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Background: Severe maternal morbidity is increasing in the United States. Black women experience the highest rates of severe maternal morbidity and also of preterm births, which are associated with severe maternal morbidity. The racial disparity of severe maternal morbidity across weeks of gestation has not been well-studied., Objective: This study aimed to evaluate differences in severe maternal morbidity between Black and White birthing people by week of gestation. Differences may indicate periods of pregnancy when Black women are particularly vulnerable to severe maternal morbidity and may require additional interventions., Study Design: This was a cross-sectional study using the National Inpatient Sample from 2019. We used International Classification of Diseases codes from Centers for Disease Control and Prevention guidelines to identify severe maternal morbidity from delivery hospitalizations. We examined the rates of severe maternal morbidity in Black vs White women by week of gestation to evaluate periods of pregnancy when Black women experience additional risks of severe maternal morbidity while adjusting for age, region, medical comorbidities, and Medicaid enrollment. Severe maternal morbidity was analyzed while both including and excluding cases for which blood transfusion was the only indicator of severe maternal morbidity., Results: Overall, Black birthing people had twice the rate of severe maternal morbidity births compared with White birthing people (2.7% vs 1.3%; P<.0001) and were more likely to deliver preterm (14.7% vs 9.4%; P<.0001). The racial disparity of severe maternal morbidity was present throughout all weeks of gestation, with the largest gap observed at extremely and moderately preterm gestations (22-33 weeks). Rates of severe maternal morbidity for Black women peaked at 22 to 33 weeks' gestation and were lowest at term (≥37 weeks). Black women had a greater proportion of severe maternal morbidity cases due to blood transfusion (68.3% vs 64.5%; P<.01) and acute renal failure (11.1% vs 8.5%; P<.001)., Conclusion: Black women experience a substantially higher rate of severe maternal morbidity at preterm gestations (22-36 weeks) in addition to higher rates of preterm delivery. Even when accounting for age, medical comorbidities, and social determinants, Black birthing people have higher odds of severe maternal morbidity throughout pregnancy., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Adolescents with congenital heart disease (CHD) have elevated risk for acquired cardiovascular complications, increasing their vulnerability to e-cigarette-related health harms. Impulsivity and risky decision-making have been associated with adolescent substance use, but the relationships between these factors and e-cigarette-related outcomes among cardiovascular at-risk adolescents with CHD are unknown. This cross-sectional study aimed to (a) determine the associations of impulsivity and risky decision-making with e-cigarette-related outcomes (i.e. susceptibility, ever use, perceptions of harm and addictiveness) via variable-oriented analysis (logistic regression), (b) identify groups of adolescents with similar profiles of impulsivity and risky decision-making via exploratory person-oriented analysis (latent profile analysis; LPA), and (c) examine differences on e-cigarette-related outcomes between profile groups. Adolescents aged 12 to 18 years with CHD ( N  = 98) completed a survey assessing impulsivity facets (Short UPPS-P) and e-cigarette-related outcomes and were administered a risky decision-making task (Iowa Gambling Task, Version 2; IGT2). In variable-oriented analyses, impulsivity facets (negative urgency, positive urgency, lack of premeditation) but not risky decision-making were associated with e-cigarette susceptibility and ever use. The exploratory LPA identified two groups with similar patterns of responding on the Short UPPS-P and IGT2 labeled "Low Impulsivity" and "High Impulsivity," which were primarily characterized by significant differences in negative and positive urgency. Adolescents in the High Impulsivity group had increased odds of e-cigarette susceptibility but not ever use compared to the Low Impulsivity group. This work indicates that strategies to prevent e-cigarette use among adolescents with CHD may be enhanced by addressing impulsivity, particularly negative and positive urgency.

Competing Interests: Competing interests: None declared.

Obesity in children and adolescents has increased globally. Increased body mass index (BMI) during adolescence carries significant long-term adverse health outcomes, including chronic diseases such as cardiovascular disease, stroke, diabetes, and cancer. Little is known about the metabolic consequences of changes in BMI in adolescents outside of typical clinical parameters. Here, we used untargeted metabolomics to assess changing BMI in male adolescents. Untargeted metabolomic profiling was performed on urine samples from 360 adolescents using UPLC-QTOF-MS. The study includes a baseline of 235 subjects in a discovery set and 125 subjects in a validation set. Of them, a follow-up of 81 subjects (1 year later) as a replication set was studied. Linear regression analysis models were used to estimate the associations of metabolic features with BMI z-score in the discovery and validation sets, after adjusting for age, race, and total energy intake (kcal) at false-discovery-rate correction (FDR) ≤ 0.1. We identified 221 and 16 significant metabolic features in the discovery and in the validation set, respectively. The metabolites associated with BMI z-score in validation sets are glycylproline, citrulline, 4-vinylsyringol, 3'-sialyllactose, estrone sulfate, carnosine, formiminoglutamic acid, 4-hydroxyproline, hydroxyprolyl-asparagine, 2-hexenoylcarnitine, L-glutamine, inosine, N-(2-Hydroxyphenyl) acetamide glucuronide, and galactosylhydroxylysine. Of those 16 features, 9 significant metabolic features were associated with a positive change in BMI in the replication set 1 year later. Histidine and arginine metabolism were the most affected metabolic pathways. Our findings suggest that obesity and its metabolic outcomes in the urine metabolome of children are linked to altered amino acids, lipid, and carbohydrate metabolism. These identified metabolites may serve as biomarkers and aid in the investigation of obesity's underlying pathological mechanisms. Whether these features are associated with the development of obesity, or a consequence of changing BMI, requires further study.

Objective: Adolescents with congenital heart disease (CHD) are exposed to disease-related stressors and have elevated risk for cardiovascular and cognitive complications that are exacerbated by e-cigarettes and marijuana. The aims of this cross-sectional study are to: (1) identify the association between perceived global and disease-related stress and susceptibility to e-cigarettes and marijuana, (2) determine if the association between stress and susceptibility differs by gender, and (3) explore the association between stress and ever use of e-cigarettes and marijuana among adolescents with CHD., Methods: Adolescents with CHD (N = 98; aged 12-18 years) completed self-report measures of susceptibility to/ever use of e-cigarettes and marijuana and global and disease-related stress., Results: Susceptibility to e-cigarettes and marijuana was reported by 31.3% and 40.2% of adolescents, respectively. Ever use of e-cigarettes and marijuana was reported by 15.3% and 14.3% of adolescents, respectively. Global stress was associated with susceptibility to and ever use of e-cigarettes and marijuana. Disease-related stress was associated with susceptibility to marijuana. Females reported more global and disease-related stress than males, but the association of stress with susceptibility to e-cigarettes and marijuana did not differ by gender., Conclusions: Susceptibility to e-cigarettes and marijuana is common among adolescents with CHD and is associated with stress. Future work to examine the longitudinal associations between susceptibility, stress, and use of e-cigarettes and marijuana is warranted. Global stress may be an important consideration in the development of strategies to prevent these risky health behaviors among adolescents with CHD., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Competing Interests: We declare no competing interests.

