Academic Appointments


2017-18 Courses


All Publications

  • Health Beliefs of American Indian Imagery on Natural American Spirit Packs TOBACCO REGULATORY SCIENCE Epperson, A. E., Henriksen, L., Lambin, E. F., Prochaska, J. J., Flora, J. A. 2019; 5 (4): 369–80

    View details for DOI 10.18001/TRS.5.4.7

    View details for Web of Science ID 000474418000007

  • Gender and racial/ethnic differences in adolescent intentions and willingness to smoke cigarettes: Evaluation of a structural equation model. Journal of health psychology Epperson, A. E., Wallander, J. L., Song, A. V., Depaoli, S., Peskin, M. F., Elliott, M. N., Schuster, M. A. 2019: 1359105319829536


    Dual-process theories may be effective at predicting adolescent smoking; however, little is known about the effectiveness of these models across race/ethnicity and gender. Adolescents ( N = 4035) completed biopsychosocial and tobacco-related perception measures in Grade 7 and reported on smoking initiation in Grade 10. Using structural equation modeling and comparing models by gender and race/ethnicity showed differences, where both intentions and willingness predicted smoking initiation for only Black and male adolescents, compared to their Latino and White and female counterparts. Intentions and willingness appear to play a role in whether an adolescent will initiate smoking in the future, but this does not apply universally across gender and race/ethnicity.

    View details for PubMedID 30773937

  • The price of Natural American Spirit relative to other cigarette brands. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco Epperson, A. E., Johnson, T. O., Schleicher, N. C., Henriksen, L. 2019


    Introduction: American Spirit cigarettes feature American Indian/Alaska Native (AI/AN) imagery in the branding, are marketed as environmentally friendly, without additives, and four varieties contain organic tobacco. This study is the first to examine retail price of American Spirit relative to other cigarette brands and to assess how its price varies by neighborhood demography.Methods: In a random sample of licensed tobacco retailers (n=1277), trained data collectors recorded availability and price of American Spirit, Pall Mall, Newport, Marlboro and the cheapest cigarettes regardless of brand. Data were collected in January-March 2017 in California, the state with the largest AI/AN population. Paired t-tests assessed prices (before sales tax) of American Spirit relative to others. Ordinary least squares regressions modeled prices as a function of neighborhood demography, adjusting for store type.Results: American Spirit was sold in 77% of stores at an average price of $7.03 (SD=0.66), which was $0.75 to $1.78 (12.0% to 34.4%) higher than Pall Mall, Newport, and Marlboro in the same stores. American Spirit cost significantly less in neighborhoods with a higher proportion of school-age residents, however this pattern was not unique to that brand. Contrary to expectation, American Spirit did not cost less in neighborhoods with a higher proportion of AI/ANs.Conclusion: This study is the first to document lower prices for American Spirit in neighborhoods with a higher proportion of school-age youth. Future research should consider whether the ultra-premium price of American Spirit contributes to misperceptions that the brand is organic and less harmful than other cigarettes.Implications: In a large random sample of licensed tobacco retailers in California, American Spirit cost significantly more than other brands,12.0% to 34.4% more than Pall Mall, Newport, and Marlboro in the same stores.After controlling for store type, American Spirit price was significantly lower in neighborhoods with a higher proportion of school-age residents. Research about how an ultra-premium price contributes to misperceptions that all American Spirit varieties are organic and the brand is less harmful, less addictive than other cigarette brands would be informative for ongoing litigation and product regulation.

    View details for PubMedID 30759248

  • "The Packaging Is Very Inviting and Makes Smokers Feel Like They're More Safe": The Meanings of Natural American Spirit Cigarette Pack Design to Adult Smokers. Health education & behavior : the official publication of the Society for Public Health Education Epperson, A. E., Averett, P. E., Blanchflower, T., Gregory, K. R., Lee, J. G. 2019: 1090198118820099


    BACKGROUND/AIMS: The aim of this investigation was to identify which design elements on Natural American Spirit packs are salient to (i.e., noticed by) U.S. adult smokers and what meanings smokers derive from these elements.METHOD: We conducted a secondary analysis of qualitative data from a study of cigarette packaging design. U.S. adult smokers ( n = 33) from all nine census regions participated in six telephone-based focus groups in March 2017. We used constant comparison analysis to identify key themes.RESULTS: Four themes were identified, two focused on salient design elements and two focused on design element meanings. The themes of "bright and flashy color" and "the American Indian logo" were identified as key design elements, while the themes of "healthy and safer" and "targeting at-risk smokers" were identified as meanings smokers derived from design elements.CONCLUSIONS: Pack design elements influence smokers' perceptions about reduced health risk of Natural American Spirit cigarettes and may be especially dangerous to vulnerable populations, including young adults and American Indians. Findings from this study suggest that the banning of text descriptors may not be enough to address misconceptions about "healthier" cigarettes.

