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Introduction Mentholated cigarettes are at least as dangerous to an individual's health as non-mentholated varieties. The addition of menthol to cigarettes reduces perceived harshness of smoke, which can facilitate initiation. Here, we examine correlates of menthol use, national trends in smoking menthol and non-menthol cigarettes, and brand preferences over time. Methods We estimated menthol cigarette use during 2004-2010 using annual data on persons ≥12 years old from the National Surveys on Drug Use and Health. We adjusted self-reported menthol status for selected brands that were either exclusively menthol or nonmenthol, based on sales data. Data were weighted to provide national estimates. Results Among cigarette smokers, menthol cigarette use was more common among 12-17 year olds (56.7%) and 18-25 year olds (45.0%) than among older persons (range 30.5% to 34.7%). In a multivariable analysis, menthol use was associated with being younger, female and of non-Caucasian race/ethnicity. Among all adolescents, the percentage who smoked non-menthol cigarettes decreased from 2004-2010, while menthol smoking rates remained constant; among all young adults, the percentage who smoked non-menthol cigarettes also declined, while menthol smoking rates increased. The use of Camel menthol and Marlboro menthol increased among adolescent and young adult smokers, particularly non-Hispanic Caucasians, during the study period. Conclusions Young people are heavy consumers of mentholated cigarettes. Progress in reducing youth smoking has likely been attenuated by the sale and marketing of mentholated cigarettes, including emerging varieties of established youth brands. This study should inform the Food and Drug Administration regarding the potential public health impact of a menthol ban. [ABSTRACT FROM AUTHOR]

Objective Scanty and controversial information is available on the impact of macroeconomic fluctuations on smoking behaviour. No study has quantified the effects of fiscal crises on smoking prevalence. This study aimed to investigate the effects of the 2007-2008 economic crisis on smoking prevalence and number of smokers in the USA. Methods Using data from the repeated Behavioural Risk Factor Surveillance System (BRFSS) surveys in pre-crisis (2005-2007) and post-crisis (2009-2010) periods on a total of 1 981 607 US adults, we separated the expected (after allowance for the demographic growth of the US population, secular smoking prevalence trends and changes in sociodemographic characteristics) from the unexpected (assumed attributable to the economic crisis) changes in the number of smokers across different employment statuses. Results Joinpoint regression analysis revealed no significant changes in smoking prevalence trends over the period 2005-2010. The crisis resulted in an increase in the number of smokers in the US by 0.6 million. This is largely due to an unexpected decrease of 1.7 million smokers among employed and an increase of 2.4 million smokers among unemployed individuals, whose smoking prevalence also remains extremely high in the post-crisis period (32.6%). Conclusions The 2008 financial crisis had a weak effect on smoking prevalence. The pro-cyclical relationship (ie, the crisis results in a lower number of smokers) found among the employed is offset by the counter-cyclical relationship (ie, the crisis results in a higher number of smokers) found among unemployed individuals. Public health interventions should specifically target those in unemployment, particularly in hard times. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To describe relationships between tobacco-related environments and disparities in smoking by sexual orientation. METHODS: We examined three aspects of state-level tobacco environments, which were derived from the ImpacTeen State Level Tobacco Control Policy and Prevalence Database: (1) tobacco price and tax data and tobacco control funding; (2) tobacco control policies and (3) tobacco prevalence and norms data. This information was linked to individual-level data on sexual orientation, tobacco use and nicotine dependence in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (N=34 653; 577 LGB respondents), a cross-sectional, nationally representative survey of adults in the USA. RESULTS: Lesbian, gay and bisexual (LGB) adults in states with more restrictive tobacco environments were less likely to have ever smoked (AOR=0.78, 95% CI 0.62 to 1.00) and to currently smoke (AOR=0.77, 95% CI 0.60 to 0.99) than LGB adults in more permissive tobacco environments. Further, sexual orientation disparities in past and current smoking, as well as in current nicotine dependence, were lower in states with the most restrictive tobacco environments. Results were robust to adjustment for confounders at the individual and state levels. CONCLUSIONS: Restrictive state-level tobacco environments are correlates of smoking behaviours among LGB adults in the USA; such environments could potentially reduce social inequalities in smoking based on sexual orientation. [ABSTRACT FROM AUTHOR]

Background Government agencies, public health organisations and tobacco control researchers rely on accurate estimates of cigarette prices for a variety of purposes. Since the 1950s, the Tax Burden on Tobacco (TBOT) has served as the most widely used source of this price data despite its limitations. Purpose This paper compares the prices and collection methods of the TBOT retail-based data and the 2003 and 2006/2007 waves of the population-based Tobacco Use Supplement to the Current Population Survey (TUS-CPS). Methods From the TUS-CPS, we constructed multiple state-level measures of cigarette prices, including weighted average prices per pack (based on average prices for single-pack purchases and average prices for carton purchases) and compared these with the weighted average price data reported in the TBOT. We also constructed several measures of tax avoidance from the TUS-CPS self-reported data. Results For the 2003 wave, the average TUS-CPS price was 71 cents per pack less than the average TBOT price; for the 2006/2007 wave, the difference was 47 cents. TUS-CPS and TBOT prices were also significantly different at the state level. However, these differences varied widely by state due to tax avoidance opportunities, such as cross-border purchasing. Conclusions The TUS-CPS can be used to construct valid measures of cigarette prices. Unlike the TBOT, the TUS-CPS captures the effect of price-reducing marketing strategies, as well as tax avoidance practices and non-traditional types of purchasing. Thus, self-reported data like TUS-CPS appear to have advantages over TBOT in estimating the 'real' price that smokers face. [ABSTRACT FROM AUTHOR]