Background: Adherence to COVID-19 protective measures is lowest for young people and males. The current study investigated characteristics associated with adherence to COVID-19 protective measures among male youth during the early months of the pandemic., Method: The study used data from a prospective cohort study among male youth with baseline assessment in 2015/2016 and follow-up measurements in 2019 and summer 2020. Attrition-weighted multivariable ordinal logistic and log-binomial regression models were used to assess factors associated with adherence to overall and specific adherence measures, respectively., Results: Among 571 male youth (mean age 18.5), overall adherence was higher for those who were older (OR: 1.15; 95% CI: 1.03-1.30), non-White (OR: 1.96; 95% CI: 1.20-3.32), and residing in an urban area (OR: 2.06; 95% CI: 1.46-3.01). Overall adherence was lower for those who had a history of being drunk (OR: 0.65; 95% CI: 0.42-0.99). For outdoor mask-wearing, adherence was higher for youth with attention-deficit disorder or attention-deficit/hyperactivity disorder (RR: 1.58; 95% CI: 1.16-1.97) and lower for youth who currently used tobacco products (RR: 0.42; 95% CI: 0.21-0.70). Before a statewide mask mandate was issued, non-White youth were more likely to report wearing masks in outdoor spaces than their non-Hispanic White peers (RR: 2.34; 95% CI: 1.75-3.23)., Conclusion: The study identified demographic, psychosocial, and behavioral factors associated with adherence to COVID-19 protective behaviors among male youth. The findings illustrate characteristics that could be leveraged for targeted preventive efforts during the ongoing pandemic and future outbreaks in a low-compliance group., (© 2022. International Society of Behavioral Medicine.)

Smokers are more likely to be low-income with limited access to health services. Although Medicaid expansion under the Patient Protection and Affordable Care Act improved access to care for low-income adults, long-term trends in health care access among low-income smokers remain uncharacterized. The study evaluated changes in five access measures among low-income nonelderly (19-64) adults (N = 28976) across smoking status using pooled data from a statewide survey in Ohio covering pre- (i.e., 2012) and post-Medicaid expansion periods (2015, 2017, and 2019) guided by a comprehensive framework of health care access. We found improvements in some, but not all, health care access measures among low-income smokers in the post-Medicaid-expansion period compared to the pre-expansion period. Compared to 2012, the odds for unmet dental care needs declined in 2015 (aOR = 0.67, 95 % CI = 0.45-1.01), 2017 (aOR = 0.53, 95 % CI = 0.35-0.81), and 2019 (aOR = 0.65, 95 % CI = 0.40-1.05) (p trend < 0.001). Similarly, the odds for unmet other health care needs (i.e., medical exams and supplies) were lower in 2015 (aOR = 0.64, 95 % CI = 0.39-1.06), 2017 (aOR = 0.56, 95 % CI = 0.34-0.93), and 2019 (aOR = 0.47, 95 % CI = 0.27-0.83) (p trend < 0.001). Difficulty paying medical bills was also significantly lower in 2015 (aOR = 0.62, 95 % CI = 0.43-0.89), 2017 (aOR = 0.57, 95 % CI = 0.39-0.83) and 2019 (aOR = 0.57, 95 % CI = 0.37-0.87) (p trend < 0.001). While there was notable progress in measures of affordability (i.e., paying medical bills) as well as care availability and accommodation (i.e., unmet needs), there were no meaningful changes in the approachability of care (i.e., having a usual source of care)., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Manufacturers of Puff Bar electronic cigarettes (e-cigarettes) and Fre nicotine pouches claim that their products contain synthetic nicotine. The packages for Puff Bar and Fre have modified versions of the warning labels required by the Food and Drug Administration (FDA) for tobacco products, which specify that Puff Bar and Fre products contain "tobacco free" or "non-tobacco" nicotine, respectively. We evaluated whether exposure to these "tobacco free" warning labels was associated with differing perceptions about the products. Method: N  = 239 young adult men who were enrolled in a cohort study completed a short online experiment. Participants were randomly assigned to view either packages of Puff Bar and Fre nicotine pouches with the standard FDA warning or packages with the standard FDA warning + the tobacco free descriptor. We compared harm and addictiveness perceptions and products' perceived substitutability for cigarettes and smokeless tobacco (SLT) by exposure to a "tobacco free" warning. Results: Viewing a Puff Bar package with a "tobacco free" warning label was associated with increased perceived substitutability of the product for cigarettes and smokeless tobacco (p' s <.05). Viewing a Fre package with a "non-tobacco" warning label was associated with thinking the product was less harmful than SLT ( p <.01). Conclusions: "Tobacco free" descriptors in warning labels for e-cigarettes and nicotine pouches affect young adults' perceptions of the products. To date, it is unclear whether the FDA will continue to permit "tobacco free" descriptors in warning labels. As e-cigarettes and nicotine pouches are increasingly marketed with "tobacco free" language, urgent action is needed.

Introduction: A growing body of evidence indicates that exposure to tobacco advertising among adolescents increases the likelihood of subsequent tobacco use. It is important to understand the process by which this occurs, in order to appropriately target factors for intervention. The objective of this study was to test whether attitudes towards tobacco advertising mediates the impact of advertising exposure on tobacco use., Methods: From an ongoing prospective cohort study of male adolescents (aged 11-16 at baseline), we recruited a subset of tobacco users and non-users to participate in an additional ecological momentary assessment (EMA) project (N = 164). Adolescents completed smartphone-based surveys 2-3 times/day over a 10-day period with items assessing their exposures and attitudes towards tobacco-related advertising. If participants reported exposure to tobacco advertising, they were asked about their attitudes toward it (how much they enjoyed it, liked it, and found it appealing)., Results: Adolescents who reported a greater amount of advertising exposure during the EMA period were more likely to report past-30-day tobacco use at their next cohort follow-up (6-12 months later). Moreover, the impact of advertising exposure on subsequent use was mediated by attitudes toward the tobacco advertisements, as reported during the EMA. This effect remained after controlling for baseline tobacco use., Conclusions: By pairing EMA with long-term follow-up, we identified attitudes as a mediator between adolescent advertising exposure and subsequent tobacco use. Interventions to lessen adolescents' positive attitudes toward tobacco advertisements may help disrupt this impact., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objective: To identify important risk factors for carbapenem-resistant Enterobacterales (CRE) infections among hospitalized patients., Design: We utilized a case-case-control design that compared patients with CRE infections to patients with carbapenem-susceptible Enterobacterales (CSE) infections and randomly selected controls during the period from January 2011 through December 2016., Setting: The study population was selected from patients at a large metropolitan tertiary-care and instructional medical center., Patients: Cases of CRE were defined as initial admission of adults diagnosed with a bacterial infection of an Enterobacterales species resistant clinically or through sensitivity testing to carbapenems 48 hours or more after admission. Cases of CSE were selected from the same patient population as the CRE cases within a 30-day window for admission, with diagnostic pathogens identified as susceptible to carbapenems. Controls were defined as adult patients admitted to any service within a 30-day window from a CRE case for >48 hours who did not meet either of the above case definitions during that admission., Results: Antibiotic exposure within 90 days prior to admission and length of hospital stay were both associated with increased odds of CRE and CSE infections compared to controls. Patients with CRE infections had >18 times greater odds of prior antibiotic exposure compared to patients with CSE infections., Conclusions: Antibiotic exposure and increased length of hospital stay may result in increased patient risk of developing an infection resistant to carbapenems and other β-lactams., (© The Author(s) 2022.)

