Project RESIST: Increasing Resistance to Tobacco Marketing Among Young Adult Sexual Minority Women Using Inoculation Message Approaches
Phase: NA
Conditions: Cigarette Smoking Behavior
Sponsor: Abramson Cancer Center at Penn Medicine

 
 
Cover Page 
 
Project RESIST: Increasing Resistance to Tobacco Marketing Among Young Adult Sexual Minority 
Women Using Inoculation Message Approaches 
 
NCT04812795  
 
Date August 17 2023 
 
 

 
 
PROTOCOL TITLE: Project RESIST – Increasing Resistance to Tobacco Marketing Among Young 
Adult Sexual Minority Women Using Inoculation Message Approaches 
 
INTRODUCTION AND PURPOSE:  
 
This protocol is part of Project RESIST, an R01 study funded by NCI focused on determining the effects 
of using culturally tailored inoculation approaches to increase resilience to tobacco marketing influences 
among young adult sexual minority women ages 18-30 and incorporates critical stakeholder inputs that 
support later adoption and implementation. 
 
Overall objectives 
 
Our long-term goal is to eliminate smoking-related health disparities among LGBTQ populations. The 
objectives of this study are to determine the effects of using a culturally-tailored inoculation approach to 
increase resilience to tobacco marketing influences among young adult sexual minority women (SMW) 
and obtain stakeholders critical inputs that support later adoption and implementation. Our central hypoth-
esis is that culturally tailored inoculation messages will be more effective versus non-tailored messages to 
increase resilience to tobacco marketing.  
 
Specific aims of Project Resist are: 
Aim 1: Engage with key stakeholders to optimize message construction and collect pilot data to inform 
future intervention design. 
Aim 2: Evaluate the effects of culturally tailored anti-smoking messages versus non-tailored messages on 
young adult SMW's smoking and quitting intentions. 
Aim 3: Evaluate the effects of inoculation message type, dose, and latency on young adult SMW's resili-
ence to tobacco marketing, smoking and quitting intentions. 
Supplement: Evaluate the effectiveness of culturally tailored anti-smoking messages with the LGBTQ 
community at large. 
 
This protocol describes Aim 2 of the project which tests the hypotheses that culturally tailored anti-smok-
ing messages that are co-designed with community advisors’ and including LGBTQ+ branding will lead 
to greater increase in intentions to quit smoking (among participants who smoke currently) and greater 
decrease in intentions to purchase cigarettes (among participants who smoke and those who do not 
smoke) at 1-month follow-up compared with identical control messages without LGBTQ+ branding..  
 
Background 
 
US young adult cis-gender sexual minority women, including lesbian and bisexual women, (SMW there-
after) have up to 4.8 times greater odds of cigarette smoking than heterosexual women. Nationally, 
~660,000 young adult SMW who smoke are at risk of smoking-related cancers and illnesses. Factors that 
increase smoking among SMW include tobacco marketing, minority stressors (i.e., victimization, internal-
ized homophobia, and concealment), alcohol and drug use. Prior anti-smoking campaigns utilized inocu-
lation messages that highlight tobacco companies targeted marketing to LGBTQ people to increase re-
sistance against marketing influences, analogous to vaccines conferring immunity against infectious dis-
eases. The inoculation approach is consistent with promoting resilience, defined as the ability to overcome 
significant risks or adversity, to protect LGBTQ populations from factors that in-crease risk behaviors in-
cluding smoking. In addition, culturally-tailored anti-smoking messages (i.e., using LGBTQ-relevant im-
agery, symbols, and language) are more acceptable and may be effective in reducing smoking among 

 
 
LGBTQ young adults. However, effects of cultural tailoring inoculation messages and the optimal mes-
sage type (e.g., focusing on health risks of smoking vs. industry manipulation), dose (i.e., single or multi-
ple doses), and latency of inoculation (i.e., immediate or delayed exposure) for young adult SMW have 
not yet been examined. This knowledge will inform the development of effective counter-marketing inter-
ventions to reduce smoking among young adult SMW. 
 
Significance: 
This study is significant because: 1) young adult SMW are disproportionately impacted by smoking-re-
lated health disparities, 2) tobacco marketing, minority stress, resilience, and social determinants are key 
factors influencing smoking behaviors among young adult SMW, 3) this study addresses a key scientific 
gap in published research on effective culturally tailored and resilience-focused interventions to reduce 
smoking prevalence among young adult SMW specifically, 4) engaging stakeholders in evidence genera-
tion is critical to enhance future intervention adoption and implementation, and 5) the study will advance 
knowledge on the pathways and social and contextual factors associated with smoking and quitting inten-
tions among young adult SMW.  
 
Study Design  
 
The following Figure illustrates the overview of Project Resist’s research inputs, processes, findings, and 
intervention development to provide the foundation for future evidence-based interventions to reduce 
smoking among young adult SMW. We integrated inputs from the Expert Advisory Committee (EAC) 
comprising LGBTQ organization leaders, investigators in sexual and gender minority health, community 
members, and national agencies (NCI, CDC, and FDA), findings from inoculation and cultural tailoring 
research, and existing campaigns. Next, we conducted formative research to design, pretest, and refine 
culturally appropriate messages that were utilized for the survey experiment in Aim 2. We will conduct 
field pilot testing to assess the generalizability of the approach in real-world circumstances and engage 
EAC members collect contextual data to support future work. 
 
 
 
The following section describes the study design of Aim 2 of Project Resist.  
 
