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OBJECTIVE: The objective of this study was to examine the association of cigarette smoking and weight concerns in adolescents, given that adolescents may begin smoking or have difficulty quitting because of their expectancies of the effects of smoking on body weight. METHODS: This study used data from a cross-sectional survey of 4523 Connecticut high school adolescents to assess the influence of gender, smoking intensity, and dietary-restrictive behavior on smoking-related weight concerns. RESULTS: Heavy smokers were significantly less likely to engage in healthy dietary restrictions than nonsmokers; however, light smokers did not differ from nonsmokers. Both light and heavy smokers were significantly more likely to engage in unhealthy dietary restriction when compared with nonsmokers. In the model that was used to examine smokers only, heavy smokers were significantly less likely to engage in healthy dietary restriction than light smokers, but smoking level was not associated with unhealthy dietary restrictions. Dietary restrictions are significantly associated with smoking-related weight concerns; however, this seems to be related to type of dietary-restrictive behavior, with greater weight concerns observed only in those smokers who engaged in unhealthy dietary restrictions and not in those who engaged in healthy dietary restrictions or no restrictions. CONCLUSIONS: Although limited by its cross-sectional nature, the findings from this large, geographically diverse sample have clinical implications for smoking prevention and cessation interventions in adolescents. [ABSTRACT FROM AUTHOR]

Background: Shared medical appointments (SMAs) are a novel modality for treating patients with similar conditions, together, by a team of interdisciplinary providers. SMAs benefit patients with substance use disorder (SUD), but no research has focused on the feasibility of implementation of SMAs in a teaching clinic., Methods: Primary care residents rotated in a half-day ambulatory addiction clinic for 4 weeks where a third-year resident co-facilitated 4 SMAs. Confidence, knowledge, and attitudes about SUD care were assessed using web-based surveys at weeks 0, 4, and 8. Pre- and post-intervention scores were compared using a t test for paired samples., Results: Ten residents were included in the analyses. Using a 10-point Likert scale, confidence in SUD knowledge (7.0-8.3, P  = .003), confidence in counseling patients with SUD (7.1-8.2, P  = .023), and confidence in facilitating an SMA (5.7-8.3, P  = .007) showed statistically significant increases from baseline following exposure to the SMAs. Confidence that counseling and other treatments will make a difference for patients with illicit drug use increased (7.1-8.0, P  = .142), but did not differ statistically. Furthermore, on a 4-point Likert scale, understanding of behavioral therapies for treating and preventing the relapse of SUD (2.9-3.2, P  = .180) showed a similar increase. Attitudes toward patients with SUD (42.4-42.1, P  = .303) and physician empathy (119.3-119.2, P  = .963) did not change from pre- to post-intervention., Conclusions: SMAs are a feasible training tool in the education of primary care residents on an addiction medicine rotation. Residents develop confidence co-facilitating SMAs after 4 weeks. Overall, exposure to SMAs during residency can provide an opportunity to increase confidence in treating patients with SUD, as well as provide a training modality that may shift the way residents interact with patients receiving SUD treatment., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Nicotine vaping and cannabis use are common among youth. Among youth who use e-cigarettes, little is known about how and why they use cannabis and patterns of cannabis and nicotine co-use. Given the popularity of both products among youth, the study aim is to utilize qualitative data to better understand cannabis use among youth who use e-cigarettes., Method: Six focus groups of high schoolers who reported past-month e-cigarette use (N = 50; 52% male) were conducted to inform e-cigarette cessation programming. We conducted secondary data analysis examining report of cannabis use during focus groups. Transcripts were examined for report of cannabis use, reasons for use, and nicotine and cannabis co-use., Results: In focus groups, cannabis was commonly discussed. Youth reported vaping cannabis, however other forms of cannabis delivery were common (e.g. blunts, joints). Themes related to reasons for simultaneous use of nicotine and cannabis were to experience stronger psychoactive effects than using either product alone and needing to use less nicotine product overall. Reasons for liking cannabis were positive psychoactive effects and stress relief. Reasons for disliking were related to health concerns. Notably, when youth reported disliking cannabis due to health concerns, a common discussion was strategies to acquire and continue cannabis use in ways that they perceived mitigated health concerns., Conclusion: Qualitative evidence identified associations between e-cigarette use and cannabis use among youth. Research and interventions targeting youth using e-cigarettes should consider how to address dual use of these products., (Copyright © 2022 Elsevier B.V. All rights reserved.)