Objectives: Earlier initiation of alcohol use and problematic drinking among adolescents are linked with adverse health outcomes. Exposure to alcohol advertisements is associated with drinking among adolescents, but the association between the attitudes toward alcohol advertisements and drinking behaviors is understudied. We evaluated the association between attitudes towards alcohol advertisements and initiation of alcohol use among adolescent boys., Methods: Adolescent boys from urban and Appalachian Ohio enrolled in a prospective study and reported whether they had ever consumed alcohol or been drunk at baseline (N = 1220; ages 11-16 years) and at the 24-month follow up (N = 891). Attitudes toward alcohol advertisements were measured at baseline following a brief advertisement viewing activity. Adjusted logistic regression models were used to estimate associations between attitudes toward advertisements and initiating alcohol use or drunkenness at the 24-month follow-up., Results: Adolescent boys reporting any positive attitudes toward alcohol advertisements had higher odds of initiating alcohol use (aOR = 2.00, 95% CI [1.16, 3.44]), and attitudes were marginally associated with incident drunkenness (aOR = 2.20, 95% CI [0.94, 5.12]). Increasing age, higher household income, ever use of tobacco, and frequency of visiting alcohol retailers were also associated with greater odds of incident alcohol use and/or drunkenness., Conclusions: Attitudes toward alcohol advertisements at baseline were associated with alcohol drinking behaviors 24-months later among adolescent boys. Results highlight the importance of media literacy interventions targeted to adolescents., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Limited access to evidence-based smoking cessation interventions among rural populations contributes to high rates of cigarette smoking and poor cessation outcomes. Yet, accessible digital interventions for cessation focusing on rural populations are lacking. In a secondary analysis, we determined the acceptability and efficacy of an Acceptance and Commitment Therapy (ACT)-based smartphone application (iCanQuit) relative to a U.S. Clinical Practice Guidelines (USCPG)-based smartphone application (QuitGuide) for smoking cessation among rural participants enrolled in the two-arm randomized iCanQuit trial. Participants were enrolled between May 2017 and September 2018 and randomized to either receive iCanQuit or QuitGuide for 12-months. Rural residence was determined by sub-county level Rural-Urban Commuting Area codes. A total of 550 rural participants were recruited from 43 U.S. states. Self-reported complete-case 30-day point-prevalence abstinence was 15% (33/226) for iCanQuit vs. 9% (22/253) for QuitGuide at 3-months (OR = 1.83; 95% CI: 1.03, 3.25) and 29% (66/231) for iCanQuit vs. 25% (64/288) for QuitGuide at 12-months (OR = 1.19 95% CI: 0.80, 1.79). Retention rate was 89% at 12-months and did not differ by arm. iCanQuit vs. QuitGuide participants were significantly more engaged and satisfied with the iCanQuit application. Increased acceptance of internal cues to smoke mediated the effect of treatment on cessation. Findings suggest that iCanQuit had significantly higher short-term quit rates, descriptively higher long-term quit rates, and operated through its hypothesized mechanisms of action relative to QuitGuide. Future larger studies are needed to further evaluate the efficacy of and methods for disseminating the iCanQuit application for smoking cessation among U.S. rural adults nationwide. Trial registrationClinicalTrials.gov Identifier: NCT02724462., (Published by Elsevier Inc.)

Background: The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program., Methods: The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness., Discussion: Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020)., (© 2022. The Author(s).)

Objectives: In 2017, the e-cigarette brand, blu, released advertisements featuring large, boxed, positively-framed messages. These messages mimicked the format of FDA-mandated warnings that would appear on e-cigarette advertisements in the United States in 2018. We compared attention to blu's parody warnings and FDA-mandated warning appearing on blu advertisements., Methods: N = 73 young adults who had used tobacco participated in an eye-tracking study. Participants viewed three blu e-cigarette advertisements in random order: one with a parody warning and two with the FDA-mandated warning (one with a model's face and one without). Areas of interest (AOIs) were the parody or FDA-mandated warning. We compared dwell time on AOIs between the three advertisements., Results: Participants viewed parody warnings longer than each FDA-mandated warning on average (254 and 608 ms longer; p's < 0.02). Comparing the advertisements with FDA-mandated warnings revealed that participants spent less time looking at the warning in the advertisement with a model's face (354 fewer milliseconds; p = 0.001)., Conclusions: Parody warnings attracted more visual attention than FDA-mandated warnings, and the presence of a face in the advertisement drew attention away from the FDA-mandated warning. Results underscore the need for advertisement regulations that support increased attention to health warnings., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Competing Interests: Disclosures: The authors have no relevant financial disclosures or conflicts of interest.

Objective: Examine trends in e-cigarette use, and Juul use specifically, among U.S. college students., Participants: In 2016, we established a cohort of 529 incoming first-year students to a large Midwestern University. In 2018, these students (now third-years) were re-contacted, and a new sample of 611 incoming first-year students was enrolled., Methods: First-year students in 2016 completed a survey assessing their e-cigarette use; in 2018, first- and second-year students reported on e-cigarette use, and use of Juul specifically., Results: From 2016 to 2018, past 30-day e-cigarette use rose from 5.9% to 27.7%. In 2018, for Juul alone, ever use was above 35% and past 30-day use was above 20% for both cohorts. Juul use did not differ by gender, but was associated with higher socioeconomic status (SES) and being White., Conclusions: Findings present disturbing possibilities for long-term nicotine addiction among the next generation, and underscore the need for a rapid public health response.

Purpose: The aim of this study was to compare prevalence of JUUL use and JUUL risk perceptions between adolescents living in an urban area versus Appalachian areas of the U.S., Methods: Data were drawn from a prospective cohort study of adolescent males (the Buckeye Teen Health Study, or BTHS); our cross-sectional analysis used data from one timepoint, collected between January and December 2019 (N = 873). Chi-square tests and multivariable logistic regression compared JUUL use prevalence and risk perceptions between participants in an urban Ohio county and nine predominantly rural Appalachian Ohio counties., Results: Over a quarter of the sample (29.2%) had ever used JUUL. In the unadjusted model, prevalence of JUUL use was similar between regions but Appalachian participants perceived JUUL as more harmful (p &lt; .001) and more addictive (p = .04) than urban participants. In the adjusted model, region was not significantly related to current JUUL use (OR: 1.20, 95% CI: 0.77, 1.87) or ever JUUL use (OR: 1.15, 95% CI: 0.83, 1.60)., Conclusions: JUUL use was similar between urban and Appalachian participants despite regional differences in risk perceptions. Interventions that only target risk perceptions may not be sufficient to prevent adolescent e-cigarette use, particularly in rural communities.

