraging young adults who use cigarettes to quit smoking and use nicotine vapes), especially among LGBTQ+ participants. However, participants were concerned that comparative messages could unintentionally promote vaping among nicotine-naïve young adults. Qualitative participants preferred gain-framed efficacy messages that encouraged rather than demanded behavior change. Efficacy messages that emphasized "switching" were described as permissive for vaping, and participants were concerned that these may encourage sustained nicotine use. Some questioned whether vaping could effectively help young adults quit smoking. Survey results supported qualitative findings: messages with highest PME scores addressed toxic constituents, heart and lung disease, and cancer. Addiction messages were least effective. Among participants engaged in dual use, PME-smoking scores were higher when viewing candidate comparative messages than regulatory messages, but there were no significant differences between standard and comparative messages. The most effective candidate efficacy messages addressed quitting all smoking and vaping to reduce health risks. Messages that encouraged quitting smoking and switching to vapes were rated least effective. Conclusions: Comparative messaging was associated with higher PME-smoking among young adults engaged in dual use but did not consistently outperform standard messaging. Qualitative findings suggest that comparative framing may be misinterpreted as endorsing vaping as "safe" rather than "lower harm than cigarettes." Further research is needed to examine potential unintended consequences of comparative messaging, including sustained nicotine use among young adults who smoke or normalization of vaping among nicotine-naïve young adults.