More effective treatments to reduce pathological alcohol drinking are needed. The glutamatergic system and the NMDA receptor (NMDAR), in particular, are implicated in behavioral and molecular consequences of chronic alcohol use, making the NMDAR a promising target for novel pharmacotherapeutics. Ethanol exposure upregulates Fyn, a protein tyrosine kinase that indirectly modulates NMDAR signaling by phosphorylating the NR2B subunit. The Src/Fyn kinase inhibitor saracatinib (AZD0530) reduces ethanol self-administration and enhances extinction of goal-directed ethanol-seeking in mice. However, less is known regarding how saracatinib affects habitual ethanol-seeking. Moreover, no prior studies have assessed the effects of Src/Fyn kinase inhibitors on alcohol-seeking or consumption in human participants. Here, we tested the effects of saracatinib on alcohol consumption and craving/seeking in two species, including the first trial of an Src/Fyn kinase inhibitor to reduce drinking in humans. Eighteen male C57BL/6NCrl mice underwent operant conditioning on a variable interval schedule to induce habitual responding for 10% ethanol/0.1% saccharin. Next, mice received 5 mg/kg saracatinib or vehicle 2 h or 30 min prior to contingency degradation to measure habitual responding. In the human study, 50 non-treatment seeking human participants who drank heavily and met DSM-IV criteria for alcohol abuse or dependence were randomized to receive 125 mg/day saracatinib ( n = 33) or placebo ( n = 17). Alcohol Drinking Paradigms (ADP) were completed in a controlled research setting: before and after 7-8 days of treatment. Each ADP involved consumption of a priming drink of alcohol (0.03 mg%) followed by ad libitum access (3 h) to 12 additional drinks (0.015 g%); the number of drinks consumed and craving (Alcohol Urge Questionnaire) were recorded. In mice, saracatinib did not affect habitual ethanol seeking or consumption at either time point. In human participants, no significant effects of saracatinib on alcohol craving or consumption were identified. These results in mice and humans suggest that Fyn kinase inhibition using saracatinib, at the doses tested here, may not reduce alcohol consumption or craving/seeking among those habitually consuming alcohol, in contrast to reports of positive effects of saracatinib in individuals that seek ethanol in a goal-directed manner. Nevertheless, future studies should confirm these negative findings using additional doses and schedules of saracatinib administration., Competing Interests: SO'M is a member of the American Society of Clinical Psychopharmacology's (ASCP's) Alcohol Clinical Trials Initiative, supported by Alkermes, Amygdala, Arbor Pharma, Dicerna, Ethypharm, Indivior, Lundbeck, Mitsubishi Tanabe, Otsuka; Consultant/advisory board member, Alkermes, Amygdala, Dicerna, Opiant; Medication supplies, Astra Zeneca, Novartis; DSMB member, Indiana University, Emmes Corporation. SK-S, PhD has received medication supplies from Astra Zeneca, Novartis. JK has been a consultant (< $10,000/year) for the following: Aptinyx, Inc., Atai Life Sciences, AstraZeneca Pharmaceuticals, Biogen, Idec, MA, Biomedisyn Corporation, Bionomics, Limited (Australia), Boehringer Ingelheim International, Cadent Therapeutics, Inc., Clexio Bioscience, Ltd., COMPASS Pathways, Limited, United Kingdom, Concert Pharmaceuticals, Inc., Epiodyne, Inc., EpiVario, Inc., Greenwich Biosciences, Inc., Heptares Therapeutics, Limited (UK), Janssen Research & Development, Jazz Pharmaceuticals, Inc., Otsuka America Pharmaceutical, Inc., Perception Neuroscience, Holdings, Inc., Spring Care, Inc., Sunovion Pharmaceuticals, Inc., Takeda Industries, and Taisho Pharmaceutical Co., Ltd. JK serves on the scientific advisory board for: Biohaven Pharmaceuticals, BioXcel Therapeutics, Inc. (Clinical Advisory Board), Cadent Therapeutics, Inc. (Clinical Advisory Board), Cerevel Therapeutics, LLC, EpiVario, Inc., Eisai, Inc., Jazz Pharmaceuticals, Inc., Lohocla Research Corporation, Novartis Pharmaceuticals Corporation, PsychoGenics, Inc., RBNC Therapeutics, Inc., Tempero Bio, Inc., Terran Biosciences, Inc. JK holds stock in: Biohaven Pharmaceuticals, Sage Pharmaceuticals, Spring Care, Inc. JK has stock options in: Biohaven Pharmaceuticals Medical Sciences, EpiVario, Inc., RBNC Therapeutics, Inc., Terran Biosciences, Inc., Tempero Bio, Inc. JK has received income (>$10,000) from their position as Editor - Biological Psychiatry. JK holds the following patents and inventions: 1. Seibyl JP, Krystal JH, Charney DS. Dopamine and noradrenergic reuptake inhibitors in treatment of schizophrenia. US Patent #:5,447,948.September 5, 1995. 2. Vladimir, Coric, Krystal, John H, Sanacora, Gerard – Glutamate Modulating Agents in the Treatment of Mental Disorders. US Patent No. 8,778,979 B2 Patent Issue Date: July 15, 2014. US Patent Application No. 15/695,164: Filing Date: 09/05/2017. 3. Charney D, Krystal JH, Manji H, Matthew S, Zarate C., - Intranasal Administration of Ketamine to Treat Depression United States Patent Number: 9592207, Issue date: 3/14/2017. Licensed to Janssen Research & Development. 4. Zarate, C, Charney, DS, Manji, HK, Mathew, Sanjay J, Krystal, JH, Yale University “Methods for Treating Suicidal Ideation,” Patent Application No. 15/379,013 filed on December 14, 2016 by Yale University Office of Cooperative Research. 5. Arias A, Petrakis I, Krystal JH. – Composition and methods to treat addiction. Provisional Use Patent Application no.61/973/961. April 2, 2014. Filed by Yale University Office of Cooperative Research. 6. Chekroud, A., Gueorguieva, R., & Krystal, JH. “Treatment Selection for Major Depressive Disorder” (filing date 3rd June 2016, USPTO docket number Y0087.70116US00). Provisional patent submission by Yale University. 7. Gihyun, Yoon, Petrakis I, Krystal JH – Compounds, Compositions and Methods for Treating or Preventing Depression and Other Diseases. U. S. Provisional Patent Application No. 62/444,552, filed on January10, 2017 by Yale University Office of Cooperative Research OCR 7088 US01. 8. Abdallah, C, Krystal, JH, Duman, R, Sanacora, G. Combination Therapy for Treating or Preventing Depression or Other Mood Diseases. U.S. Provisional Patent Application No. 62/719,935 filed on August 20, 2018 by Yale University Office of Cooperative Research OCR 7451 US01. 9. John Krystal, Godfrey Pearlson, Stephanie O'Malley, Marc Potenza, Fabrizio Gasparini, Baltazar Gomez-Mancilla, Vincent Malaterre. Mavoglurant in treating gambling and gaming disorders. U.S. Provisional Patent Application No. 63/125,181filed on December 14, 2020 by Yale University Office of Cooperative Research OCR 8065 US00. JK received the drug, Saracatinib from AstraZeneca Pharmaceuticals for research related to NIAAA grant “Center for Translational Neuroscience of Alcoholism” (CTNA-4). JK received the drug, Mavoglurant, from Novartis for research related to NIAAA grant “Center for Translational Neuroscience of Alcoholism” (CTNA-4). RG discloses the following interests unrelated to this work: royalties from book “Statistical Methods in Psychiatry and Related Fields” published by CRC Press, honorarium as a member of the Working Group for PTSD Adaptive Platform Trial of Cohen Veterans Bioscience and a United States patent application 20200143922 by Yale University: Chekroud, A., Krystal, J., Gueorguieva, R. and Chandra, A. “Methods and Apparatus for Predicting Depression Treatment Outcomes.” The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Thompson, Gianessi, O'Malley, Cavallo, Shi, Tetrault, DeMartini, Gueorguieva, Pittman, Krystal, Taylor and Krishnan-Sarin.)

E-cigarettes are popular among adolescents. Given that flavors enhance e-cigarette appeal, this study examined the influence of flavors on nicotine in e-cigarettes. Youth e-cigarette users (average 26.2 days [SD = 3.6] in past 28 days) were randomized to use e-cigarettes containing 6 or 12 mg/mL of freebase nicotine and completed 4 test sessions. During the first 3 test sessions, participants completed 3 fixed puffing bouts (1 puffing bout = 10 puffs, 3 s each, 30-s interval), using menthol, green-apple, and unflavored e-liquids (50 propylene glycol [PG]/50 vegetable glycerin [VG]) with their assigned nicotine concentration in a random order using a ∼5.5-W V2 e-cigarette device. After each puffing bout, participants assessed subjective effects of nicotine and flavor. In the 4th test session, participants used any of the e-liquids they had tried in the earlier sessions, ad libitum for 60 min and the amount of e-liquid used for each flavor and the number of puffs was assessed. Participants (n = 49; 6 mg/mL [n = 24]; 12 mg/mL [n = 25]) were 63.3% male, 65.3% non-Hispanic White with an average age of 18.7 (SD = 0.9). Mixed models analysis revealed that green apple and 6 mg/mL of nicotine independently increased liking of e-cigarette taste. In addition, green apple produced higher ratings of fruitiness, sourness, sweetness, and menthol produced higher ratings of coolness. We did not observe any interactions between nicotine and flavor. Youth liked the taste of e-liquids containing green-apple flavor or low nicotine concentration which highlights the appeal of fruit flavors in e-cigarettes to adolescents. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Introduction: Adolescents are using e-cigarettes at high rates and there is limited information on how to help them quit. We aimed to inform e-cigarette cessation interventions by understanding why adolescents use and dislike e-cigarettes and their quit experiences., Methods: Six focus groups with current users (i.e., past-month use) and 2 focus groups with past users (i.e., no past-month use) were conducted in Fall 2019 in Connecticut (N = 62). We used a focus group guide and an iterative approach to identify themes., Results: Adolescents used e-cigarettes because of social reasons and to relieve stress and reported disliking e-cigarettes due to the cost, negative health effects, and addiction. They reported both intentional and unintentional experiences with quitting e-cigarettes. Reasons for unintentional quitting included lack of access to e-cigarettes. Reasons for intentional quitting included short-term "tolerance breaks" and health concerns. Of those who tried to quit, common quitting methods were "cold turkey," giving away their device, and limiting interactions with peer users. The most common withdrawal symptom was negative mood. Notable barriers to quitting included exposure to social influences at school, easy access to e-cigarettes, and lack of motivation to quit., Discussion: Our qualitative evidence suggests that e-cigarette cessation interventions need to motivate youth to quit, and teach them to manage social influences, stress and other negative mood, and withdrawal symptoms. Interventions that address social norms related to use of e-cigarettes in school and reduce cues related to e-cigarette use may also be beneficial., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: Screening, Brief Intervention, and Referral to Treatment (SBIRT) has demonstrated efficacy for addressing unhealthy alcohol use in primary care, yet recent research indicates weaker efficacy for drug use as well as very limited success in referral to specialty care for patients with substance use disorder (SUD). Technology-based interventions for SUD delivered in primary care settings are a potential strategy of efficiently delivering treatment to those who need it., Methods: We conducted a randomized clinical trial evaluating feasibility, satisfaction, and substance use outcomes for 58 individuals with SUD. Participants being treated in a primary care practice which provides integrated addiction treatment were randomized to standard care or standard care plus access to a web-based SUD intervention (computer-based training in cognitive behavioral therapy, or CBT4CBT). Self-reported substance use and urine toxicology screens were assessed at 8 weeks after randomization., Results: Uptake of CBT4CBT in this setting was high; 77% of those assigned to this condition accessed the program at least once; of those, 77% completed all 7 modules. Satisfaction with the program was very high. Participants reported >90% days abstinent for all classes of drugs; with no significant differences between conditions., Conclusions: This study demonstrates feasibility of implementing technology-based treatments in primary care settings to address weak follow-through with the referral component of SBIRT. The overall positive outcomes in this specialized, integrated treatment setting may have undercut the ability to demonstrate differential effects on substance use; results suggest evaluation in less specialized primary care settings is warranted., Trial Registration: clinicaltrials.gov NCT03013478.