Exposure to tobacco advertisements is associated with initiation of tobacco use among youth. The mechanisms underlying this association are less clear. We estimated longitudinal associations between youths' cognitive and affective responses to advertisements for cigarettes, e-cigarettes, and smokeless tobacco (SLT) and initiation of these products. N = 1220 Ohio-residing boys of ages 11-16 were recruited into a cohort in 2015 and 2016. Participants completed surveys every six months for four years. Surveys assessed cognitive and affective responses to tobacco advertisements (which included health warnings) and tobacco use after an advertisement viewing activity. We used mixed-effects Poisson regression models with robust standard errors to estimate risk of initiating use of each tobacco product according to participants' cognitive (i.e., memorability of health risks) and affective (i.e., likability of advertisement) responses to advertisements for that product. No associations between affective responses to advertisements and tobacco use outcomes were detected in adjusted models. However, finding health risks memorable was associated with reduced risk of ever smoking initiation (aRR = 0.57; 95% CI: 0.34, 0.95) and a reduced risk of ever SLT initiation that approached statistical significance (aRR = 0.61; 95% CI: 0.36, 1.05). Measures to increase saliency of health risks on cigarette and SLT advertisements might reduce use among youth.

Introduction: Tobacco 21 (T21), which sets the minimum legal sales age for tobacco to age 21, is now a national law in the United States. Although T21 is expected to help curb youth tobacco use, its impact may be dampened due to poor retailer compliance. Even within environments where enforcement is strong (ie, compliance checks are conducted with tough sanctions for violations), compliance might vary due to other factors., Aims and Methods: Three studies were conducted in Columbus, OH, where T21 became strongly enforced in 2018. These studies examined how retailer compliance related to features of the neighborhood in which a retailer was located (Study 1), features of the retailer (Study 2), and features of the retail cashier (Study 3)., Results: Study 1 found that, after controlling for race- and age-based factors, retailers located in high (vs. low)-poverty neighborhoods had a lower likelihood of conducting identification (ID) checks. Study 2 found that ID checks were related to whether retailers displayed signage about T21, as required by the city law. Study 3 found that, among cashiers, T21 awareness (which was high) and perceptions about T21 (which were moderate) were not generally related to their retailer's compliance; having (vs. not having) scanners for ID checks was related to a higher likelihood of compliance., Conclusions: These studies emphasize the many, multilevel factors influencing T21 outcomes. Findings also indicate the potential for T21 to widen disparities in tobacco use, indicating the need for strategies to equitably improve T21 compliance., Implications: T21, which sets the minimum legal sales age for all tobacco products to age 21, is now a national law in the United States. Despite optimistic projections about what T21 could achieve, the ultimate impact may be dampened when it is applied in real-world settings. Our project revealed the many, multilevel factors influencing T21 compliance. Findings also indicate the potential for T21 to widen disparities in tobacco use if gaps in compliance persist. Strategies for equitably improving T21 compliance are discussed. This article is of relevance to areas interested in implementing or improving their local T21 enforcement., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Background: In January 2019, electronic nicotine delivery systems (ENDS) market leader Juul Labs (JUUL) launched an advertising campaign encouraging adult smokers to 'make the switch' from combustible cigarettes to JUUL. Our primary aim was to describe consumer perceptions of JUUL as communicated by members of JUUL's online social community via testimonials promoted on JUUL's website., Methods: User testimonials that were displayed on the JUUL website in December 2019 and January 2020 were collected and coded by three reviewers. A total of 220 testimonials were coded for primary and secondary themes (eight codes within four broader themes)., Results: Testimonial writers were, on average, 43.0 years old (range 28 to 74) and reported using JUUL for an average of 21.8 months (range 9 to 59 months). The most prominent theme, present in nearly half of the testimonials, was a description of how to use JUUL, with a mention of JUUL's benefits and tips on how to use the product. Nearly four in 10 statements encouraged smokers to give JUUL a try or noted that JUUL is a better product compared with cigarettes. About one in 10 statements focused on switching from smoking cigarettes to using JUUL., Conclusion: This study presents a foundation for understanding how adult users describe JUUL, including their experiences using JUUL to 'switch' or stop smoking. Currently, the effectiveness of ENDS for smoking cessation is not supported by substantial evidence; however, if cessation is defined as 'quitting combustible tobacco products', then regulators should be aware that switch and cessation messages may not be distinct., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Waterpipe (WP) smoking has rapidly grown in popularity in the United States and other Western countries with the fastest uptake among younger individuals. This growth has been encouraged by the misperception that WP smoke is harmless or less harmful than cigarette smoke. To better understand how WP affects the health of young people, we conducted a narrative review of the literature focusing on the adverse health effects of WP smoking in adolescents and younger adults. We searched scientific literature databases including PubMed, MEDLINE, EMBASE, and ISI Web and selected papers that met the inclusion criteria. Sixty-three papers met the inclusion criteria and were selected for review. Data were abstracted from the selected papers into a standardized table. The evidence demonstrates that WP smoking can cause acute lung infection and injury, and carbon monoxide (CO) poisoning, in adolescents and young adults. It is also associated with adverse subclinical effects in this sub-population, including oral and systemic genotoxicity, lung function decline, and the alteration of vascular and hemodynamic functions. Limited evidence that is available indicates associations with psychological and neurological effects and asthma. No identified publications examined the association between WP use and type 2 diabetes, a condition that is associated with cigarette smoking among young people. WP smoking by younger individuals can result in their hospitalization due to systemic CO poisoning and acute lung disease, and induce subclinical adverse effects in the oral cavity, pulmonary system, and in circulation, that are involved in the pathogenesis of local and systemic chronic diseases., Competing Interests: The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. O. Adetona, S. Mok, J. Rajczyk and M.C. Brinkman report that since the initial planning of the work a grant was paid to their institution by the US National Institutes of Health. A.K. Ferketich reports that since the initial planning of the work she received from NIH a grant (R01CA229306)., (© 2021 Adetona O. et al.)

Individuals diagnosed with psychosis have high rates of smoking-related morbidity and early mortality. Only a small proportion of these smokers will attempt to quit, and many existing cessation interventions have limited effectiveness. To explore the unique and potentially unmet cessation needs of individuals with psychosis, we sought first-person experiences with smoking cessation and reactions to a proposed intervention. Twenty-four smokers with psychosis participated in focus group interviews. Multiple participants reported previous quit attempts using pharmacotherapy or behavioral methods, but few indicated they had previously tried cessation counseling. Though some individuals reported modest success with cessation, most participants tended to express negative perceptions of many available cessation approaches. When informed about the development of a novel smoking cessation intervention, participants had mixed but generally positive perceptions. Smokers diagnosed with psychosis are interested in sustained, individualized delivery of cessation services as part of their broader mental health care., (© 2021 Wiley Periodicals LLC.)