Objective This paper examines trends in cigarette prices and corresponding purchasing patterns over a 9-year period and explores characteristics associated with the quantity and location of cigarettes purchased by adult smokers in the USA. Methods The data for this paper come from a nationally representative longitudinal survey of 6669 adult smokers (18 years and older) who were recruited and surveyed between 2002 and 2011. Telephone interviews were conducted annually, and smokers were asked a series of questions about the location, quantity (ie, single vs multiple packs or cartons) and price paid for their most recent cigarette purchase. Generalised estimating equations were used to assess trends and model characteristics associated with cigarette purchasing behaviours. Results Between 2002 and 2011, the reported purchase of cigarette cartons and the use of coupons declined while multipack purchases increased. Compared with those purchasing by single packs, those who purchased by multipacks and cartons saved an average of $0.53 and $1.63, respectively. Purchases in grocery and discount stores declined, while purchases in tobacco only outlets increased slightly. Female, older, white smokers were more likely to purchase cigarettes by the carton or in multipacks and in locations commonly associated with tax avoidance (ie, duty free shops, Indian reservations). Conclusions As cigarette prices have risen, smokers have begun purchasing via multipacks instead of cartons. As carton sales have declined, purchases from grocery and discount stores have also declined, while an increasing number of smokers report low tax sources as their usual purchase location for cigarettes. [ABSTRACT FROM AUTHOR]

Objective Following aneurysmal subarachnoid hemorrhage, cerebral vasospasm/delayed cerebral ischemia accounts for significant morbidity and mortality. In this paper we provide the first glimpse of actual practice in the management of cerebral vasospasm in the USA. Methods All active members of the Joint American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Cerebrovascular Section were emailed the survey. The responses were collected anonymously. Results The response rate for this survey was 44% (177 responses/400 total members). Non-responders were characterized by the fact that multiple responders were not obtained from practices that had multiple providers with uniform practice. Both high-volume and low-volume centers were equally represented. Optimizing medical management is first-line treatment in practice. Although there is some variability regarding screening methods, the greatest variability occurs with regard to the choice of intra-arterial treatment drug and dose. There is also considerable variability in the perceived effectiveness of endovascular treatment for vasospasm. Conclusions In this preliminary glimpse of actual cerebral vasospasm management practice in the USA, two salient points emerge: (1) there is considerable variability in intra-arterial therapies for vasospasm; and (2) there are major differences in the perceived effectiveness of these therapies. Standardization of intra-arterial therapies may contribute to improved outcomes. A prospective randomized trial evaluating endovascular treatment for cerebral vasospasm is needed. [ABSTRACT FROM AUTHOR]

Background A growing number of smokers support smoke-free laws. The theory of self-control provides one possible explanation for why smokers support laws that would restrict their own behaviour: the laws could serve as a self-control device for smokers who are trying to quit. Objective To test the hypothesis that support for smoke-free laws predicts smoking cessation. Methods We used longitudinal data (1999-2000) from a US national sample of adult smokers (n=6415) from the Current Population Survey, Tobacco Use Supplements. At baseline, smokers were asked whether they made a quit attempt in the past year. They were also asked whether they thought smoking should not be allowed in hospitals, indoor sporting events, indoor shopping malls, indoor work areas, restaurants, or bars and cocktail lounges. At 1-year follow-up, smokers were asked whether they had quit smoking. Findings Smokers who supported smoke-free laws were more likely to have made a recent quit attempt. At 1-year follow-up, those who supported smoke-free laws in 4-6 venues were more likely to have quit smoking (14.8%) than smokers who supported smoke-free laws in 1-3 venues (10.6%) or smokers who supported smoke-free laws in none of the venues (8.0%). These differences were statistically significant in multivariate analyses controlling for demographics. Conclusions Support for smoke-free laws among smokers correlates with past quit attempts and predicts future quitting. These findings are consistent with the hypothesis that some smokers support smoke-free laws because the laws could help them quit smoking. [ABSTRACT FROM AUTHOR]

Objective In this study, we used human factors (HF) methods and principles to design a clinical decision support (CDS) that provides cognitive support to the pulmonary embolism (PE) diagnostic decision-making process in the emergency department. We hypothesised that the application of HF methods and principles will produce a more usable CDS that improves PE diagnostic decision-making, in particular decision about appropriate clinical pathway. Materials and methods We conducted a scenario-based simulation study to compare a HF-based CDS (the so-called CDS for PE diagnosis (PE-Dx CDS)) with a web-based CDS (MDCalc); 32 emergency physicians performed various tasks using both CDS. PE-Dx integrated HF design principles such as automating information acquisition and analysis, and minimising workload. We assessed all three dimensions of usability using both objective and subjective measures: effectiveness (eg, appropriate decision regarding the PE diagnostic pathway), efficiency (eg, time spent, perceived workload) and satisfaction (perceived usability of CDS). Results Emergency physicians made more appropriate diagnostic decisions (94% with PE-Dx; 84% with web-based CDS; p<0.01) and performed experimental tasks faster with the PE-Dx CDS (on average 96 s per scenario with PE-Dx; 117 s with web-based CDS; p<0.001). They also reported lower workload (p<0.001) and higher satisfaction (p<0.001) with PE-Dx. Conclusions This simulation study shows that HF methods and principles can improve usability of CDS and diagnostic decision-making. Aspects of the HF-based CDS that provided cognitive support to emergency physicians and improved diagnostic performance included automation of information acquisition (eg, auto-populating risk scoring algorithms), minimisation of workload and support of decision selection (eg, recommending a clinical pathway). These HF design principles can be applied to the design of other CDS technologies to improve diagnostic safety. [ABSTRACT FROM AUTHOR]

The article discusses a survey on smokers that assessed if the relationship between beliefs and smoking behaviors was in consistent with Cognitive Dissonance Theory. It included adult smokers from Canada, U.S., Great Britain and Australia. The findings revealed that smokers with no intetion of quitting across the three waves, were inclined towards the highest levels of rationalizations for smoking. It suggests studies to determine if the change in beliefs has any effect on intentions to quit.