Introduction: Preliminary evidence suggests adolescents use e-cigarettes in school. However, little is known about the types of devices that are used in schools, where they are used, and who uses them. Knowledge about these issues is critical to inform school regulations., Methods: Cross-sectional surveys were conducted in 6 Connecticut high schools in 2019. Adolescents reported on current use (past 30-day use) of the following e-cigarette devices inschool: JUUL, any pod system other than JUUL, vape pens, disposables, mods, and on deviceuse in different locations: class, bathroom, hallways, outside on school grounds, and other school locations. Separate binary logistic regressions investigated predictors of use (demographics and past month use frequency of each device) in school for each device., Results: Overall, 45.0% of current users (N = 1447) used e-cigarettes at school. Among users of each device, prevalence of current use at school varied by device with 45.7% reporting JUUL use, 41.3% other pod use, 34.6% vape pen use, 38.3% disposables use and 27.3% mod use. Current users used devices in bathrooms (75.1%), followed by outside on school grounds (52.2%), classrooms (45.7%), hallways (38.8%) and other school locations (11.7%). Greater e-cigarette past month use frequency for each device was associated with device use in school., Conclusions: This study is the first to examine use of specific e-cigarette devices in schools and demonstrates that e-cigarette use frequency predicts school use. Despite rules against vaping, e-cigarette use remains prevalent in many school locations, suggesting alternative strategies such as prevention and e-cigarette education are needed., Competing Interests: Declaration of Competing Interest 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., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: Prevalence estimates of electronic cigarette (e-cigarette) use may underestimate actual use in youth. Confusion resulting from the fact that a multitude of devices (eg, vape pens, JUULs) fall under the umbrella term "e-cigarettes," the use of different names to refer to e-cigarettes (eg, vapes, electronic vaping devices), and the use of different terminology to refer to e-cigarette use (eg, "vaping," "JUULing"), may lead some young e-cigarette users to incorrectly indicate nonuse. Therefore, we compared rates of endorsing lifetime e-cigarette use when adolescents were asked about lifetime e-cigarette use in two different ways., Methods: In May to June 2018, a total of 1960 students from two high schools in Connecticut completed a computerized, school-based survey. Participants first reported on lifetime "e-cigarette" use and, subsequently, on lifetime use of five different e-cigarette devices: disposables, cig-a-likes, or E-hookahs; vape pens or Egos; JUULs; pod systems other than JUULs such as PHIX or Suorin; and advanced personal vaporizers or mods., Results: In total, 35.8% of students endorsed lifetime "e-cigarette" use, whereas 51.3% endorsed lifetime use of at least one e-cigarette device. The kappa statistic indicated only 66.6% agreement between the methods of assessing e-cigarette use. Overall, 31.5% of adolescents who endorsed lifetime device use did not endorse lifetime "e-cigarette" use, although rates of discordant responding varied across subgroups of interest (eg, sex, race)., Conclusions: Assessing adolescents' use of specific e-cigarette devices likely yields more accurate results than assessing the use of "e-cigarettes." If these findings are replicated in a nationally representative sample, regulatory efforts requiring all e-cigarette devices to be clearly labeled as "e-cigarettes" may help to reduce confusion., Implications: Different prevalence estimates of lifetime e-cigarette use were obtained depending on the way that prevalence was assessed. Specifically, fewer adolescents (35.8%) endorsed lifetime e-cigarette use when they were asked "Have you ever tried an e-cigarette, even one or two puffs?" than when they were queried about lifetime use of five different e-cigarette devices (51.3%). Among those who endorsed lifetime use of at least one specific e-cigarette device, 31.5% did not endorse lifetime "e-cigarette" use. These findings suggest that when assessing adolescents' lifetime e-cigarette use, using of terms referring to specific devices likely produces more accurate prevalence estimates than using the term "e-cigarettes.", (© The Author(s) 2018. 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: Although weight-related reasons for smoking and vaping have been examined in adults, research in adolescents is lacking. Thus, we examined the prevalence and correlates of using flavored e-liquids for appetite control or weight loss in high school adolescents., Methods: The analytic sample included 529 students who completed a school-based survey in Connecticut in Spring 2017 (50.6% female, 79.5% White, mean age 16.27 [SD = 1.18], range 13-19 years). Inclusion criteria were past-30-day vaping, using ≥ 1 flavored e-liquid (past month), and having non-missing data on flavored e-liquid use for appetite control and weight loss. Participants reported on sex, age, race, past-30-day vaping and smoking frequency, nicotine e-liquid use, flavored e-liquid use (e.g., tobacco, mint, fruit, candy), and flavored e-liquid use for appetite control and/or weight loss., Results: Adolescent e-cigarette users (past 30-days) reported vaping flavored e-liquids for appetite control (13.8%) and weight loss (9.3%). Using flavored e-liquids for appetite control or weight loss, respectively, was associated with more frequent vaping (OR = 1.21; 1.21) and using more flavored e-liquids (OR = 1.33; 1.28, p-values < 0.01). Vaping candy-flavored e-liquids (OR = 1.16, p = 0.02) uniquely was associated with vaping for appetite control., Conclusions: A subset of adolescents reported using flavored e-liquids for weight-related reasons. These adolescents reported vaping more frequently than their counterparts, raising concerns about increased nicotine exposure. Research is needed to understand where adolescents learn about weight-motivated vaping (e.g., friends, social media) and whether weight-related motives promote e-cigarette initiation among e-cigarette naïve individuals or continued/escalating use among current users., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Glutamate and opioid systems play important roles in alcohol drinking behaviors. We examined if combined treatment with the NMDA antagonist memantine and the opioid antagonist naltrexone, when compared with naltrexone alone, would have a greater influence on alcohol drinking behaviors. Fifty-six, non-treatment-seeking heavy drinkers, with alcohol dependence and a positive family history (FHP) of alcoholism, participated in a randomized, double-blind, crossover trial, including two 6-8 days treatment periods, separated by a 6-day washout, and 3 alcohol drinking paradigm (ADP) sessions. After the first baseline (BAS) ADP1 session, participants were randomized to receive either naltrexone (NTX; 50 mg/day) + placebo memantine, or NTX (50 mg/day) + memantine (MEM; 20 mg/day), during the first treatment period, following which they completed ADP2. After a 6-day washout, participants were crossed over to the treatment they did not receive during the first treatment period, following which they completed ADP3. During each ADP, participants received a priming drink of alcohol followed by 3 1-hour, self-administration periods during which they had ad-lib access to 12 drinks. Individually, both NTX and NTX + MEM, when compared to BAS ADP1, significantly reduced the number of drinks consumed (p's < 0.001) and craving (p's < 0.001). When comparing NTX + MEM vs. NTX on number of drinks consumed, there was a significant treatment* sequence interaction (p = 0.004). Specifically, when NTX + MEM followed NTX alone, NTX + MEM resulted in a further reduction in drinking (mean: -1.94; 95% CI: -2.6, -0.8, p = 0.0005). However, when NTX alone followed NTX + MEM, NTX alone did not lead to further reduction in drinking (mean: 0.59; 95% CI: -0.67, 1.43, p = 0.47). Similar patterns were observed for alcohol craving; specifically, a significant reduction in craving was observed when NTX + MEM followed NTX alone (p = 0.009), but craving reduction was maintained when NTX + MEM was followed by NTX alone. Neither treatment condition significantly influenced alcohol-induced stimulation or sedation. Memantine (at a dose of 20 mg/day) enhances the efficacy of naltrexone (50 mg/day) in reducing alcohol drinking and craving among FHP drinkers with beneficial effects that appear to carryover after discontinuation of memantine treatment.

