Background: Despite excessive consumption of sugar-sweetened beverages (SSB), little is known about behavioral interventions to reduce SSB intake among adults, particularly in medically-underserved rural communities. This type 1 effectiveness-implementation hybrid RCT, conducted in 2012-2014, applied the RE-AIM framework and was designed to assess the effectiveness of a behavioral intervention targeting SSB consumption (SIPsmartER) when compared to an intervention targeting physical activity (MoveMore) and to determine if health literacy influenced retention, engagement or outcomes. Methods: Guided by the Theory of Planned Behavior and health literacy strategies, the 6 month multi-component intervention for both conditions included three small-group classes, one live teach-back call, and 11 interactive voice response calls. Validated measures were used to assess SSB consumption (primary outcome) and all secondary outcomes including physical activity behaviors, theory-based constructs, quality of life, media literacy, anthropometric, and biological outcomes. Results: Targeting a medically-underserved rural region in southwest Virginia, 1056 adult participants were screened, 620 (59 %) eligible, 301 (49 %) enrolled and randomized, and 296 included in these 2015 analyses. Participants were 93 % Caucasian, 81 % female, 31 % ≤ high-school educated, 43 % < $14,999 household income, and 33 % low health literate. Retention rates (74 %) and program engagement was not statistically different between conditions. Compared to MoveMore, SIPsmartER participants significantly decreased SSB kcals and BMI at 6 months. SIPsmartER participants significantly decreased SSB intake by 227 (95 % CI = −326,−127, p < 0.001) kcals/day from baseline to 6 months when compared to the decrease of 53 (95 % CI = −88,−17, p < 0.01) kcals/day among MoveMore participants (p < 0.001). SIPsmartER participants decreased BMI by 0.21 (95 % CI = −0.35,−0.06; p < 0.01) kg/m

High consumption of sugar-sweetened beverages (SSB) contributes to a wide range of poor health outcomes. Further, few US adults drink less than the recommended ≤8 ounces per day; and individuals with low socioeconomic, low health literacy status, and in rural areas are even less likely to meet recommendations. Unfortunately, few SSB behavioral interventions exist targeting adults, and none focus on low health literacy in rural areas. Talking Health, a type 1 effectiveness-implementation hybrid trial targeting adults in rural southwest Virginia, was developed using the RE-AIM planning and evaluation framework (reach, effectiveness, adoption, implementation, maintenance). The primary aim of this pragmatic randomized-controlled trial was to determine the effectiveness of a scalable 6-month intervention aimed at decreasing SSB consumption (SIPsmartER) when compared to a matched contact physical activity promotion control group (MoveMore). SIPsmartER was developed based upon the Theory of Planned Behavior and uses health literacy strategies to improve comprehension of the intervention content among participants. MoveMore is based on a research-tested intervention that was adapted to address all theory of planned behavior constructs and health literacy principles. Secondary aims include additional health outcomes (e.g., physical activity, weight) and reach, adoption, implementation, and maintenance indicators. This paper highlights the opportunities and considerations for developing health behavior trials that aim to determine intervention effectiveness, provide all study participants an opportunity to benefit from research participation, and collect key information on reach and the potential for organizational adoption, implementation, and maintenance with the longer-term goal of speeding translation into practice settings.

Although adolescents are a group heavily targeted by the e-cigarette industry, research in cue-reactivity has not previously examined adolescents' behavioral and neural responses to e-cigarette advertising. This study addressed this gap through two experiments. In Experiment One, adult traditional cigarette smokers (n = 41) and non-smokers (n = 41) answered questions about e-cigarette and neutral advertising images. The 40 e-cigarette advertising images that most increased desire to use the product were matched to 40 neutral advertising images with similar content. In Experiment Two, the 80 advertising images selected in Experiment One were presented to adolescents (n = 30) during an functional magnetic resonance imaging brain scan. There was a range of traditional cigarette smoking across the sample with some adolescents engaging in daily smoking and others who had never smoked. Adolescents self-reported that viewing the e-cigarette advertising images increased their desire to smoke. Additionally, all participants regardless of smoking statuses showed significantly greater brain activation to e-cigarette advertisements in areas associated with cognitive control (left middle frontal gyrus), reward (right medial frontal gyrus), visual processing/attention (left lingual gyrus/fusiform gyrus, right inferior parietal lobule, left posterior cingulate, left angular gyrus) and memory (right parahippocampus, left insula). Further, an exploratory analysis showed that compared with age-matched non-smokers (n = 7), adolescent smokers (n = 7) displayed significantly greater neural activation to e-cigarette advertising images in the left inferior temporal gyrus/fusiform gyrus, compared with their responses to neutral advertising images. Overall, participants' brain responses to e-cigarette advertisements suggest a need to further investigate the long-run impact of e-cigarette advertising on adolescents.

Objective: The objective of this study is to explore adolescent non-ecigarette users' interpretations of e-cigarette advertising and their engagement with e-cigarette information. Given adolescents' lack of persuasion knowledge and the association between advertising and behaviour, insights from non-users who are heavily targeted by the industry add evidence to a field that mainly focuses on risk perceptions and reasons for experimentation. Design: Five focus groups were conducted with 39 adolescents (mean = 14.21 years, age range 12-17, 80% female). Data were analysed using the thematic approach. Results: Three themes were emerged: (1) advertising motivates nonsmokers to use e-cigarettes, (2) there is fascination with the technical and emotional appeals featured in commercials and (3) searching for information about e-cigarettes involves little validation. Adolescents also recalled health and social appeals that are consistent with content analysis of e-cigarette advertising. Further, adolescents used digital platforms and interpersonal sources for information on e-juice ingredients, health effects, accessibility, and price to satisfy their curiosity and justify their use. Very few, however, questioned the trustworthiness of the information. Conclusion: Findings provide support for the implementation of strategies, such as media literacy in public health and media campaigns, and the development of regulations vis-'a-vis advertising and access to e-cigarette products to reduce future uptake.

Objective To assess differences, by health literacy status and behavioral condition, in participants’ abilities to accurately self-monitor behaviors and recall key behavioral messages using data from a teach-back call. Design Cross-sectional. Setting Rural, southwestern Virginia. Participants Adults (n=301). Majority (81.1%) were female, 31.9% had ≤high school education, 66.1% earned <$25,000 per year, and 32.9% were low health literate. Intervention First class session of two community-based behavioral interventions: SIPsmartER (reduce sugar sweetened beverage intake) or MoveMore (increase physical activity). Main Outcome Measures Reported accuracy of behavioral diary completion, proportion of behavioral messages recalled during the first round of teach-back, and rounds of teach-back. Analysis Descriptive statistics and GLM. Results Low health literate participants were significantly less accurate in diary completion (P<.001), recalled fewer behavioral messages correctly (P<.001), and needed more rounds of teach-back (P<.001) than high health literate participants. Compared to SIPsmartER participants, MoveMore participants more accurately completed diaries (P=.001), but recalled a lower proportion of behavioral messages correctly (P<.001) and required more rounds of teach-back Conclusions and Implications Health literacy status and behavioral target impact ability to self-monitor and recall key concepts. Researchers should consider using teach-back early in the intervention to assess and reinforce participants’ ability to self-monitor.