    View details for PubMedID 30606071

  • "The Packaging Is Very Inviting and Makes Smokers Feel Like They're More Safe": The Meanings of Natural American Spirit Cigarette Pack Design to Adult Smokers HEALTH EDUCATION & BEHAVIOR Epperson, A. E., Averett, P. E., Blanchflower, T., Gregory, K. R., Lee, J. L. 2019; 46 (2): 260–66
  • Natural American Spirit's pro-environment packaging and perceptions of reduced-harm cigarettes. Preventive medicine Epperson, A. E., Lambin, E. F., Henriksen, L., Baiocchi, M., Flora, J. A., Prochaska, J. J. 2019: 105782


    Natural American Spirit (NAS) cigarettes feature a pro-environment marketing campaign on the packs. The NAS "Respect for the Earth" campaign is the first example of on-the-pack corporate social responsibility advertising. In a randomized survey design, we tested perceptions of NAS relative to other cigarette brands on harms to self, others, and the environment. Never (n = 421), former (n = 135), and current (n = 358) US adult smokers were recruited for an online survey from January through March 2018. All participants viewed packs of both NAS and Pall Mall. Participants were randomized to view NAS vs. Pall Mall and to pack color (blue, green, or yellow/orange), which was matched between brands. Survey items assessed perceptions of health risk of the cigarette brand to self, others, and the environment and perceptions of the manufacturer. Consistently on all measures, NAS cigarettes were rated as less harmful for oneself, others, and the environment relative to Pall Mall (p's < .001). Though Reynolds American manufactures both brands, participants rated the company behind NAS as more socially responsible than the company behind Pall Mall, F[1, 909] = 110.25, p < .001. The NAS advantage was significant irrespective of smoking status, pack color, and brand order, with findings stronger for current than never smokers. Pro-environmental marketing on NAS cigarette packs contributes to misperceptions that the product is safer for people and the environment than other cigarettes and made by a company that is more socially responsible. Stricter government regulations on the use of pro-environment terms in marketing that imply modified risk is needed.

    View details for DOI 10.1016/j.ypmed.2019.105782

    View details for PubMedID 31325524

  • The Medi-Cal Incentives to Quit Smoking Project: Impact of Statewide Outreach Through Health Channels. American journal of preventive medicine Tong, E. K., Stewart, S. L., Schillinger, D., Vijayaraghavan, M., Dove, M. S., Epperson, A. E., Vela, C., Kratochvil, S., Anderson, C. M., Kirby, C. A., Zhu, S., Safier, J., Sloss, G., Kohatsu, N. D. 2018; 55 (6S2): S159–S169


    INTRODUCTION: Little is known about how incentives may encourage low income smokers to call for quitline services. This study evaluates the impact of outreach through health channels on California Medicaid (Medi-Cal) quitline caller characteristics, trends, and reach.STUDY DESIGN: Longitudinal study.SETTING/PARTICIPANTS: Medi-Cal quitline callers.INTERVENTION: Statewide outreach was conducted with health providers, Medi-Cal plans (all-household mailings with tracking codes), and public health organizations (March 2012-July 2015). For incentives, Medi-Cal callers could ask for a $20 gift card; in September 2013, callers were offered free nicotine patches.MAIN OUTCOME MEASURES: Caller characteristics were compared with chi-square analyses, joinpoint analysis of call trends was performed accounting for Medi-Cal population growth, referral source among Medi-Cal and non-Medi-Cal callers was documented, and the annual percentage of the population reached who called the Helpline was calculated. Analyses were conducted 2016-2018.RESULTS: Total Medi-Cal callers were 92,900, a 70% increase from prior annual averages: 12.4% asked for the financial incentive, 17.3% reported the mailing code, and 73.3% received nicotine patches while offered. Among the two thirds of callers who completed counseling, 15.5% asked for the financial incentive, and 13.6% reported the mailing code. A joinpoint analysis showed call trends increased 23% above expected for the Medi-Cal population growth after mailings to providers and members began, and decreased after outreach ended. Annual reach increased from 2.3% (95% CI=2.1, 2.6) in 2011 to peak at 4.5% (95% CI=3.6, 5.3) in 2014. Among subgroups with higher reach rates, some also had higher rates of asking for the financial incentive (African Americans, American Indian), reporting the tracking code (whites), or both (aged 45-64 years). Medi-Cal callers were more likely than non-Medi-Cal callers to report providers (32.3% vs 23.8%) and plans (19.7% vs 1.4%) as their referral source, and less likely to cite media (20.2% vs 44.4%, p<0.001).CONCLUSIONS: Statewide outreach through health channels incentivizing Medi-Cal members increased the utilization and reach of quitline services.SUPPLEMENT INFORMATION: This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