Rates of certain tobacco products have decreased over the past decade, but nicotine use disorder is still prevalent among adolescents. New trends in tobacco use, such as in the use of electronic cigarettes, are creating alarm. This article reviews nicotine addiction and measurement in adolescents, along with potential health risks and comorbidities. Various psychosocial and pharmacologic interventions are reviewed along with novel interventions that show promise for reducing tobacco use in this vulnerable population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: JUUL e-cigarettes are popular among youth. However, it is unknown whether adolescents understand that 5% JUUL pods contain a high nicotine concentration or consider JUULs to be e-cigarettes., Method: 3170 students from 4 Connecticut high schools completed a school-based survey (May-October 2018). Students reported on lifetime and past-month JUUL use and perceived JUUL nicotine strength (low/medium/high/don't know) when no information about nicotine concentration was provided and, subsequently, when informed JUULs contain 5% nicotine. Students reported whether they believe JUULs are e-cigarettes (no/yes/don't know)., Results: Students were never JUUL users (56.6%), ever users (13.2%), and past-month users (30.2%). When no information was provided, students reported that JUULs contain low (10.5%), medium (26.9%), or high nicotine levels (31.1%); 31.4% did not know. When informed JUULs contain 5% nicotine, students were more likely to believe JUUL's nicotine strength was low (29.5%) or medium (29.3%) than high (21.3%) and less likely to report not knowing (19.9%). 39% of students believed JUULs are not e-cigarettes or did not know., Discussion: Most students were unaware of JUUL's high nicotine concentration, with more believing that JUULs contain low or medium nicotine concentrations when informed JUULs contain 5% nicotine. Thus, youth may misinterpret the nicotine concentration printed on JUUL pod packaging, raising concerns about inadvertent exposure to high nicotine levels and dependence risk. Further, 39% of adolescents believed JUULs are not e-cigarettes or were unsure. Regulatory efforts are needed to establish understandable nicotine concentration labels, require products to be labeled accordingly, and clarify what products constitute e-cigarettes., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: We conducted a systematic review of the literature on cigar research on youth to identify potential future research agenda to generate evidence to inform cigar regulations to prevent cigar use among youth., Methods: We searched articles on Medline, EMBASE, and PsycINFO in April 2017 to identify articles relevant to cigars and adolescents. Two independent coders examined 48 articles to determine eligibility: (1) published between 2000-April 2017; (2) published in English; (3) conducted in the United States; (4) published in a peer-review journal; (5) examined cigars, cigarillos, or little cigars; (6) included youth (12-18 years old); and (7) included empirical data. Three independent coders reviewed the included articles (n = 48) to identify whether the studies addressed FDA's Research Priorities., Results: The studies addressed FDA's Research Priorities of "behavior" (n = 48), "communications" (n = 4), "marketing influences" (n = 1), and "impact analysis" (n = 1). Studies on "behavior" underscored the need for improvements in measurement, such as using brand names and distinguishing cigar products. The review revealed the need for restrictions on cigar flavors, development of media campaigns and interventions, increasing the cost (via taxation), and evaluating the impact of cigar policies., Conclusions: The studies mostly focused on surveillance of behaviors and use patterns, which revealed cigar specific issues to address in policies to decrease cigar use among youth. The lack of studies addressing other FDA's research priorities highlighted the critical need for future studies that inform prevention of youth cigar use., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Rates of e-cigarette use are high among youth, and there is little known about the long-term health effects of e-cigarettes. Since peer influence is a powerful determinant of tobacco use, we aimed to identify message themes about e-cigarettes that youth would use to encourage or discourage peers from using e-cigarettes. We conducted 10 focus groups (N = 69) with non-smokers and smokers from one middle school, high school and college in Connecticut. Participants engaged in a discussion about e-cigarettes, and each participant created one written message to encourage e-cigarette use and one to discourage use among peers. We content-analyzed the messages and identified three main themes and 12 encouraging and discouraging sub-themes. Encouraging themes included health benefits of e-cigarettes relative to cigarettes, attractive product characteristics (e.g. flavors) and social advantages (e.g. positive social image) of using e-cigarettes. Discouraging messages included health risks of e-cigarettes relative to cigarettes, unattractive product characteristics (e.g. cost) and social disadvantages (e.g. negative social image of using an e-cigarette). Overall, there were no differences by sex, age group or smoking status in generation of encouraging and discouraging message themes. This study identified youth-generated themes that may aid in e-cigarette prevention among youth., (� The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background E-cigarette use rates are high among youth, but there is limited information on the types of e-cigarette devices that are used by youth. Methods During Spring 2017, students from 4 high schools completed surveys on use of e-cigarette devices (cig-a-like, vape/hookah pen, modified devices or mods, and JUUL). Among youth who endorsed ever (lifetime) use of an e-cigarette and of at least one device (n = 875), we assessed 1) prevalence rates of ever and current (past-month) use of each device, 2) use of nicotine in each device, and 3) predictors [age, sex, race, socioeconomic status (SES), other tobacco use] of ever use of each device and of use of single versus multiple devices. Results Cig-a-likes were used least frequently (Ever use: cig-a-likes: 25.4%; vape/hookah pens: 60.6%; JUUL: 64.2%; mods: 71.2%; Current use: cig-a-likes: 7.3%; vape/hookah pens; 18.7%; mods: 33.1%; JUUL: 47.1%;). Nicotine use was highest for JUUL (JUUL: 80.3%; mods: 56.3%; cig-a-likes: 51.4%; vape/hookah pens: 46.8%). Among ever users of single devices, use of JUUL was highest (JUUL: 43%; mods: 32%; vape/hookah pens: 21%; cig-a-likes: 4%). Ever use of all devices, except JUUL, was associated with other tobacco product use. Ever use of JUUL was associated with higher SES. Ever use of multiple devices (two: 34.7%; three: 25.8%; four: 11.7%) compared with a single device (27.8%) was associated with other tobacco product use. Conclusions Targeted regulatory and prevention efforts that consider the use of multiple e-cigarette devices are needed to lower youth e-cigarette use rates., (Copyright © 2018 Elsevier B.V. All rights reserved.)