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has changed almost every aspect of our lives. Young adults are vulnerable to pandemic-related adverse mental health outcomes, but little is known about the impact on adolescents. We examined factors associated with perceived changes in mood and anxiety among male youth in urban and Appalachian Ohio., Methods: In June 2020, participants in an ongoing male youth cohort study were invited to participate in an online survey that included questions about changes in mood, anxiety, closeness to friends and family, and the major impacts of the pandemic. Weighted log-binomial regression models were used to assess the risk of worsened mood and increased anxiety. Chi-square tests were used to examine the association between perceived changes in mood and anxiety and perceived changes in closeness to friends and family and open-ended responses to a question about COVID-19's impact on participants., Results: Perceived worsened mood and increased anxiety during the pandemic were associated with higher household socioeconomic status, older age, feeling less close to friends and family, and reporting that COVID-19 negatively affected mental health. A perceived increase in anxiety was also associated with a history of symptoms of depression or anxiety., Conclusions: Specific subgroups of male youth may be at heightened risk of worsening mental health during the COVID-19 pandemic. Interventions should target vulnerable adolescents and seek to increase closeness to social contacts. Such efforts could involve novel programs that allow youth to stay connected to friends, which might mitigate the negative impact on mental health., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Individuals with psychotic-spectrum disorders may smoke due to the ameliorating effect of nicotine on the cognitive deficits that accompany these illnesses. Metacognitive remediation therapy (MCR) has been shown to produce improvements in cognitive functioning among individuals with psychotic-spectrum disorders and provides a foundation for a novel smoking cessation intervention for this population., Aims: To complete an open investigation of pharmacotherapy and a modified version of MCR [MCR to Quit (MCR-Q)] in promoting smoking cessation among individuals with psychotic-spectrum disorders., Methods: Forty-nine individuals with a psychotic-spectrum disorder and who currently smoke cigarettes participated in MCR-Q while also receiving evidence-based smoking cessation pharmacotherapy. Tobacco use was assessed as follows: (i) prior to MCR-Q, (ii) immediately after completing MCR-Q, and (iii) six weeks after completion of MCR-Q., Results: / Findings . During participation in MCR-Q, nearly 80% of participants made a 24-hour quit attempt. Following the completion of MCR-Q, participants experienced reductions in level of nicotine dependency and exhaled carbon monoxide, with reductions in nicotine dependency sustained six weeks after completion of MCR-Q. Over the course of their participation in MCR-Q, participants reported strong therapeutic alliance with their MCR-Q therapist and high levels of intrinsic motivation with regard to completing MCR-Q exercises., Conclusions: The results from the current study suggest cautious optimism with regard to the use of MCR-Q in combination with medication for individuals with psychotic-spectrum disorders who want to quit smoking., Competing Interests: Drs. Breitborde and Moe have received salary support with regard to trainings for metacognitive remediation therapy that were provided for activities not related to the current study., (Copyright © 2021 Nicholas J. K. Breitborde et al.)

Introduction: Electronic cigarette (e-cigarette) use among adolescents is associated with increased risk of subsequent cigarette smoking initiation in observational research. However, the existing research was not designed to answer causal questions about whether adolescent e-cigarette users would have initiated cigarette smoking if they had never used e-cigarettes. The current study used a causal inference framework to identify whether male adolescent e-cigarette users were at increased risk of initiating cigarette smoking and smokeless tobacco (SLT) use, compared to similar boys who had never used e-cigarettes., Methods: Boys from urban and Appalachian Ohio (N = 1220; ages 11-16 years at enrollment) reported use of e-cigarettes, cigarettes, and SLT at baseline and every six months for two years. A propensity score matching design was implemented, matching one e-cigarette user to two similar e-cigarette non-users. This analysis was completed in 25 multiple imputed datasets to account for missing data. Risk ratios (RRs) comparing risk of initiating cigarettes and SLT for e-cigarette users and nonusers were estimated., Results: Compared to non-users, e-cigarette users were more than twice as likely to later initiate both cigarette smoking (RR = 2.71; 95% CI: 1.89, 3.87) and SLT (RR = 2.42; 95% CI: 1.73, 3.38). They were also more likely to become current (i.e., past 30-day) cigarette smokers (RR = 2.20; 95% CI: 1.33, 3.64) and SLT users (RR = 1.64; 95% CI: 1.01, 2.64)., Conclusions: Adolescent boys who used e-cigarettes had increased risk of later initiating traditional tobacco products when compared to similar boys who had never used e-cigarettes., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this study was to select a health warning message location on a waterpipe (WP) that both attracted visual attention and conveyed the risks associated with WP smoking. Methods: During June through November 2019, we conducted a within-subjects randomized experiment (N = 74) using eye tracking equipment to examine visual attention to 3 placements of a health warning on the WP (stem, water bowl, hose). We asked young adult ever WP users 3 questions about WP harm perceptions. We used generalized linear mixed models to examine the amount of fixation time spent on the placement locations; we used repeated measures ANOVA to model changes in harm perceptions. Results: There were statistically significant differences across all 3 placement locations; regardless of place, all HWLs attracted a comparable amount of visual attention. Absolute WP harm perceptions significantly increased following the experiment and remained significantly higher at the one-week follow-up, compared to baseline. Conclusions: Warnings on WPs attracted visual attention and increased harm perceptions, and those harm perceptions remained high one week after the experiment. Findings indicate the value of including a warning on the WP device, and underscore the necessity and effectiveness of those health warnings to combat WP harm misperceptions.

Researchers have proposed numerous factors that may contribute to rural adolescents' heightened risk for tobacco use. Some of these include well-known risk factors for tobacco use, whereas others concern factors unique to rural populations, reflecting norms and values ("rural culture") that accept and encourage tobacco use. This study aimed to test a broad range of tobacco-use risk factors to determine which were a) universal risk factors for both urban and rural adolescents vs. b) unique risk factors for rural adolescents. Data came from a prospective cohort study of 1220 adolescent males in Ohio who were aged 11-16 (average = 14 years) when surveyed at baseline (2015-2016). Follow-up surveys occurred every 6 months. The present study examined tobacco-use outcomes-prevalent use and incident use-by the two-year follow-up (2017-2018). Findings indicated a higher prevalence of ever-use of cigarette and smokeless tobacco among rural, vs. urban, adolescents at baseline. By the two-year follow-up, the urban/rural difference was attenuated but remained. Stratified multivariable logistic regression indicated that some baseline risk factors were associated with subsequent tobacco use for both rural and urban adolescents. Having an adult tobacco user in the home (for prevalent use) and susceptibility to a male family member offer of tobacco products (for both prevalent and incident use) were associated with tobacco use only for rural adolescents. These findings align with qualitative work demonstrating that masculinity and an intergenerational tobacco culture are important to male adolescents. This unique rural profile should be considered when developing prevention efforts., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Incentive-based smoking cessation interventions increase quit rates. The optimal incentive, however, is unknown. We used a willingness-to-accept (WTA) auction where smokers submitted bids indicating the incentive they would need to receive for 1 week of smoking cessation., Aims and Methods: Smokers ready to quit (n = 35) participated in a WTA auction, naming the amount they needed to be paid to quit for 1 week. Auction winners received an incentive if they successfully quit. All smokers received nicotine replacement therapy and self-help cessation materials. Carbon monoxide concentrations were monitored remotely three times during the week and in person at the final session., Results: Participants who smoked their first cigarette within 5 min of waking demanded a significantly larger incentive in exchange for quitting than those who waited (p < .05). About 45% of auction winners quit smoking compared to 20% of nonwinners (p < .05). The cost per quit was $466 among auction winners compared to $894 among nonwinners., Conclusions: WTA auctions may be an effective way to determine the amount smokers need to be paid to quit, which would allow researchers to estimate the most cost-effective payment to offer as part of incentive-based smoking cessation programs. Replication evaluating longer-term cessation outcomes with larger samples is warranted., Implications: Incentive-based smoking cessation interventions increase quit rates. However, the optimal incentive is unknown. We found that a WTA auction is a feasible technique for estimating the amount smokers need to be paid to quit. Incentives are a surprisingly cost-effective way to facilitate smoking cessation because they are only paid to those who successfully quit. WTA auctions are a promising tool for determining the incentive that strikes the optimal balance between being large enough to motivate cessation, but small enough that it can be offered to the largest possible population of smokers for a given program budget., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Health warning messages could be an effective means of communicating the health risks associated with waterpipe (WP) smoking. The objective of this study was to select a message that conveyed the risks associated with WP smoking., Methods: A mixed-methods approach was used to explore the effectiveness of the Food and Drug Administration's (FDA's) mandated message, and others, among young adults using focus groups and surveys. Two focus group studies and one convenience survey were conducted to examine the FDA's mandated message and 11 other WP warning messages. The final study, conducted with a random sample of first-year university students, examined the effectiveness and reactance of the chosen message using previously validated items (scored on a 1-5 scale)., Results: The FDA's mandated message did not resonate well with focus group participants. In the random sample of students, the top message ( WARNING: Hookah smoke contains poisons that cause lung and oral cancers ) had high effectiveness (M = 4.49) and a low reactance (M = 2.12)., Conclusions: Our studies suggest that other messages are more effective for communicating the risks associated with WP smoking than the FDA's message for WP tobacco., Competing Interests: Conflict of Interest Disclosure Statement No conflicts to report.