Background Secondhand smoke (SHS) likely provides additional exposure to nicotine and toxins for smokers, but has been understudied. Our objective was to determine whether SHS exposure among smokers yields detectable differences in cotinine levels compared with unexposed smokers at the population level. Methods Using the US National Health and Nutrition Examination Survey (NHANES) for the years 1999-2012, we compared serum cotinine levels of 4547 current adult cigarette smokers stratified by self-reported SHS exposure sources (home and/or work) and smoking intensity. A weighted multivariable linear regression model determined the association between SHS exposure and cotinine levels among smokers. Results Smokers with SHS exposure at home (43.8%) had higher cotinine levels (β=0.483, p≤0.001) compared with those with no SHS exposure at home after controlling for the number of cigarettes smoked per day and number of days smoked in the previous 5 days, survey year, age, gender and education. Smokers with SHS exposure at work (20.0%) did not have significantly higher cotinine levels after adjustment. The adjusted geometric mean cotinine levels of light smokers (1-9 cigarettes per day) with no SHS exposure, exposure at work only, home only, and both home and work were 52.0, 62.7, 67.2, 74.4 ng/mL, respectively, compared with 219.4, 220.9, 255.2, 250.5 ng/mL among moderate/heavy smokers (≥10 cigarettes per day). Conclusions Smokers living in residences where others smoke inside the home had significantly higher cotinine levels than smokers reporting no SHS exposure, regardless of individual smoking intensity. Future research should target the role that SHS exposure may have in nicotine dependence, cessation outcomes and other health impacts among smokers. [ABSTRACT FROM AUTHOR]

Objective To assess the extent to which multiple tobacco product use among adolescents and young adults falls outside current Food and Drug Administration (FDA) regulatory authority. Methods We conducted a web-based survey of 1596 16-26-year-olds to assess use of 11 types of tobacco products. We ascertained current (past 30 days) tobacco product use among 927 respondents who ever used tobacco. Combustible tobacco products included cigarettes, cigars (little filtered, cigarillos, premium) and hookah; non-combustible tobacco products included chew, dip, dissolvables, e-cigarettes, snuff and snus. We then fitted an ordinal logistic regression model to assess demographic and behavioural associations with higher levels of current tobacco product use (single, dual and multiple product use). Results Among 448 current tobacco users, 54% were single product users, 25% dual users and 21% multiple users. The largest single use category was cigarettes (49%), followed by hookah (23%), little filtered cigars (17%) and e-cigarettes (5%). Most dual and multiple product users smoked cigarettes, along with little filtered cigars, hookah and e-cigarettes. Forty-six per cent of current single, 84% of dual and 85% of multiple tobacco product users consumed a tobacco product outside FDA regulatory authority. In multivariable analysis, the adjusted risk of multiple tobacco use was higher for males, first use of a non-combustible tobacco product, high sensation seeking respondents and declined for each additional year of age that tobacco initiation was delayed. Conclusions Nearly half of current adolescent and young adult tobacco users in this study engaged in dual and multiple tobacco product use; the majority of them used products that fall outside current FDA regulatory authority. This study supports FDA deeming of these products and their incorporation into the national media campaign to address youth tobacco use. [ABSTRACT FROM AUTHOR]

Background and aims Smoke-free psychiatric hospitalisation provides opportunity for initiating tobacco cessation treatment. The current study reports on psychiatric patients' interest in continuing nicotine replacement therapy (NRT) posthospitalisation and examines patient predictors of NRT requests, quit attempts and abstinence at 1-week follow-up. Methods Daily smokers were recruited and interviewed on locked psychiatric units at three smoke-free San Francisco Bay Area hospitals. Intent to quit smoking was not required to participate and 73% of eligible smokers enrolled. Analyses focused on 816 participants (49% female) randomised to interventions providing counselling tailored to readiness to quit with availability of NRT posthospitalisation. Logistic regressions tested demographic, smoking and psychiatric factors predictive of NRT requests, quit attempts and abstinence 1-week postdischarge. Results Participants averaged 17 (SD=10) cigarettes/ day for an average of 19 (SD=14) years. Most (88%) requested study-provided NRT (74% right at discharge). Participants preparing to quit and those with more severe psychiatric symptoms were more likely to request NRT at discharge (p<0.01). Those with more severe psychiatric symptoms also were more likely to request NRT refill, as were older participants (p<0.05). Participants who requested NRT at discharge were more likely to make a 24 h quit attempt and self-report abstinence at the 1-week follow-up (54% quit attempt, 14% abstinent) than participants who did not (25% quit attempt, 4% abstinent) (p<0.05). Conclusions The great demand for NRT and the association between NRT use with quit attempts and abstinence at 1-week posthospitalisation supports adoption of tobacco treatment in acute psychiatric settings. Trial registration number # NCT00968513. [ABSTRACT FROM AUTHOR]