[This corrects the article DOI: 10.1371/journal.pone.0189015.].

Objectives: We used focus groups to understand cigar product features that increase the appeal of blunts (hollowed out cigars filled with marijuana) among adolescents and young adults., Methods: With a standardized focus group guide, we assessed cigar use behaviors and perceptions among lifetime cigar users (N = 47; 8 focus groups separated by sex and age group [adolescents, young adults]) in 2016. We analyzed data related to blunts., Results: Overall, 85.5% of the participants had smoked a blunt in the past 30 days (38% used daily). Participants perceived that cheap cigar brands were used primarily for blunts. Cigar product features that made them useful for blunts included wide availability, easy accessibility (easy to bypass underage purchasing restrictions), attractive flavors, inexpensive cost, perforated wrappers that make cigars easy to open, and ability to remove the inner wrapper (also referred to as "cancer paper") to reduce the risk of harm., Conclusions: Various product features of cigars make it easy for adolescents and young adults to manipulate them to create blunts. Tobacco regulations that include restrictions on product characteristics, as well as enforcement of prohibition of sales of cigars to underage minors are needed. Youth also need to be educated about harms of blunt use., Competing Interests: Conflict of Interest Statement None to report

Among adolescents, low socioeconomic status (SES) is associated with greater exposure to tobacco cigarette advertising and cigarette use. However, associations among SES, e-cigarette advertising and e-cigarette use are not well understood. This study examined exposure to e-cigarette advertisements as a mediator of the relationship between SES and adolescent e-cigarette use. Adolescents (N = 3473; 51% Female) from 8 high schools in Connecticut completed an anonymous survey in Spring 2015. Mediation analysis was used to examine whether the total number of sources of recent e-cigarette advertising exposure (e.g., TV, radio, billboards, magazines, local stores [gas stations, convenience stores], vape shops, mall kiosks, tobacco shops, social media) mediated the association between SES (measured by the Family Affluence Scale) and past-month frequency of e-cigarette use. We clustered for school and controlled for other tobacco product use, age, sex, race/ethnicity and perceived social norms for e-cigarette use in the model. Our sample recently had seen advertisements via 2.1 (SD = 2.8) advertising channels. Mediation was supported (indirect effect: β = 0.01, SE = 0.00, 95% CI [0.001, 0.010], p = 0.02), such that higher SES was associated with greater recent advertising exposure, which, in turn, was associated with greater frequency of e-cigarette use. Our study suggests that regulations to reduce youth exposure to e-cigarette advertisement may be especially relevant to higher SES youth. Future research should examine these associations longitudinally and evaluate which types of advertisements target different SES groups., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Urine adulteration is a concern among patients treated for opioid use disorder. Quantitative urine testing for buprenorphine (B) and norbuprenorphine (NB), and the appropriate interpretation of B and NB levels, can facilitate constructive conversations with patients that may lead to modifications in the treatment plan, and strengthening of the patient-provider relationship., Case Summary: Three cases are presented in which discordant urine B and NB levels were recognized. Each patient was submerging buprenorphine/naloxone strips in their urine to mask ongoing illicit drug use. The authors used an approach to addressing intentional adulteration of urine samples that adheres to the principles of harm-reduction, the centrality of the patient-provider relationship, and the acknowledgment that ongoing illicit drug use and subsequent dishonesty about disclosure may be common among persons with substance use disorders. Each of the three patients ultimately endorsed diluting their urine, which allowed for strengthening of the patient-provider relationship and modifications to their treatment plans. Two of the three patients stabilized and achieved abstinence, while the third was eventually referred to a methadone treatment program., Conclusion: Providers should routinely monitor B and NB levels, rather than qualitative screening alone, and discordant levels should elicit a timely conversation with the patient. The authors use of a nonjudgmental approach to address urine adulteration, including giving patients an opportunity to reflect on potential solutions, has been effective at helping patients and providers to reestablish a therapeutic alliance and maintain retention in treatment., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: Many e-cigarette users find the variety of e-cigarette flavors appealing. We examined whether preferences for e-liquid flavors and the total number of flavors preferred differed between samples of adolescent and adult e-cigarette users. We also examined whether these preferences were associated with e-cigarette use frequency for adolescents or adults, respectively., Materials and Methods: The analytic samples comprised 1) 396 adolescent, past-month e-cigarette users from 5 Connecticut high schools who completed an anonymous, school-based survey in Fall 2014 (56.1% male; 16.18 [1.18] years; 42.2% past-month smokers), and 2) 590 adult, past-month e-cigarette users who completed an anonymous, MTurk survey in Fall 2014 (53.7% male; 34.25 [9.89] years; 51.2% past-month smokers)., Results: Compared to adults, a larger proportion of adolescents preferred fruit, alcohol, and "other"-flavored e-liquids, whereas adults disproportionately preferred tobacco, menthol, mint, coffee, and spice-flavored e-liquids (p-values < .05). Adults also preferred a greater total number of flavors compared to adolescents and used e-cigarettes more frequently (p-values < .001). Flavor preferences uniquely were associated with frequency of e-cigarette use within the adolescent sample; the total number of flavors preferred was associated with more days of e-cigarette use (ηp2 = 0.04), as were preferences for fruit (ηp2 = 0.02), dessert (ηp2 = 0.02), and alcohol-flavored (ηp2 = 0.02) e-liquids., Conclusions: Flavor preferences differed between adolescent and adult samples. While youth reported less frequent e-cigarette use overall, their preferences for specific flavors and the total number of flavors preferred were associated with more days of e-cigarette use, indicating that flavor preferences may play an important role in adolescent e-cigarette use.