Objective: There has been a growth in popularity of hookah (or waterpipes) among American college students, despite the health risks. This study investigated factors that predict hookah susceptibility and whether hookah susceptibility predicts hookah initiation and continued use., Method: The study established a cohort of 529 incoming college freshmen (51.6% female) who completed an online survey approximately 1 week before their arrival to a large U.S. university. Students were sent four follow-up surveys throughout the 2016-2017 academic year; 90.5% completed at least one follow-up survey., Results: A total of 13.2% of the sample had used hookah at baseline and 9.9% initiated hookah use over the course of their freshman year. Among the nonusers who had no hookah susceptibility at baseline, 30.0% came to indicate some susceptibility. Multivariable logistic regression indicated that the personality construct conscientiousness was protective against becoming susceptible, whereas coming from a rural part of the state was a risk factor. Susceptibility predicted both continued use among the baseline ever-users and initiation among the baseline never-users., Conclusions: These findings highlight the role of susceptibility in the trajectory of hookah use among U.S. college students.

Objective: Although burnout has been linked to negative workplace-level effects, prior studies have primarily focused on individuals rather than job-related characteristics. This study sought to evaluate variation in burnout between agencies and to quantify the relationship between burnout and job-related demands/resources among emergency medical services (EMS) professionals., Methods: An electronic questionnaire was sent to all licensed, practicing EMS professionals in South Carolina. Work-related burnout was measured using the Copenhagen Burnout Inventory. Multivariable generalized estimating equations were used to estimate odds ratios (ORs) for specific job demands and resources while adjusting for confounding variables. Composite scores were used to simultaneously assess the relationship between burnout and job-related demands and resources., Results: Among 1271 EMS professionals working at 248 EMS agencies, the median agency-level burnout was 35% (interquartile range [IQR]: 13% to 50%). Job-related demands, including time pressure, were associated with increased burnout. Traditional job-related resources, including pay and benefits, were associated with reduced burnout. Less tangible job resources, including autonomy, clinical performance feedback, social support, and adequate training demonstrated strong associations with reduced burnout. EMS professionals facing high job demands and low job resources demonstrated nearly a 10-fold increase in odds of burnout compared with those exposed to low demands and high resources (adjusted OR [aOR]: 9.50, 95% confidence interval [CI]: 6.39-14.10). High job resources attenuated the impact of high job demands., Conclusion: The proportion of EMS professionals experiencing burnout varied substantially across EMS agencies. Job resources, including those reflective of organizational culture, were associated with reduced burnout. Collectively, these findings suggest an opportunity to address burnout at the EMS agency level., Competing Interests: The authors have no conflict of interest to disclose., (© 2020 The Authors. JACEP Open published by Wiley Periodicals, Inc. on behalf of the American College of Emergency Physicians.)

The prevalence of smoking among rural Americans and Americans of lower socioeconomic status (SES) remains higher than among their urban and higher SES counterparts. Potential factors contributing to these disparities are area-based differences in the retail environment and tobacco control policies. We describe the association between neighborhood demographics and cigarette prices in rural and urban areas. Prices of one pack of Marlboro Reds, Newport menthols, and the cheapest cigarettes in the store were recorded from a stratified random sample of tobacco retailers in urban (N = 104) and rural (N = 109) Ohio in 2016. Associations between prices and census tract demographics (SES and race) were modeled separately in each region, controlling for store type. In the rural region, as the census tract income increased, the price of Marlboro and Newport cigarettes decreased, and the price of the cheapest pack of cigarettes increased. In the urban region, as the census tract income and percentage of White non-Hispanic people increased, the price of Marlboro decreased; there were no associations between census tract characteristics and the price of Newports or the cheapest cigarettes. Results describe a complex association between cigarette brand, prices, and area characteristics, where the cheapest brands of cigarettes can be obtained for the lowest prices in lower SES rural areas. Tobacco control policies that raise the price of cheap cigarettes, particularly minimum price laws, have the potential to reduce SES-related smoking disparities in both rural and urban populations.

Objective: Blu's 'Something Better' advertising campaign ran in popular print magazines in 2017. The campaign included advertisements with fake warnings conveying positive messages, which mimicked the Food and Drug Administration (FDA)'s warning requirements for electronic cigarette (e-cigarette) advertisements that took effect in 2018. We report adolescent males' recall of these fake warnings and how exposure to fake warnings affected recall of other advertisement components, including the actual warning or health risks, brand and product., Methods: Ohio males ages 12-19 years (N = 775; 73.8 % white non-Hispanic) were randomly assigned to view an e-cigarette advertisement with or without a fake warning. Afterward, they were asked what they remembered most about the advertisement. Responses were qualitatively coded. Statistical analyses included survey-weighted descriptive statistics and logistic regression., Results: Of participants who viewed an e-cigarette advertisement with a fake warning, 27.0 % reported the fake warning was what they remembered most, and 18.8 % repeated the fake warning message. Participants viewing advertisements with a fake warning had lower odds of recalling the actual warning or health risks (OR = 0.29; 95% CI: 0.11 to 0.77) or brand (OR = 0.43; 95% CI: 0.22 to 0.85), compared with participants viewing other e-cigarette advertisements., Conclusions: Adolescents viewing an advertisement with a fake warning were less likely to recall the advertisement's actual warning or health risks. Although e-cigarette advertisements now carry large FDA-mandated warnings, this tactic could be used for cigarette advertisements that continue to carry small warnings in the USA. Findings underscore the necessity of tobacco advertisement surveillance and study of advertisements' effects on adolescents., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives. To conduct a content analysis of news articles to investigate the relationship between language used to describe e-cigarettes, how the news articles framed (conveyed information to influence a certain perception of the news read by its audience) e-cigarettes, and the Food and Drug Administration's (FDA's) oversight of e-cigarettes. Methods. We searched a database of articles published across the United States from February 1, 2016, to February 28, 2017, using the headline terms "e-cigarette," "e-cig," and "vape." We then dichotomized terms into 2 categories: technical ("e-cigarette" or "e-cig") and nontechnical ("vape"). We coded the frame of each article body as positive, negative, or neutral or mixed. Results. Articles containing the term "vape" in the headline were more likely to positively frame e-cigarettes ( P  ≤ .001) and negatively frame FDA oversight ( P  ≤ .001) in the body than were those with "e-cigarette" or "e-cig" in the headline. Conclusions. Omitting the word "cigarette" when describing tobacco products may reduce the negative perception associated with tobacco use, making it more appealing. It is important to know which terms are used to describe e-cigarettes and how these terms can make those products appear less harmful.