Objective Regulations that reduce nicotine and eliminate menthol in cigarettes have been proposed to the US Food and Drug Administration (FDA) as product alterations that could reduce smoking prevalence in the USA. This study sought to assess the public response to either action. Methods A mail survey of a representative sample of 1074 adults was conducted in two major metropolitan areas to determine the level of support for immediate, gradual or no reduction of menthol and nicotine in cigarettes. Results There was more support for reducing nicotine (79%) than for reducing or removing menthol (59.5%). Most smokers (59.2%; 95% CI 50.7 to 67.2) and 36% of non-smokers (95% CI 31.7 to 40.8) opposed eliminating menthol, but few smokers (23.8%) or nonsmokers (20.3%) were opposed to reducing nicotine. Logistic regression showed no significant effect of smoking status on support for reductions in nicotine, but that smokers were significantly less supportive than nonsmokers of FDA action on menthol (OR=0.32, 95% CI 0.21 to 0.49). A significant race by smoking status interaction showed that African-American smokers were more supportive of removing menthol than non-African-American smokers. Conclusions The greater smoker support for reductions in nicotine than menthol could be due to inaccurate beliefs about the disease risk associated with the two substances (ie, a belief that nicotine is more harmful than menthol), or to greater awareness of the sensory role that menthol plays in smokers' satisfaction. In any case, if FDA goes ahead with regulations to remove menthol, it will be important to develop strategies to reduce smoker resistance. [ABSTRACT FROM AUTHOR]

Background Google Trends is an innovative monitoring system with unique potential to monitor and predict important phenomena that may be occurring at a population level. We sought to validate whether Google Trends can additionally detect regional trends in youth and adult tobacco use. Methods We compared 2011 Google Trends relative search volume data for cigars, cigarillos, little cigars and smokeless tobacco with state prevalence of youth (grades 9-12) and adult (age 18 and older) use of these products using data from the 2011 United States state-level Youth Risk Behaviors Surveillance System and the 2010-2011 United States National Survey on Drug Use and Health (NSDUH), respectively. We used the Pearson correlation coefficient to measure the associations. Results We found significant positive correlations between state Google Trends cigar relative search volume and prevalence of cigar use among youth (r=0.39, R² = 0.154, p=0.018) and adults (r=0.49, R² = 0.243, p<0.001). Similarly, we found that the correlations between state Google Trends smokeless tobacco relative search volume and prevalence of smokeless tobacco use among youth and adults were both positive and significant (r=0.46, R² = 0.209, p=0.003 and r=0.48, R² = 0.226, p<0.001, respectively). Conclusions The results of this study validate that Google Trends has the potential to be a valuable monitoring tool for tobacco use. The near real-time monitoring features of Google Trends may complement traditional surveillance methods and lead to faster and more convenient monitoring of emerging trends in tobacco use. [ABSTRACT FROM AUTHOR]

Background Cigarette price increases have been associated with increases in smoking cessation, but relatively little is known about this relationship at the level of individual smokers. To address this and to inform tax policy, the goal of this study was to apply a behavioural economic approach to the relationship between the price of cigarettes and the probability of attempting smoking cessation. Methods Adult daily smokers (n=1074; ie, 5+ cigarettes/day; 18+ years old; ≥8th grade education) completed in-person descriptive survey assessments. Assessments included estimated probability of making a smoking cessation attempt across a range of cigarette prices, demographics and nicotine dependence. Results As price increases, probability of making a smoking cessation attempt exhibited an orderly increase, with the form of the relationship being similar to an inverted demand curve. The largest effect size increases in motivation to make a quit attempt were in the form of ‘left-digit effects,' (ie, maximal sensitivity across pack price whole-number changes; eg, US$5.80-6/pack). Significant differences were also observed among the left-digit effects, suggesting the most substantial effects were for price changes that were most market relevant. Severity of nicotine dependence was significantly associated with price sensitivity, but not for all indices. Conclusions These data reveal the clear and robust relationship between the price of cigarettes and an individual's motivation to attempt smoking cessation. Furthermore, the current study indicates the importance of left-digit price transitions in this relationship, suggesting policymakers should consider relative price positions in the context of tax changes. [ABSTRACT FROM AUTHOR]

Background In the USA, tobacco marketing expenditure is increasingly concentrated at the point of sale (POS). Previous studies have demonstrated an association between exposure to tobacco POS advertising and increased smoking initiation, but limited evidence is available on adult smokers' decisions and behaviours. Methods An immediate post-cigarette purchase survey was administered to 301 cigarette purchasers outside of two grocery stores in Vermont to assess the prevalence of unplanned purchases and opinions about POS tobacco advertising and displays. Results In total, 11.3% of purchases were reported as unplanned. Certain groups were more likely to make unplanned purchases including: 18-24-year-olds (OR: 2.1, 95% CI 1.0 to 4.4), less than daily smokers (OR: 5.6, 95% CI 1.9 to 16.9), smokers who made 3+ quit attempts in the previous year (OR: 2.4, 95% CI 0.9 to 6.0), those who plan to quit in the next month (OR: 3.7, 95% CI 1.6 to 9.0), and those who agreed that tobacco POS advertising makes quitting smoking harder (OR: 2.3, 95% CI 1.1 to 4.8). Overall, 31.2% of participants agreed that tobacco POS advertising makes quitting smoking harder. Individuals who intended to quit within the next month, made 3+ quit attempts in the last year, or made an unplanned cigarette purchase were the most likely to agree. Conclusions Young adults and individuals making multiple quit attempts or planning to quit in the next month are more likely to make unplanned cigarette purchases. Reducing unplanned purchases prompted by tobacco POS advertising could improve the likelihood of successful cessation among smokers. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effectiveness of the US Navy and Marine Corps tobacco policy in protecting submariners from secondhand smoke (SHS) by determining if non-tobacco users experienced a significant increase in urinary cotinine levels at sea when compared with in port levels. Methods From February to August 2009, 634 volunteers recruited from nine US Navy submarines completed a survey to collect demographic data, information on tobacco use and pre-deployment exposure to SHS. Non-tobacco users (n¼239) were requested to provide two urine samples (pre-deployment and while at sea) to quantify exposure to SHS using urinary cotinine as a biomarker. Matched samples were analysed using liquid chromatographyetandem mass spectrometry. Results Overall, deployed cotinine levels were 2.1 times the in port levels in non-tobacco using submariners (95% CI 1.8 to 2.4, p<0.001, n¼197). A significant increase in deployed urinary cotinine levels was found aboard six of nine submarines (p<0.05). A subgroup of submariners (n¼91) who reported no SHS exposure within 10 days prior to in port cotinine sampling had deployed cotinine levels 2.7 times the in port levels (95% CI 2.2 to 3.3, p<0.001). Applying a 4.5:1 urine cotinine to serum cotinine correction factor, submariners’ deployed geometric means are similar to recent US male population values at the 75th percentile. Conclusions This study provides evidence that nontobacco using submariners were exposed to SHS. Exposure was seen in all submarine classes and was not limited to personnel working in proximity to the smoking area. The existing policy was inadequate to protect nonsmokers from exposure to SHS and required revision. As a result of a policy review, informed by this study, smoking below decks was banned aboard all US Navy submarines effective 31 December 2010. [ABSTRACT FROM AUTHOR]