Background: Electronic cigarette (e-cigarette) use is common among youth, and there are concerns that e-cigarette use leads to future conventional cigarette use. We examined longitudinal associations between past-month cigarette and e-cigarette use to characterize the stability and directionality of these tobacco use trajectories over time., Methods: High school students ( N = 808, 53% female) completed surveys across 3 waves (2013, 2014, and 2015) in 3 public schools in Connecticut. Using autoregressive cross-lagged models, we examined bidirectional relationships between past-month cigarette and e-cigarette use over time. Models were adjusted for covariates related to tobacco use (ie, sex, race/ethnicity, socioeconomic status, and use of other tobacco products)., Results: Past-month e-cigarette use predicted future cigarette use (wave 1-2: odds ratio [OR] = 7.08, 95% confidence interval [CI] = 2.34-21.42; wave 2-3: OR = 3.87, 95% CI = 1.86-8.06). However, past-month cigarette use did not predict future e-cigarette use (wave 1-2: OR = 2.02, 95% CI = 0.67-6.08; wave 2-3: OR = 1.90, 95% CI = 0.77-4.71). Additionally, frequency of cigarette and e-cigarette use increased over time. By wave 3, 26% of cigarette users and 20.5% of e-cigarette users reported using 21-30 days out of the past month., Conclusions: E-cigarette use was associated with future cigarette use across 3 longitudinal waves, yet cigarette use was not associated with future e-cigarette use. Future research needs to examine mechanisms through which e-cigarette use leads to cigarette use. E-cigarette regulation and prevention programs may help prevent future use of cigarettes among youth., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Introduction: Identifying youth at risk for future e-cigarette use is critical for informing prevention efforts. Prior research established measures of susceptibility to conventional cigarettes, and this study aimed to examine whether items adapted for e-cigarette susceptibility predicted subsequent e-cigarette use among never e-cigarette users., Methods: Longitudinal school-wide survey data were collected from middle and high school students in Fall 2013 (wave 1) and Spring 2014 (wave 2). Among never e-cigarette users at wave 1 (n = 1720), e-cigarette susceptibility was measured by two items assessing anticipation of experimenting with e-cigarettes in the future and willingness to use an e-cigarette if offered by a best friend. Logistic regression models examined susceptibility as a predictor of e-cigarette initiation and past 30-day use 6 months later at wave 2. Models were clustered by school and controlled for sex, age, race, SES, and other substance use (alcohol, marijuana, and other tobacco)., Results: In total, 8.9% (n = 153) of youth initiated e-cigarettes and 3.7% (n = 63) reported past 30-day use at wave 2. E-cigarette susceptibility was a significant independent predictor of subsequent initiation (OR = 4.27, 95% CI = 3.12-5.85) and past 30-day e-cigarette use (OR = 5.10, 95%CI = 3.38-7.68) 6 months later. Susceptible youth were more likely to be male, older, and have used alcohol, marijuana, or other tobacco products., Conclusions: These findings provide initial support for adapting two susceptibility items to identify adolescents at risk for future e-cigarette use. Identifying strategies that are effective for targeting susceptible youth and preventing future e-cigarette use will be critical areas for future research., Implications: More than a quarter of the sample who reported both a willingness to try e-cigarettes if offered by a best friend and anticipation of experimenting with e-cigarettes in the future went on to try e-cigarettes within the academic year, suggesting that targeting this group will be critical for preventing youth e-cigarette initiation. There were notable demographic differences between susceptible and non-susceptible youth, suggesting targeting e-cigarette prevention efforts to male students who have used other substances may be especially important for preventing future e-cigarette use. Research is needed to determine the most effective prevention strategies to reach susceptible youth., (© The Author(s) 2016. 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: Identifying risk factors for youth e-cigarette use is critical, given high rates of e-cigarette use and unknown health effects of long-term use. The current study examined whether an early age of onset of e-cigarette use mediates the association between impulsivity and e-cigarette frequency., Methods: Cross-sectional survey data of e-cigarette users (n=927) were collected from 8 high schools in southeastern Connecticut. The sample was 44.7% female (mean age 16.2 [SD=1.2], mean age of e-cigarette onset 14.7 [SD=1.6]). Two domains of self-reported, trait impulsivity were assessed using the abbreviated Barratt Impulsiveness Scale: impaired self-regulation (e.g., problems with concentration or self-control) and behavioral impulsivity (e.g., doing things without thinking). Mediation was tested with Mplus, and the model included school as a cluster variable and controlled for covariates related to e-cigarette use (i.e., sex, age, race, peer use, and other tobacco products ever tried)., Results: The hypothesized mediation was supported for both domains of impulsivity (impaired self-regulation a 1 b=0.09, SE=0.02, 95%CI [0.03-0.14], p=.002; behavioral impulsivity a 2 b=0.07, SE=0.03, 95%CI [.01-.14], p=0.03). Specifically, impaired self-regulation (B=-0.33, SE=0.06, p<0.001) and behavioral impulsivity (B=-0.26, SE=0.11, p=0.02) predicted trying e-cigarettes at an earlier age, and earlier initiation was associated with more days of e-cigarette use in the past month (B=-0.28, SE=0.08, p<0.001)., Conclusions: Adolescents who endorse aspects of impulsivity, such as acting without thinking, are at greater risk for more frequent e-cigarette use through an early age of e-cigarette initiation. Further research is needed to evaluate these relationships longitudinally and to develop targeted e-cigarette interventions for impulsive youth., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: This exploratory study examines the prevalence and predictors of current and former smokers' use of electronic (e-) cigarettes for smoking cessation among a sample of adolescent and young adult established smokers., Methods: We conducted school-wide surveys in two middle (n = 1166) and four high schools (n = 3614) in fall 2013 and one public college (n = 625) in spring 2014. We analyzed data from 189 established smokers (reported smoking 100 cigarettes in their lifetime) who also reported ever-use of e-cigarettes (50.7% female, 89.4% White race, Mage 18.3 [SD = 2.8]). We further classified participants as current smokers (reported past-month cigarette smoking) and former smokers (no past-month smoking). Adjusted logistic regression assessed associations of using e-cigarettes to quit smoking with demographic, cigarette and e-cigarette use patterns, e-cigarette flavor preference, and risk perception variables., Results: Overall, 41.8% of the sample reported that they "have used an e-cigarette to quit smoking." In adjusted models, older age, White race, higher e-cigarette frequency, and preference for using a combination of e-cigarette flavors predicted increased odds of having used e-cigarettes to quit smoking (p < .05). Using e-cigarettes to quit smoking was not associated with current or former cigarette smoking status or perceptions that "e-cigarettes help people quit smoking" or "e-cigarettes are safer than quit smoking medications.", Conclusions: Adolescents and young adults who report more frequent e-cigarette use and preference for using flavor combinations are more likely to use e-cigarettes for smoking cessation. Future studies are needed to determine whether e-cigarette use leads to tobacco abstinence in youth smokers., Implications: Among young established smokers, more frequent e-cigarette use and preference for using flavors mixed together, but not perceptions of harmfulness of e-cigarettes or comparative safety of e-cigarettes compared with cigarettes or other smoking cessation medications or helpfulness of e-cigarettes in quitting smoking, are associated with using e-cigarettes for smoking cessation., (© The Author 2016. 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: Tobacco products containing menthol are widely used by youth. We used e-cigarettes to conduct an experimental evaluation of the independent and interactive effects of menthol and nicotine among youth., Procedures: Pilot chemosensory experiments with fourteen e-cigarette users identified low (barely perceptible, 0.5%) and high (similar to commercial e-liquid, 3.5%) menthol concentrations. Sixty e-cigarette users were randomized to a nicotine concentration (0mg/ml, 6mg/ml, 12mg/ml) and participated in 3 laboratory sessions. During each session, they received their assigned nicotine concentration, along with one of three menthol concentrations in random counterbalanced order across sessions (0, 0.5%, 3.5%), and participated in three fixed-dose, and an ad-lib, puffing period. Urinary menthol glucuronide and salivary nicotine levels validated menthol and nicotine exposure. We examined changes in e-cigarette liking/wanting and taste, coolness, stimulant effects, nicotine withdrawal and ad-lib use., Results: Overall, the high concentration of menthol (3.5%) significantly increased e-cigarette liking/wanting relative to no menthol (p<0.001); there was marginal evidence of nicotine* menthol interactions (p=0.06), with an increase in liking/wanting when 3.5% menthol was combined with 12mg/ml nicotine, but not 6mg/ml nicotine. Importantly, both 0.5% and 3.5% menthol concentrations significantly improved taste and increased coolness. We did not observe nicotine or menthol-related changes in stimulant effects, nicotine withdrawal symptoms or ad-lib use., Conclusions: Menthol, even at very low doses, alters the appeal of e-cigarettes among youth. Further, menthol enhances positive rewarding effects of high nicotine-containing e-cigarettes among youth., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To identify the appealing components of cigar packaging among youth., Methods: We conducted 8 focus groups among cigar users, separated by sex and age group (ie, adolescents, young adults) in Connecticut between February and July, 2016. Participants were shown cigar packages and instructed to circle aspects of the images on the packages that appealed to them independently and a group discussion followed., Results: The appealing components identified were flavors (46.8%), price promotions (28.8%), branding (21.2%), marketing claims (17.2%, eg, "natural"), product features (15.2%, eg, the word "cigarillo"), number of cigars (8.0%), color (4.4%), re-sealable features (2.8%), and other (6.0%; eg "limited offer," geographic region). Relative to female participants, male participants were more likely to find flavors and price promotions appealing, and less likely to find colors as appealing (ps < .05). Relative to young adults, adolescents were more likely to find price promotions, branding, marketing claims and number of cigars appealing, and less likely to find colors as appealing (ps < .05)., Conclusions: In order to reduce the appeal of cigars to youth, regulatory agencies should consider prohibiting flavors, appealing colors, price promotions, misleading marketing claims, and logos/trademarks on cigar packaging., Competing Interests: Conflict of Interest All authors of this article declare they have no conflicts of interest.