    View details for PubMedID 30454670

  • Tobacco use among Latinx adolescents: exploring the immigrant paradox. BMC pediatrics Epperson, A. E., Wallander, J. L., Elliott, M. N., Schuster, M. A. 2018; 18 (1): 379


    BACKGROUND: Research suggests that an immigrant paradox exists where those who were not born in the United States (1st generation) have significantly better health than those who were born in the U.S. (2nd generation or more). The aim of the current study was to examine the immigrant paradox with respect to tobacco-related perceptions and parenting influences in smoking initiation among Latinx adolescents.METHODS: Data came from the 7th and 10th grade Healthy Passages assessments of Latinx participants in three U.S. urban areas (N=1536) who were first (18%), second (60%), and third (22%) generation. In addition to demographics, measures included perceived cigarette availability and peer smoking, intentions and willingness to smoke, and general monitoring by parents. Parents reported on generational status and their own tobacco use. The primary outcome was participant's reported use of cigarettes.RESULTS: By 10th grade, 31% of Latinx youth had tried a cigarette, compared to 8% in 7th grade. After controlling for age, gender, and socioeconomic status, regression analyses indicated that there were no significant differences related to generational status in cigarette smoking initiation in either 7th or 10th grade. Youth tobacco-related perceptions, general parental monitoring, and parental tobacco use predicted Latinx adolescent cigarette use initiation by 10th grade.CONCLUSIONS: Latinx adolescents might not have deferential smoking rates based on generation status, suggesting that the immigrant paradox concept may not hold for smoking initiation among Latinx adolescents. Rather, factors influencing cigarette initiation generally in adolescents as a group appear to apply to Latinxs as well.

    View details for PubMedID 30501626

  • Natural American Spirit brand preference among smokers with mental illness TOBACCO INDUCED DISEASES Epperson, A. E., Anzai, N., Prochaska, J. J. 2018; 16

    View details for DOI 10.18332/tid/94456

    View details for Web of Science ID 000444727600004

  • The Healing and Empowering Alaskan Lives Toward Healthy-Hearts (HEALTHH) Project: Study protocol for a randomized controlled trial of an intervention for tobacco use and other cardiovascular risk behaviors for Alaska Native People. Contemporary clinical trials Prochaska, J. J., Epperson, A., Skan, J., Oppezzo, M., Barnett, P., Delucchi, K., Schnellbaecher, M., Benowitz, N. L. 2018


    BACKGROUND: Tobacco use and tobacco-related diseases disproportionately affect Alaska Native (AN) people. Using telemedicine, this study aims to identify culturally-tailored, theoretically-driven, efficacious interventions for tobacco use and other cardiovascular disease (CVD) risk behaviors among AN people in remote areas.DESIGN: Randomized clinical trial with two intervention arms: 1) tobacco and physical activity; 2) medication adherence and a heart-healthy AN diet.PARTICIPANTS: Participants are N = 300 AN men and women current smokers with high blood pressure or high cholesterol.INTERVENTIONS: All participants receive motivational, stage-tailored, telemedicine-delivered counseling sessions at baseline and 3, 6, and 12 months follow-up; an individualized behavior change plan that is updated at each contact; and a behavior change manual. In Group 1, the focus is on tobacco and physical activity; a pedometer is provided and nicotine replacement therapy is offered. In Group 2, the focus is on medication adherence for treating hypertension and/or hypercholesterolemia; a medication bag and traditional food guide are provided.MEASUREMENTS: With assessments at baseline, 3, 6, 12, and 18 months, the primary outcome is smoking status, assessed as 7-day point prevalence abstinence, biochemically verified with urine anabasine. Secondary outcomes include physical activity, blood pressure and cholesterol, medication compliance, diet, multiple risk behavior change indices, and cost-effectiveness.COMMENTS: The current study has the potential to identify novel, feasible, acceptable, and efficacious interventions for treating the co-occurrence of CVD risk factors in AN people. Findings may inform personalized treatment and the development of effective and cost-effective intervention strategies for use in remote indigenous communities more broadly. Clinical Trial Registration # NCT02137902.