Purpose: In autumn 2017, Columbus, Ohio, joined numerous other US locations in raising their legal sales age for purchasing tobacco to 21 (ie, becoming "T21"). The present study sought to establish a baseline for ID checks in Columbus prior to T21 enforcement and to examine whether store type and marketing were associated with better rates of ID checks., Design: Fieldworkers aged 20 to 21 years visited a random sample of 110 tobacco retailers during summer 2017 (drawn from >10 000 licensed retailers in the county). After collecting store-related information, they attempted to purchase cigarettes and recorded whether their ID was checked (federal law requires ID checks for anyone who looks younger than 27 years)., Setting: Columbus, Ohio., Measures: Store type, external tobacco advertising, and ID check outcome., Analysis: Descriptive and inferential statistics., Results: Among stores where cigarettes were purchased, 61.1% did not conduct ID checks. Absent ID checks were associated with the store being a convenience store or tobacco shop, χ 2 (2) = 4.45, P = .035, and having a greater amount of external advertising, t (93) = 2.00, P = .049., Conclusion: Overall, the low rate of ID checks for young adults purchasing tobacco in Columbus is concerning. Continued monitoring of retailer compliance will be important as retailers adjust to the arrival of T21. Targeted enforcement and additional outreach with tobacco shops, convenience stores, and stores with a high amount of external advertising may be particularly needed.

Objectives: The tobacco industry has a history of making "natural" claims in advertisements. We report how viewing advertisements with such claims affected what adolescents found memorable., Methods: Adolescent boys (N = 1220; 11-16 years old) were randomly assigned to view a Natural American Spirit (NAS) or other brand cigarette advertisement, and were asked what they remembered about the advertisement. Survey-weighted logistic regression models assessed whether memorability of advertisement components differed by NAS advertisement exposure., Results: Adolescents viewing a NAS advertisement (vs another brand) had lower odds of finding memorable the advertisement's warning (OR = 0.58; 95% CI: [0.34, 0.98]) or brand (OR = 0.25; 95% CI: [0.11, 0.54]). They had higher odds of mentioning tobacco (OR = 2.33; 95% CI: [1.49, 3.63]) and packaging (OR = 2.57; 95% CI: [1.51, 4.37]). An estimated 6.7% of those viewing an NAS advertisement said the product was not addictive., Conclusions: Reduced-harm claims on cigarette advertisements may affect what adolescents find salient about the advertisement. As the FDA's agreement with Santa Fe Natural Tobacco Company to remove these claims is not inclusive of all reduced-harm claims and does not apply to other companies, findings underscore the need for prohibiting all reduced-harm claims from cigarette advertisements., Competing Interests: Conflict of Interest Statement All authors have no conflicts of interest to disclose.

Aims: Most research into reasons for smoking among adults with serious mental illness (SMI) has focused on reasons related to SMI symptoms. The current study reports reasons for smoking and barriers to cessation that are both related and unrelated to SMI symptoms among adults with SMI., Methods: Four focus groups were conducted among current smokers receiving outpatient care for a psychotic disorder in 2017 (N = 24). Participants were asked why they currently smoke and their barriers to quitting smoking., Results: Smoking as a coping mechanism and to self-medicate SMI symptoms were reasons for current smoking and barriers to cessation. Avoidance of other unhealthy behaviors, routine, and enjoyment emerged as reasons for smoking and barriers to cessation that were unrelated to mental illness., Conclusion: Consideration of factors that are both related and unrelated to SMI symptoms in smoking cessation interventions and brief cessation counseling may improve cessation success in this population., (© 2019 Wiley Periodicals, Inc.)

Purpose: Research indicates that tobacco marketing contributes to higher pro-tobacco attitudes and behaviors among adolescents, but no studies have been able to assess the impact of real-world tobacco marketing exposures in real-time. The purpose of this study was to examine the magnitude and impact of tobacco marketing exposure on adolescents using ecological momentary assessment (EMA). Our primary hypotheses were that (1) youth would most frequently report tobacco marketing at the retail points-of-sale and (2) greater exposures to tobacco marketing would be associated with more favorable tobacco-related attitudes, use, and expectancies., Methods: Participants were adolescent males from rural and urban Ohio (N = 176, ages 11-16). For ten days, these adolescents were prompted at two-three random times/day to complete a brief smartphone-based survey about their exposures and responses to tobacco-related advertising., Results: Adolescents reported exposures to tobacco marketing an average of 1.9 times over the 10-day EMA period, with over 10% seeing a tobacco advertisement 5 or more times. Reports of marketing exposures occurred most frequently at the point-of-sale; exposures were higher among tobacco users and rural adolescents. Consistent with hypotheses, marketing exposure was related to more positive attitudes to the tobacco advertisements, more tobacco use, and higher expectancies to use in the future., Conclusions: Overall, these findings signal the magnitude of tobacco marketing exposures and their pernicious impact on youth. Findings underscore the importance of federal, state, and local-level tobacco regulatory policies to protect youth from the marketing that puts them at risk for a lifetime of nicotine addiction and tobacco-related diseases., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: This study aimed to better examine substance use among college students during the acute period of transition between high school and college., Methods: One week before coming to campus, participants completed an online survey assessing their alcohol, tobacco, and marijuana use. Next, beginning on the first Friday of the semester, they completed a 10-day experience sampling (ES) protocol, receiving one app-based survey each morning assessing recent substance use., Results: Among students who used any tobacco product prior to college, 70% or more reported alcohol use during ES. Among previous marijuana users, 85.7% reported alcohol use during ES. Baseline alcohol and tobacco use were not associated with subsequent marijuana use., Conclusions: Substance use prevention should target the transition to college., Competing Interests: Conflict of Interest Statement: The authors declare no conflicts of interest.

Background: The tobacco industry spends billions on retail marketing and such marketing is associated with tobacco use. Previous research has not examined actual and potential exposures that adolescents have on a daily basis., Objective: The objective of this study was to determine whether both self-reported and geographically estimated tobacco retailer exposures differ by participant or neighborhood characteristics among urban and rural adolescents., Methods: The data for this study were part of a cohort study of 1220 adolescent males residing in urban and rural (Appalachian) regions in Ohio. The baseline survey asked participants how often they visited stores that typically sell tobacco in the past week (self-reported exposures). The number of tobacco retailers between home and school was determined using ArcGIS software (potential exposures). Adjusted regression models were fit to determine the characteristics that were associated with self-reported or potential exposures to retailers., Results: Adolescents who were non-Hispanic black or other racial/ethnic minority, had used tobacco in the past, and lived in rural areas had higher self-reported exposures. Urban adolescents, non-Hispanic black or other racial/ethnic minority, and those living in neighborhoods with a higher percentage of poverty had more potential exposures to tobacco retailers in their path between home and school., Conclusions: Rural adolescents had more self-reported marketing exposures than urban adolescents. However, urban adolescents had more potential tobacco exposures between home and school. Thus, point of sale marketing limitations might be a more effective policy intervention in rural areas whereas limits on tobacco retailers might be more effective for urban areas.