Problem: Substance use is highly prevalent in the United States, but little time in the curriculum is devoted to training internal medicine residents in addiction medicine., Approach: In 2014, the authors developed and launched the Addiction Recovery Clinic (ARC) to address this educational gap while also providing outpatient clinical services to patients with substance use disorders. The ARC is embedded within the residency primary care practice and is staffed by three to four internal medicine residents, two board-certified addiction medicine specialists, one chief resident, and one psychologist. Residents spend one half-day per week for four consecutive weeks at the ARC seeing new and returning patients. Services provided include pharmacological and behavioral treatments for opioid, alcohol, and other substance use disorders, with direct referral to local addiction treatment facilities as needed. Visit numbers, a patient satisfaction survey, and an end-of-rotation resident evaluation were used to assess the ARC., Outcomes: From 2014 to 2015, 611 patient encounters occurred, representing 97 new patients. Sixty-one (63%) patients were seen for opioid use disorder. According to patient satisfaction surveys, 29 (of 31; 94%) patients reported that the ARC probably or definitely helped them to cope with their substance use. Twenty-eight residents completed the end-of-rotation evaluation; all rated the rotation highly., Next Steps: The ARC offers a unique primary-care-based approach to exposing internal medicine residents to the knowledge and skills necessary to diagnose, treat, and prevent unhealthy substance use. Future research will examine other clinical and educational outcomes.

Objective: To understand reasons for cigarillo initiation and cigarillo manipulation methods among adolescents., Methods: We conducted surveys in 8 Connecticut high schools to assess reasons for trying a cigarillo and cigarillo manipulation methods. We used multivariable logistic regressions to assess associations with demographics and tobacco use status., Results: Among ever cigarillo users (N = 697, 33.6% girls, 16.7 years old [SD = 1.14], 62.1% White), top reasons for trying a cigarillo were curiosity (41.9%), appealing flavors (32.9%), because "friends use it" (25.3%), and low cost (22.4%). Overall, 40.3% of ever cigarillo users added marijuana (to create blunts) and 39.2% did not manipulate the product. Endorsement of these reasons for initiation and manipulation methods differed significantly across sex, age, SES and other tobacco use., Conclusions: Cigarillo regulations should include restricting all appealing flavors, increasing the cost, monitoring the restriction of sales of cigarillos to minors, and decreasing the appeal of cigarillo manipulation., Competing Interests: Conflict of Interest All authors of this article declare they have no conflicts of interest.

Background: Electronic cigarettes (e-cigarettes) electrically heat and vaporize e-liquids to produce inhalable vapors. These devices are being used to inhale vapors produced by dripping e-liquids directly onto heated atomizers. The current study conducts the first evaluation of the prevalence rates and reasons for using e-cigarettes for dripping among high school students., Methods: In the spring of 2015, students from 8 Connecticut high schools ( n = 7045) completed anonymous surveys that examined tobacco use behaviors and perceptions. We assessed prevalence rates of ever using e-cigarettes for dripping, reasons for dripping, and predictors of dripping behaviors among those who reported ever use of e-cigarettes., Results: Among 1080 ever e-cigarette users, 26.1% of students reported ever using e-cigarettes for dripping. Reasons for dripping included produced thicker clouds of vapor (63.5%), made flavors taste better (38.7%), produced a stronger throat hit (27.7%), curiosity (21.6%), and other (7.5%). Logistic regression analyses indicated that male adolescents (odds ratio [OR] = 1.64), whites (OR = 1.46), and those who had tried multiple tobacco products (OR = 1.34) and had greater past-month e-cigarette use frequency (OR = 1.07) were more likely to use dripping ( P s < .05)., Conclusions: These findings indicate that a substantial portion (∼1 in 4) of high school adolescents who had ever used e-cigarettes also report using the device for dripping. Future efforts must examine the progression and toxicity of the use of e-cigarettes for dripping among youth and educate them about the potential dangers of these behaviors., (Copyright © 2017 by the American Academy of Pediatrics.)

Objective: We examined the associations between socioeconomic status (SES) and adolescent polytobacco use profiles (including e-cigarettes and blunts)., Methods: Adolescents (N = 1932) completed surveys conducted in 2014 in 3 Connecticut high schools. Within a Latent Class Analysis (LCA) framework, logistic regressions examined associations between SES and polytobacco use profiles comprising never, ever, and current e-cigarette, blunt, cigarette, cigar, cigarillo, hookah, and smokeless tobacco use., Results: We identified 5 classes: (1) current polytobacco users; (2) ever polytobacco users; (3) current e-cigarette, blunt, and cigarette users; (4) ever e-cigarette and blunt users; and (5) never users. Low SES, relative to high SES, was associated with greater likelihood of being: (1) an ever polytobacco user; (2) a current e-cigarette, blunt, and cigarette user; and (3) an ever e-cigarette and blunt user, relative to a never user., Conclusions: Low SES is associated with membership in distinct polytobacco use latent classes. Regulatory initiatives that focus exclusively on cigarette use may miss the opportunity to influence adolescent use of other products, which may be especially relevant to low-income individuals. Future research should examine whether targeting a broader range of products reduces SES-related tobacco use disparities., Competing Interests: Conflict of Interest Disclosure Statement: All authors of this article declare they have no conflicts of interest.