Objective: Young adults in the USA have one of the highest smoking prevalence rates of any age group, and young adulthood is a critical time period of targeting by the tobacco industry. The authors examined relationships between potential exposure to tobacco-related media campaigns from a variety of sponsors and 2-year smoking change measures among a longitudinal sample of US adults aged 20-30 years from 2001 to 2008. Methods: Self-report data were collected from a longitudinal sample of 12 931 US young adults from age 20 to 30. These data were merged with tobacco-related advertising exposure data from Nielsen Media Research. Two-year measures of change in smoking were regressed on advertising exposures. Results: Two-year smoking uptake was unrelated to advertising exposure. The odds of quitting among all smokers and reduction among daily smokers in the 2 years between the prior and current survey were positively related to anti-tobacco advertising, especially potential exposure levels of 104-155 ads over the past 24 months. Tobacco company advertising (including corporate image and anti-smoking) and pharmaceutical industry advertising were unrelated to quitting or reduction. Conclusion: Continued support for sustained, public health-based well-funded anti-tobacco media campaigns may help reduce tobacco use among young adults. [ABSTRACT FROM AUTHOR]

Purpose This study utilises an ecological design to analyse the relation between concurrent temporal trends in sudden infant death syndrome (SIDS) rates and prevalence of smoke-free households with infants in the USA, controlling for an important risk factor, infant supine sleep position. Methods Annual state-specific SIDS cases were computed using period linked birth/infant death files; the prevalence of 100% smoke-free homes with infants using Tobacco Use Supplement to the Current Population Survey data, and percentage of infants in supine sleep position from National Infant Sleep Position data, for years 1995-2006. Incidence rate ratios relating trends in SIDS cases and risk factors were determined using time-series negative binomial regression. Population-level health effects were assessed with secondhand smoke (SHS) exposure population attributable fractions and excess attributable SIDS deaths. Results For every 1% absolute increase in the prevalence of smoke-free homes with infants, SIDS rates decreased 0.4% from 1995 to 2006, controlling for supine sleep position. Nationally, it is possible that 20% of the 1326 total SIDS cases were attributable to childhood SHS exposure at home in 2006 with potentially 534 fewer infant deaths attributable to SHS exposure in 2006 than in 1995, owing to an increasing prevalence of 100% smoke-free homes with infants. Cumulatively, 4402 (lower 95% CI) to 6406 (upper 95% CI) excess SIDS cases may have been attributable to SHS exposure in the home over the 12-year study period. Conclusions The uptake of voluntary restrictions on smoking inside the home may present a public health benefit for infants in their first year of life. In light of inherent ecological study design limitations, these results warrant further individual level research linking postnatal SHS exposure and SIDS. [ABSTRACT FROM AUTHOR]

Background Little is known about patient/family comfort voicing care concerns in real time, especially in the intensive care unit (ICU) where stakes are high and time is compressed. Experts advocate patient and family engagement in safety, which will require that patients/families be able to voice concerns. Data on patient/family attitudes and experiences regarding speaking up are sparse, and mostly include reporting events retrospectively, rather than pre-emptively, to try to prevent harm. We aimed to (1) assess patient/family comfort speaking up about common ICU concerns; (2) identify patient/family-perceived barriers to speaking up; and (3) explore factors associated with patient/family comfort speaking up. Methods In collaboration with patients/families, we developed a survey to evaluate speaking up attitudes and behaviours. We surveyed current ICU families in person at an urban US academic medical centre, supplemented with a larger national internet sample of individuals with prior ICU experience. Results 105/125 (84%) of current families and 1050 internet panel participants with ICU history completed the surveys. Among the current ICU families, 50%-70% expressed hesitancy to voice concerns about possible mistakes, mismatched care goals, confusing/conflicting information and inadequate hand hygiene. Results among prior ICU participants were similar. Half of all respondents reported at least one barrier to voicing concerns, most commonly not wanting to be a 'troublemaker', 'team is too busy' or 'I don't know how'. Older, female participants and those with personal or family employment in healthcare were more likely to report comfort speaking up. Conclusion Speaking up may be challenging for ICU patients/families. Patient/family education about how to speak up and assurance that raising concerns will not create 'trouble' may help promote open discussions about care concerns and possible errors in the ICU. [ABSTRACT FROM AUTHOR]