    View details for PubMedID 29864548

  • Natural American Spirit Brand Preference among Smokers with Mental Illness. Tobacco induced diseases Epperson, A. E., Anzai, N. E., Prochaska, J. J. 2018; 16


    Despite steady declines in the US smoking prevalence over the past 50 years, Natural American Spirit cigarettes (NAS), marketed as natural and organic, have seen a 400% rise in sales. In a sample of smokers with mental illness, based on previous research, we hypothesized that preference for NAS would be associated with younger age, higher education, and a stronger health-orientation.Adult smokers were interviewed during acute psychiatric hospitalization in California between 2009-2013, reporting their preferred top 3 brands of cigarettes, smoking behaviors, self-rated health, and dietary and physical activity behaviors. The sample (N=956; M age=38.7, SD=13.5; 48.7% women) identified as 14.5% Hispanic ethnicity and 49.6% White, 23.7% African American, and 23.8% other race.NAS was identified as a top preferred brand by 15.2% of participants and was the fourth most popular brand for the sample overall. In a multivariate logistic regression, preference for NAS was significantly greater among participants who were younger (OR=0.97), had some college education or more (OR=2.64 to 4.31), ate a low-fat diet (OR=1.56) and reported better overall health (OR=1.26), p's<.05. Identifying as Hispanic ethnicity (OR=1.80) and White race (OR=3.00) also predicted NAS preference, p's<.05. NAS preference did not differ by gender or psychiatric diagnosis.Study findings indicate greater NAS brand appeal among smokers living with mental illness who are younger, more highly educated, and have a stronger orientation to health, perhaps because they perceive NAS to be a healthier cigarette to smoke. Marketing language that obscures the harms of smoking ought to be prohibited.

    View details for DOI 10.18332/tid/94456

    View details for PubMedID 31210981

    View details for PubMedCentralID PMC6576234

  • Natural American Spirit Brand Marketing Casts Health Halo Around Smoking. American journal of public health Epperson, A. E., Henriksen, L., Prochaska, J. J. 2017; 107 (5): 668-670

    View details for DOI 10.2105/AJPH.2017.303719

    View details for PubMedID 28398789

  • Perceived Physical Appearance: Assessing Measurement Equivalence in Black, Latino, and White Adolescents. Journal of pediatric psychology Epperson, A. E., Depaoli, S., Song, A. V., Wallander, J. L., Elliott, M. N., Cuccaro, P., Tortolero Emery, S., Schuster, M. 2017; 42 (2): 142-152


    This aim of this study was to examine whether the construct of physical appearance perception differed among the three largest racial/ethnic groups in the United States using an adolescent sample.Black (46%), Latino (31%), and White (23%) adolescents in Grade 10 from the Healthy Passages study ( N  = 4,005) completed the Harter's Self-Perception Profile for Adolescents-Physical Appearance Scale (SPPA-PA) as a measure of physical appearance perception.Overall, Black adolescents had a more positive self-perception of their physical appearance than Latino and White adolescents. However, further analysis using measurement invariance testing revealed that the construct of physical appearance perception, as measured by SPPA-PA, was not comparable across the three racial/ethnic groups in both males and females.These results suggest that observed differences may not reflect true differences in perceptions of physical appearance. Measures that are equivalent across racial/ethnic groups should be developed to ensure more precise measurement and understanding.

    View details for DOI 10.1093/jpepsy/jsw047

    View details for PubMedID 27257099

  • The flip side of Natural American Spirit: corporate social responsibility advertising. Tobacco control Epperson, A. E., Prochaska, J. J., Henriksen, L. 2017

    View details for DOI 10.1136/tobaccocontrol-2016-053576

    View details for PubMedID 28237942

  • Associations Among Body Size, Body Image Perceptions, and Weight Loss Attempts Among African American, Latino, and White Youth: A Test of a Mediational Model JOURNAL OF PEDIATRIC PSYCHOLOGY Epperson, A. E., Song, A. V., Wallander, J. L., Markham, C., Cuccaro, P., Elliott, M. N., Schuster, M. A. 2014; 39 (4): 394-404


    Little is known about influences on weight loss attempts, yet about one-half report making such attempts during adolescence. The aim was to examine the relationships among weight loss attempts, body size, and body perception in racially/ethnically diverse young adolescents.3,954 African American, Latino, and White 5th-graders completed the Self-Perception Profile-Physical Appearance Scale and questions regarding body perceptions and past and current weight loss attempts, and had their weight and height measured.Latino youth most often and White youth least often reported weight loss attempts. Larger body size and negative body perception were related to more reported weight loss attempts in White and Latino youth. Body perception mediated the relationship between body size and weight loss attempts for White youth.Motivations to lose weight appear to differ among racial/ethnic groups, suggesting that interventions for healthy weight control in youth may need to target racial/ethnic groups differently.

    View details for DOI 10.1093/jpepsy/jst096

    View details for Web of Science ID 000336206900002

    View details for PubMedID 24424440