Objectives: E-cigarettes are now the most commonly-used tobacco product among adolescents; yet, little work has examined how the appealing food and flavor cues used in their marketing might attract adolescents' attention, thereby increasing willingness to try these products. In the present study, we tested whether advertisements for fruit/sweet/savory-flavored ("flavored") e-cigarettes attracted adolescent attention in real-world scenes more than tobacco flavored ("unflavored") e-cigarettes. Additionally, we examined the relationship between adolescent attentional bias and willingness to try flavored e-cigarettes., Methods: Participants were 46 adolescents (age range: 16-18 years). All participants took part in an eye-tracking paradigm that examined attentional bias to flavored and unflavored e-cigarette advertisements embedded in pictures of real-world storefront scenes. Afterwards, participants' willingness to try flavored and unflavored e-cigarettes was assessed., Results: In support of our primary hypothesis, adolescents looked longer and fixated more frequently on flavored (vs unflavored) e-cigarette advertisements. Moreover, this attentional bias towards flavored e-cigarette advertisements predicted a greater willingness to try flavored vs unflavored e-cigarettes., Conclusions: These findings suggest that flavored e-cigarette marketing attracts the attention of adolescents, in- creases their willingness to try flavored e-cigarette products, and could, therefore, put them at greater risk for tobacco initiation., Competing Interests: Conflict of Interest Disclosure Statement All authors of this article declare they have no conflicts of interest.

Objectives: We evaluated the association of health literacy and attention to the pictorial imagery of 9 health warning labels (HWLs) in a tobacco advertisement among rural US smokers. We hypothesized that lower health literacy would be associated with greater visual attention to pictorial portions of HWLs and evaluated the association between health literacy and recall of advertisement elements., Methods: Adult smokers from Appalachian Ohio (N = 180) viewed a pictorial HWL encompassing 20% or 33% of a cigarette advertisement while eye tracking software recorded eye movements toward the advertisement. Health literacy was measured with The Short Test of Functional Health Literacy in Adults., Results: Generalized linear regression revealed that every one-unit decrease in health literacy increased viewing time of the pictorial portion of the health warning label by 1.3 percentage points. Logistic regression revealed that the odds of recalling elements of the pictorial portion of the health warning label increased 20% for every one-unit increase in health literacy., Conclusions: Rural smokers with lower health literacy view pictorial portions of health warning labels longer than those with greater health literacy supporting that health literacy is an important consideration in health communications, including future cigarette warning labels.

Introduction: Media tobacco and alcohol portrayals encourage adolescent substance use. Preventing adolescent initiation with these substances is critical, as they contribute to leading causes of morbidity and mortality in the United States. Television tobacco and alcohol portrayals have not been examined for more than 7 years. This study analyzed tobacco and alcohol portrayals on adolescents' favorite television shows and evaluated the rate of portrayals by parental rating., Methods: Adolescent males (N = 1,220) from Ohio reported 3 favorite television shows and how frequently they watch them. For each of the 20 most-watched shows in the sample, 9 episodes were randomly selected and coded for visual and verbal tobacco and alcohol incidents. Demographics of characters who used or interacted with the substances were recorded. Negative binomial regression modeled rates of tobacco and alcohol incidents per hour by parental rating., Results: There were 49 tobacco and 756 alcohol portrayals across 180 episodes. Characters using the products were mostly white, male, and adult. The rate of tobacco incidents per hour was 1.2 for shows rated TV-14 (95% CI, 0.4-3.6) and 1.1 for shows rated TV-MA (95% CI, 0.3-4.5). The estimated rate of alcohol incidents per hour was 20.9 for shows rated TV-14 (95% CI, 6.3-69.2) and 7.2 for shows rated TV-MA (95% CI, 1.5-34.1)., Conclusions: Adolescent males' favorite television shows rated TV-14 expose them to approximately 1 tobacco incident and 21 alcohol incidents per hour on average. Limiting tobacco and alcohol incidents on television could reduce adolescents' risk of substance use.

Background: Previous studies have examined what adolescents find appealing in tobacco and alcohol advertisements and how different themes in advertisements are used to manipulate consumer behaviors. Yet, we know little about the relationship between the themes portrayed in advertisements and youth attitudes towards those themes., Objectives: This study compared attitudes towards advertisements for different consumer products in a sample of urban and rural adolescent boys in order to examine how key marketing themes impact adolescent attitudes towards those advertisements., Methods: Participants were 11- to 16-year-old boys (N = 1220) residing in either urban or rural Ohio Appalachian counties. Each participant viewed five print advertisements (one each for cigarettes, electronic cigarettes (e-cigarettes), smokeless tobacco (SLT), non-alcoholic beverages, and alcohol), presented in a random order, for eight seconds each. All advertisements had appeared in magazines that adolescent males commonly read. Attitudes towards each of the five advertisements were assessed. The advertisements were then coded for the presence of various themes, including social acceptance and masculinity. Analyses were conducted to determine associations between advertisement type and the attitude measure, and between the presence of a theme and the attitude measure., Results: Overall, participants preferred non-tobacco advertisements to tobacco advertisements, rural participants had less positive attitudes and participants who had peers who used tobacco had more positive attitudes. Social acceptance and entertainment themes increased the appeal of SLT advertisements, and sex appeal increased the appeal of e-cigarette advertisements. Conclusions/Importance: Findings suggest that advertisements that promote the social nature of use in SLT advertisements may be of particular concern for their influence on adolescent boys.

Background: People with developmental disabilities are not immune from the addictive effects and poor health outcomes associated with cigarette use. Direct support professionals often play a large role in the social environments of people with developmental disabilities and the literature suggests that one's environment can influence behavior., Objectives: To examine the relationship between the smoking behaviors of people with developmental disabilities and their direct support professional providers. Two exploratory aims of the study were to assess how direct support professionals facilitate smoking behaviors and to describe the use of home smoking policies., Methods: The Ohio Department of Disabilities' online provider search database was used to randomly select participants. A total of 398 direct support professionals completed an online survey about smoking. Direct support professionals served as proxy reporters for the smoking behaviors of those with developmental disabilities. Descriptive statistics were calculated and Chi-Square tests were used., Results: Findings suggest that there was no significant relationship (χ 1 2  = 0.300, p = 0.584) between the current smoking behaviors of people with developmental disabilities and their direct support providers. Direct support professionals were most likely to facilitate smoking behaviors by allowing people with developmental disabilities to smoke in front of them and waiting for them to finish smoking before moving on to a new activity. Approximately 46% of people with developmental disabilities were reported to have some type of home smoking policy., Conclusions: Future research is needed to better understand the reasons why people with developmental disabilities initially start smoking and continue to smoke., (Copyright © 2018 Elsevier Inc. All rights reserved.)