Objective: The role of diet in multiple sclerosis (MS) course remains largely unknown. Children with MS have a higher relapse rate compared with MS in adults. Thus, studying the effect of diet on relapse rate in this age group is likely to provide more robust answers.Methods: This is a multicentre study done at 11 paediatric MS centres in the USA. Patients with relapsing-remitting MS (RRMS) or clinically isolated syndrome (CIS) with disease onset before 18 years of age and duration of less than 4 years were included in this study. Dietary intake during the week before enrolment was assessed with the validated Block Kids Food Screener. The outcome of the study was time from enrolment to the next relapse. 219 patients with paediatric RRMS or CIS were enrolled. Each 10% increase in energy intake from fat increased the hazard of relapse by 56% (adjusted HR 1.56, 95% CI 1.05 to 2.31, p=0.027), and in particular each 10% increase in saturated fat tripled this hazard (adjusted HR: 3.37, 95% CI 1.34 to 8.43, p=0.009). In contrast, each additional one cup equivalent of vegetable decreased the hazard of relapse by 50% (adjusted HR: 0.50, 95% CI 0.27 to 0.91, p=0.024). These associations remained with mutual adjustment and persisted when adjusting for baseline 25(OH) vitamin D serum level. Other studied nutrients were not associated with relapse.Conclusions: This study suggests that in children with MS, high energy intake from fat, especially saturated fat, may increase the hazard to relapse, while vegetable intake may be independently protective. [ABSTRACT FROM AUTHOR]

Background Improving the resiliency of healthcare workers is a national imperative, driven in part by healthcare workers having minimal exposure to the skills and culture to achieve work--life balance (WLB). Regardless of current policies, healthcare workers feel compelled to work more and take less time to recover from work. Satisfaction with WLB has been measured, as has work--life conflict, but how frequently healthcare workers engage in specific WLB behaviours is rarely assessed. Measurement of behaviours may have advantages over measurement of perceptions; behaviours more accurately reflect WLB and can be targeted by leaders for improvement. Objectives 1. To describe a novel survey scale for evaluating work--life climate based on specific behavioural frequencies in healthcare workers. 2. To evaluate the scale's psychometric properties and provide benchmarking data from a large healthcare system. 3. To investigate associations between work-life climate, teamwork climate and safety climate. Methods Cross-sectional survey study of US healthcare workers within a large healthcare system. Results 7923 of 9199 eligible healthcare workers across 325 work settings within 16 hospitals completed the survey in 2009 (86% response rate). The overall work-life climate scale internal consistency was Cronbach &#945=0.790. t-Tests of top versus bottom quartile work settings revealed that positive work-life climate was associated with better teamwork climate, safety climate and increased participation in safety leadership WalkRounds with feedback (p<0.001). Univariate analysis of variance demonstrated differences that varied significantly in WLB between healthcare worker role, hospitals and work setting. Conclusions The work-life climate scale exhibits strong psychometric properties, elicits results that vary widely by work setting, discriminates between positive and negative workplace norms, and aligns well with other culture constructs that have been found to correlate with clinical outcomes. [ABSTRACT FROM AUTHOR]

Objectives The vast majority of tobacco users began before the age of 21. Raising the tobacco sales age to 21 has the potential to reduce tobacco use initiation and progression to regular smoking. Our objective was to assess the level of public support nationally for 'Tobacco 21' initiatives in the USA. Methods The Social Climate Survey of Tobacco Control, a cross-sectional dual-frame survey representing national probability samples of adults was administered in 2013. Respondents were asked to state their agreement level with, 'The age to buy tobacco should be raised to 21.' Results Of 3245 respondents, 70.5% support raising the age to buy tobacco to 21. The majority of adults in every demographic and smoking status category supported raising the tobacco sales age to 21. In multivariable analyses, support was highest among never smokers, females, African-Americans and older adults. Conclusions This national study demonstrates broad public support for raising the sales age of tobacco to 21 and will help facilitate wide dissemination of initiatives to increase the legal purchase age at national, state and local levels. Increasing public awareness about the susceptibility and rapid addiction of youth to nicotine may further increase public support for raising the tobacco sale age to 21. [ABSTRACT FROM AUTHOR]

Introduction A recent report showed that 13.1% of US middle and high school students were exposed to tobacco coupons in the past 30 days in 2012. The current study reanalysed data from the National Youth Tobacco Survey 2012 to examine the associations between exposure to tobacco coupons in the past 30 days and predictors of smoking among US youth, by smoking status. Methods 24 658 middle and high school students were asked if and where they had received tobacco coupons in the past 30 days. Demographics, smoking behaviours, smoking-related beliefs, susceptibility to smoking and confidence in quitting smoking were assessed. Analyses were stratified by smoking status (never smokers, experimenters and current smokers). Data were weighted to be representative of the US youth. Results Exposure to tobacco coupons was associated with lower likelihood of denying the social benefits of cigarette smoking and believing all tobacco products are dangerous; higher likelihood of being susceptible to smoking (among never smokers); lower likelihood to feel confident in quitting cigarettes completely (among current smokers); and higher likelihood to intend to purchase cigarettes in the next 30 days (among experimenters and current smokers; p<0.05). Conclusions Tobacco coupons may promote smoking and hinder smoking cessation among youth. Regulating tobacco coupons may reduce youth smoking in the USA. Further research is needed to determine the effect of tobacco coupons on youth tobacco use globally. [ABSTRACT FROM AUTHOR]