 
Existing Literature 
•Inoculation campaigns
•Cultural tailoring
Randomized experiment to 
test inoculation message 
type, dose, and latency 
effects (Aim 3)
Formative Research (Aim 2)
Argument strength and image rating
Message design and pretesting
Eye-tracking
Randomized experiment to 
test cultural tailoring effects 
(Aim 2)
Effectiveness of 
culturally tailored 
messages
Effectiveness of 
inoculation message 
type, dose, and 
latency
Aim 1
Field pilot 
testing
Key 
informant 
interviews 
with EAC
Apply data to multiple 
levels:
•Individual-level 
behavioral change
•Interpersonal e.g., 
healthcare professional 
and peer-led 
intervention
•Policy e.g., local and 
state policies
•Community-level 
health promotion 
•Public health media 
campaigns
Existing Campaigns
•This Free Life
•Tobacco advertisement 
databases e.g., SRITA
•Social media
•LGBTQ magazines and 
publications
External Advisory 
Committee Inputs
(Aim 1)
Inputs
Process
Findings
Intervention 
Development
Future Intervention 
Research
Refine 
messages

 
 
Design 
This study utilized a randomized controlled experiment design. We conducted the experiment using the 
Qualtrics survey platform to assess baseline outcome measures, deliver 20 anti-smoking messages to par-
ticipants in two arms (tailored arm versus control arm) over 4 weeks, and to assess the follow-up outcome 
measures at 1-month.  
 
Study Sample 
Participant recruitment. We recruited participants who were U.S. young adult SMW ages 18-30 years 
between September 2021 and May 2022. Recruitment of this sample were through a combination of an 
online panel (Prolific), The Population Research in Identity and Disparities for Equality (PRIDE) Study,  
social media advertising (Instagram ads), canvassing through LGBTQ+-serving community organiza-
tions’ social media accounts, and advertising on a dating app (HER). The sample was stratified by smok-
ing status such that approximately half were current smokers (at least one cigarette within the past 30 
days) and half did not smoke cigarettes. 
 
Experiment procedure 
Participants were first screened for eligibility (ages 18-30, identify as sexual minority, and identify as 
women). Eligible participants completed questions on their baseline outcome measures and characteristics 
prior to randomization. They were randomly assigned using the Qualtrics built-in randomizer function to 
view either tailored or control messages. We used block randomization to achieve balance across the two 
conditions based on sexual orientation and race/ethnicity. Each participant viewed 5 messages within each 
condition to ensure sufficient exposure. They subsequently answered additional questions on prior health 
campaign exposure, more detailed tobacco use history, and general mental health. Participants received 
invitations to view 5 different messages (delivered via a Qualtrics survey) within their assigned condition 
at 1, 2, and 3 weeks after their baseline survey to reinforce the message exposure. Each participant had the 
potential of viewing up to 20 unique messages during the study period. The order of viewing the sets of 5 
messages across 4 exposures (initial and boosters) and the order of messages within each set were ran-
domized to minimize potential ordering effects. One month after the baseline survey, participants were 
invited to complete a follow-up survey to measure the study outcomes and additional questions on partici-
pants’ characteristics.  
 
Anti-smoking messages  
Prior to this trial, we used an iterative formative research process informed by cultural tailoring ap-
proaches to design and refine anti-smoking messages as outlined in the above Figure. To design the mes-
sages, we selected images that included photographs of young adult women (including individuals who 
self-identified as SMW), graphics depicting the tobacco industry’s targeted marketing among young peo-
ple, and images displaying the negative environmental impacts of cigarette manufacturing and use. These 
images were paired with statements including harms of smoking, benefits of quitting smoking, tobacco 
industry targeting, and environmental impacts. Where appropriate for the topic, we utilized uplifting state-
ments and avoided stigmatizing language about people who smoke. The tailored and control ads utilized 
identical anti-smoking statements and images. The experimental manipulation we assessed consisted of a 
campaign logo using Pride colors and a slogan indicating that the focus of the campaign was on LGBTQ+ 
health and wellness at the bottom of the ads compared with the control ads that used an identical logo in 
yellow and slogans indicating health and wellness as the focus of the campaign.  
 
Outcome Measures 
Intention to quit smoking. We used a 4-item scale on intention to quit smoking at baseline and at one-
month follow-up. Participants were asked to rate 4 statements including “I will make an effort to quit 
smoking in the next 30 days” on 7-point Likert-like scales (e.g., unlikely to likely). Responses were 
summed to create a scale for intention to quit (range from 4-28). Higher values indicate greater intention 

 
 
to quit smoking in the next 30 days. Cronbach’s alpha for this scale was 0.90 at baseline and 0.91 at fol-
low-up. 
 
Intention to purchase cigarettes. We used the Juster scale to measure intention to purchase cigarettes at 
baseline and at one-month follow-up. Participants were asked, “How likely are you to purchase cigarettes 
in the next 6 months?” Responses ranged from 0=No chance, almost no chance (1 in 100) to 10=Certain, 
practically certain (99 in 100). Higher values reflect higher intention to purchase. 
 
Statistical analyses.  
Main treatment effects analyses. We first compared covariate distributions across conditions, stratified by 
smoking status, to evaluate the extent to which randomization was successful. Our main analytic strategy 
was to fit lagged linear regression models to predict follow-up intention variables by experimental condi-
tion, controlling for baseline measures of each outcome, and stratified by smoking status. We report aver-
age differences in follow-up measures by experimental condition and compute 95% confidence intervals 
using a heteroskedastically robust variance estimator (HC2). Having confirmed covariate balance across 
conditions, we present treatment effects without additional covariate adjustment. We analyzed the differ-
ences between follow-up and baseline measures of each outcome in both conditions, stratified by smoking 
status, using paired t-tests. Sensitivity analyses that included additional regression adjustment for covari-
ates did not yield precision improvements of treatment estimates. We conducted sensitivity analyses using 
inverse-probability-of-censoring weighting to account for study attrition, which was well balanced across 
treatment conditions.