Objectives We assessed the comparability of self-reported smoking prevalence estimates from a dual-frame survey with those from two large-scale, national surveys. Methods The Social Climate Survey of Tobacco Control (SCS-TC) obtained self-reported current smoking status via a dual-frame methodology in the fall of 2010. One frame used random digit dialling procedures and consisted of households with a landline telephone; the other frame consisted of a population-based probability-based online panel. Current smoking prevalence was compared with national estimates from the 2010 National Health Interview Survey (NHIS) and the 2009-2010 National Health and Nutrition Examination Survey (NHANES). Results 18.3% (95% CI 17.0% to 19.6%) of SCS-TC respondents reported current smoking. NHIS and NHANES estimates found 19.4% (95% CI 18.8% to 20.1%) and 20.3% (95% CI 18.7% to 22.1%), respectively, reporting current smoking. Conclusions Prevalence estimates for cigarette smoking obtained from the dual-frame SCS-TC are comparable to those from other national surveys. A mixed-mode approach may be a useful strategy to transition cross-sectional surveys with established trend data to newer dual-frame designs to maintain compatibility with surveys from previous years and to include the growing number of households that do not have landline telephones. [ABSTRACT FROM AUTHOR]

Background Childhood poverty is positively correlated with overweight status during childhood, adolescence and adulthood. Repeated exposure of childhood poverty could contribute to race/ethnicity and gender disparities in young adult overweight/obese (OV/OB) weight status. Methods Young adults born between 1980 and 1990 who participated in the Young Adult file of the 1979 National Longitudinal Study of Youth were examined (N=3901). The accumulation of childhood poverty is captured via poverty exposure from each survey year from the prenatal year through age 18 years. Body mass index was calculated and categorised into the reference criteria for adults outlined by the Center for Disease Control. Logistic regression models were stratified by race/ethnicity and included a term interacting poverty and gender, along with a number of covariates, including various longitudinal socioeconomic status measures and indicators for the intergenerational transmission of economic disadvantage and body weight. Results Reoccurring exposure to childhood poverty was positively related to OV/OB for white, black and Hispanic young adult women and inversely related for white young adult men. A direct relationship between the accumulation of childhood poverty and OV/OB was not found for black and Hispanic young adult men. Conclusions Helping families move out of poverty may improve the long-term health status of white, black and Hispanic female children as young adults. Community area interventions designed to change impoverished community environments and assist low-income families reduce family level correlates of poverty may help to reduce the weight disparities observed in young adulthood. [ABSTRACT FROM AUTHOR]

Background Few studies have examined the degree to which racial disparities in the development of diabetes are accounted by differences in lifecourse socioeconomic position (SEP). We assessed the association between race, lifecourse SEP measures and prevalence of diabetes in a representative US sample of black and white adults. Methods A generalised estimating equations approach was used with a sample of 3497 adults from the Americans' Changing Lives study. Sex-specific models were calculated to compute prevalence ratios (PR) for associations of race and SEP with self-reported diagnoses of diabetes. Results For men, childhood and adult SEP were unrelated to diabetes, and adjustment for lifecourse SEP had little effect on the excess diabetes in blacks (PR=1.56, 95% CI 1.11 to 2.21). Adjustment for measures of lifecourse SEP reduced the PR for the association between race and diabetes in women from 1.96 (95% CI 1.52 to 2.54) to 1.40 (95% CI 1.04 to 1.87) with the respondent's education responsible for most of the reduction in the association. However, diabetes was also inversely associated with father's education, and low SEP throughout the lifecourse was associated with a nearly threefold increase in diabetes (PR=2.89, 95% CI 2.10 to 3.99). Conclusions Racial disparities in diabetes existed among both men and women, but lifecourse SEP was related to diabetes only among women. The pathway and cumulative hypotheses for lifecourse SEP effects on diabetes may be especially salient for women. [ABSTRACT FROM AUTHOR]

Background The adoption of healthier behaviours has been hypothesised as a mechanism to explain empirical findings of population health improvements during some economic downturns. Methods We estimated the effect of the local unemployment rate on health behaviours using pooled annual surveys from the 2003-2010 Behavioral Risk Factor Surveillance Surveys, as well as population-based telephone surveys of the US adult general population. Analyses were based on approximately 1 million respondents aged 25 years or older living in 90 Metropolitan Statistical Areas and Metropolitan Divisions (MMSAs). The primary exposure was the quarterly MMSA-specific unemployment rate. Outcomes included alcohol consumption, smoking status, attempts to quit smoking, body mass index, overweight/obesity and past month physical activity or exercise. Results The average unemployment rate across MMSAs increased from a low of 4.5% in 2007 to a high of 9.3% in 2010. In multivariable models accounting for individual-level sociodemographic characteristics and MMSA and quarter fixed effects, a one percentage-point increase in the unemployment rate was associated with 0.15 (95% CI -0.31 to 0.01) fewer drinks consumed in the past-month and a 0.14 (95% CI -0.28 to 0.00) percentage-point decrease in the prevalence of past-month heavy drinking; these effects were driven primarily by men. Changes in the unemployment rate were not consistently associated with other health behaviours. Although individual-level unemployment status was associated with higher levels of alcohol consumption, smoking and obesity, the MMSA-level effects of the recession were largely invariant across employment groups. Conclusions Our results do not support the hypothesis that health behaviours mediate the effects of local-area economic conditions on mortality. [ABSTRACT FROM AUTHOR]

Background Firearms may be obtained illegally from federally-licensed dealers and pawnbrokers through surrogate (straw) purchases, undocumented purchases and theft. Some retailers knowingly make illegal sales. Objective To obtain information about the frequency of and risk factors for these events, and retailers' reactions to them, directly from licensed retailers. Methods Survey of a random sample of 1601 licensed dealers and pawnbrokers in 43 states who were believed to sell ≥50 firearms annually, conducted by mail during June.August 2011. Results The response rate was 36.9%, typical of establishment surveys using such methods. In the preceding year, 67.3% of respondents experienced attempted straw purchases; 42.4% experienced undocumented purchase attempts. For each event, 10% reported ≥1 occurrence/month. A quarter (25.6%) experienced firearm theft in the preceding 5 years. Pawnbroker status, sales volume, denied sales and sales of firearms that were subsequently traced by law enforcement were associated with all outcomes in multivariate analysis. Estimates of retailer involvement in illegal sales (median 3%, IQR 1-10%) were related in multivariate analysis to respondents' age and sex, and to denied sales. In a hypothetical case involving 50 illegal sales, respondents recommended prolonged incarceration (median 10 years, IQR 5-20 years) and a substantial fine (median $50 000, IQR $10 000-$250 000) for retailers and made similar recommendations for buyers. Conclusions Attempts to acquire firearms illegally from licensed dealers and pawnbrokers are common. Characteristics associated with frequency of occurrence may facilitate prevention efforts. Licensed retailers consider selling and buying firearms illegally to be serious crimes. [ABSTRACT FROM AUTHOR]

The article reports a study which discussed whether initial low energy permissive underfeeding compared with full calorie enteral feeding in the intensive care unit affect physical function and other physical, psychological, and cognitive outcomes in patients with acute lung injury. The results revealed that there is no difference between the two feeding regimens in physical function, survival, or psychological, and cognitive outcomes at six and 12 month follow-up.

Objectives This study estimates the relative contribution of policies implemented between 1998 and 2010 to reductions in smoking prevalence by 2010. It then models the impact of implementing stronger policies, relative to a scenario of inaction, on smoking prevalence and smoking-attributable mortality in Ireland. Methods IrelandSS is an adapted version of SimSmoke, a dynamic simulation model used to examine the effect of tobacco control policies on smoking prevalence, through initiation and cessation, and associated future premature mortality. Results Model predictions for smoking prevalence are reasonably close to those from surveys. As a result of tobacco control policies implemented between 1998 and 2010, there was a 22% relative reduction in smoking prevalence and 1716 fewer smoking-attributable deaths (SADs) by 2010 increasing to a 29% relative reduction in prevalence and 50 215 fewer SADs by 2040. With the introduction of stricter FCTC-compliant policies in 2011, the smoking prevalence can be decreased by as much as 13% initially, increasing to 28% by 30 years. With these stronger policies, a total of 24 768 SADs will be averted by 2040. Conclusions Predictions from the IrelandSS model suggest that policies implemented between 1998 and 2010 have had considerable effect; however, appreciable reductions in smoking prevalence and SADs can still be achieved through increasing taxes, maintaining a high-intensity tobacco control media campaign, introducing graphic health warnings and improving smoking cessation services. [ABSTRACT FROM AUTHOR]

Objectives Despite the passage of state laws promoting breast feeding, a formal evaluation has not yet been conducted to test whether and/or what type of laws may increase breast feeding. The enactment of breastfeeding laws in different states in the USA creates a natural experiment. We examined the impact of state breastfeeding laws on breastfeeding initiation and duration as well as on disparities in these infant feeding practices. Methods Using data from the Pregnancy Risk Assessment Monitoring System, we conducted differences-in-differences models to examine breastfeeding status before and after the institution of laws between 2000 and 2008 among 326 263 mothers from 32 states in the USA. For each mother, we coded the presence of two types of state breastfeeding laws. Mothers reported whether they ever breast fed or pumped breast milk (breastfeeding initiation) and, if so, how long they continued. We defined breastfeeding duration as continuing to breast feed for ⩾4 weeks. Results Breastfeeding initiation was 1.7 percentage points higher in states with new laws to provide break time and private space for breastfeeding employees (p=0.01), particularly among Hispanic mothers (adjusted coefficient 0.058). While there was no overall effect of laws permitting mothers to breast feed in any location, among Black mothers we observed increases in breastfeeding initiation (adjusted coefficient 0.056). Effects on breastfeeding duration were in the same direction, but slightly weaker. Conclusions State laws that support breast feeding appear to increase breastfeeding rates. Most of these gains were observed among Hispanic and Black women and women of lower educational attainment suggesting that such state laws may help reduce disparities in breast feeding. [ABSTRACT FROM AUTHOR]

Background Achieving high levels of patient satisfaction requires hospital management to be proactive in patient-centred care improvement initiatives and to engage frontline clinicians in this process. Method We developed a survey to assess the attitudes of clinicians towards hospital management activities with respect to improving patient satisfaction and surveyed clinicians in four academic hospitals located in Denmark, Israel, the UK and the USA. Results We collected 1004 questionnaires (79.9% response rate) from four hospitals in four countries on three continents. Overall, 90.4% of clinicians believed that improving patient satisfaction during hospitalisation was achievable, but only 9.2% of clinicians thought their department had a structured plan to do so, with significant differences between the countries (p<0.0001). Among responders, only 38% remembered targeted actions to improve patient satisfaction and just 34% stated having received feedback from hospital management regarding patient satisfaction status in their department during the past year. In multivariate analyses, clinicians who received feedback from hospital management and remembered targeted actions to improve patient satisfaction were more likely to state that their department had a structured plan to improve patient satisfaction. Conclusions This portrait of clinicians' attitudes highlights a chasm between hospital management and frontline clinicians with respect to improving patient satisfaction. It appears that while hospital management asserts that patientcentred care is important and invests in patient satisfaction and patient experience surveys, our findings suggest that the majority do not have a structured plan for promoting improvement of patient satisfaction and engaging clinicians in the process. [ABSTRACT FROM AUTHOR]