Objectives: We examined sources of e-cigarette acquisition among youth, and changes in these sources, between 2014 and 2015. We also assessed whether youth were ever refused the sale of e-cigarettes., Methods: Anonymous, cross-sectional surveys conducted in five high schools in 2014 and 2015 in Connecticut assessed demographics, e-cigarette and cigarette use, and e-cigarette acquisition sources (friends/boyfriends/girlfriends, tobacco shops, siblings, online, parents/adult family members, other). We restricted analyses to adolescents younger than 18 years old who had used e-cigarettes in the past month (2014: N = 400, 2015: N = 390)., Results: Top sources of e-cigarette acquisition were friends (2014: 50.2%, 2015: 45.4%), tobacco shops (2014: 17.5%, 2015: 12.6%), and online shops (2014: 9.8%, 2015: 10.5%). A multilevel model, controlling for sex, age, and cigarette smoking status, while clustering by schools showed a decrease in the proportion of youth obtaining e-cigarettes from friends (AOR = .84) between 2014 and 2015. In 2015, 69.8% and 85.8% purchased e-cigarettes from a physical store and an online store, respectively., Conclusions: Peers were the most popular source of e-cigarette acquisition. Many adolescents were able to purchase e-cigarettes from commercial sources. Future studies should continue to conduct surveillance of where adolescents obtain e-cigarettes to inform prevention strategies., Competing Interests: Conflict of Interest Statement All authors of this article declare they have no conflicts of interest.

Background: Effective electronic cigarette (e-cigarette) prevention messages are needed to combat the rising popularity/uptake of e-cigarettes among youth. We examined preferences for e-cigarette prevention messages that either emphasized gains (e.g., You save money by not using e-cigarettes) or losses (e.g., You spend money by using e-cigarettes) among adolescents and young adults., Methods: Using surveys in two middle schools, four high schools, and one college in CT (N=5405), we assessed students' preferences for gain- or loss-framed e-cigarette prevention messages related to four themes: financial cost, health risks, addiction potential, and social labeling as a smoker. We also assessed whether preferences for each message framing theme differed by sex, school level, cigarette-use status, and e-cigarette use-status. We also examined whether preference for message framing differed by cigarette and e-cigarette susceptibility status among never e-cigarette users., Results: Overall, loss-framing was preferred for message themes related to health risks, addiction potential, and social labeling as a smoker, whereas gain-framing was preferred for message themes related to financial cost. Logistic regression analyses showed that 1) females preferred loss-framed messages for all themes relative to males, 2) lifetime e-cigarette users preferred loss-framed health risks and social labeling messages relative to never users, and 3) high school students preferred gain-framed social labeling messages relative to college students. The preference for message framing did not differ by cigarette or e-cigarette susceptibility., Conclusions: Preference for message framing differed by themes and individual characteristics. This formative research could inform the construction of persuasive e-cigarette prevention messages., (Copyright © 2016. Published by Elsevier Ltd.)

Objective: E-cigarettes are popular among youth, but little is known about the nicotine concentrations of e-liquids used by adolescents., Materials and Method: In Spring, 2014, we conducted cross-sectional surveys in four Connecticut high schools and two middle schools. Among past-30-day e-cigarette users (n=513, 45% female, mean age 15.9 [SD=1.4]), we examined what nicotine concentration adolescents typically used in their e-cigarettes (range 0-30mg/mL and "I don't know"). We first examined whether age, sex, smoking status, e-cigarette use frequency, and/or e-cigarette acquisition source were associated with using nicotine-free e-liquid, nicotine e-liquid, or not knowing the e-liquid nicotine concentration. Among nicotine users (n=185), we then examined whether the aforementioned variables were associated with using higher nicotine concentrations., Results: Adolescents reported using nicotine-free e-liquid (28.5%), nicotine e-liquid (37.4%), or not knowing their e-liquid nicotine concentration (34.1%). Nicotine users comprised more smokers and heavier e-cigarette users compared to nicotine-free e-liquid users and those who did not know their nicotine concentration. Nicotine users also comprised more males and were more likely to purchase e-cigarettes online or from tobacco shops compared to those who did not know their nicotine concentration. Among nicotine users, cigarette smoking, male sex, and purchasing e-cigarettes from tobacco shops predicted using higher nicotine concentrations., Conclusions: Adolescents reported using e-liquids with variable nicotine concentrations. Smokers, males, and those who purchased their own e-cigarettes reported using the highest nicotine levels. Of concern, many adolescents were unaware of the nicotine concentration in their e-liquid, raising concerns about inadvertent nicotine exposure among youth., Competing Interests: No conflict declared., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Longitudinal research is needed to identify predictors of continued electronic cigarette (e-cigarette) use among youth. We expected that certain reasons for first trying e-cigarettes would predict continued use over time (eg, good flavors, friends use), whereas other reasons would not predict continued use (eg, curiosity)., Methods: Longitudinal surveys from middle and high school students from fall 2013 (wave 1) and spring 2014 (wave 2) were used to examine reasons for trying e-cigarettes as predictors of continued e-cigarette use over time. Ever e-cigarette users (n = 340) at wave 1 were categorized into those using or not using e-cigarettes at wave 2. Among those who continued using e-cigarettes, reasons for trying e-cigarettes were examined as predictors of use frequency, measured as the number of days using e-cigarettes in the past 30 days at wave 2. Covariates included age, sex, race, and smoking of traditional cigarettes., Results: Several reasons for first trying e-cigarettes predicted continued use, including low cost, the ability to use e-cigarettes anywhere, and to quit smoking regular cigarettes. Trying e-cigarettes because of low cost also predicted more days of e-cigarette use at wave 2. Being younger or a current smoker of traditional cigarettes also predicted continued use and more frequent use over time., Conclusions: Regulatory strategies such as increasing cost or prohibiting e-cigarette use in certain places may be important for preventing continued use in youth. In addition, interventions targeting current cigarette smokers and younger students may also be needed., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2016 by the American Academy of Pediatrics.)

Objective: There is limited research on adolescents' use of e-cigarettes and other substances., Materials and Methods: 2241 Connecticut high school students completed anonymous, cross-sectional surveys assessing e-cigarette and other substance use. We used latent class analysis (LCA) to: (1) classify students based on their past-month use of e-cigarettes, cigarettes, cigars, smokeless tobacco, hookah, blunts, marijuana, and alcohol, and (2) determine if age, sex, or race predicted class membership., Results: Past-month e-cigarette use was 11.6%, and use rates for the remaining substances ranged from 2.8% (smokeless tobacco) to 20.7% (alcohol). The optimal latent class solution comprised four classes: (1) primarily abstainers (81.6%; abstainers), (2) primarily e-cigarette and alcohol users (4.6%; E-cigarette-Alcohol), (3) primarily marijuana and alcohol users (6.9%; Marijuana-Alcohol), and (4) primarily users of all products (6.9%; All Products). Compared to abstainers, (1) all substance-using classes comprised older students, (2) the All Products and E-cigarette-Alcohol classes were more likely to comprise males and less likely to comprise Blacks, and (3) the Marijuana-Alcohol class was more likely to comprise Blacks and Latinos. Relative to the All Products and E-cigarette-Alcohol classes, the Marijuana-Alcohol class was more likely to comprise females, Blacks, and Latinos., Conclusions: LCA identified four substance use classes, two of which included elevated e-cigarette use. Class membership differed by age, sex, and race. Additional research should evaluate characteristics that may explain the different product use profiles identified in the current study including cultural differences, peer group norms, and differing perceptions of the harmfulness of each substance., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Research has shown that adults perceive that electronic cigarettes (e-cigarettes) are effective for smoking cessation, yet little is known about adolescents and young adults' perceptions of e-cigarettes for quitting cigarette smoking. This study describes middle, high school, and college students' beliefs about, and experiences with, e-cigarettes for cigarette smoking cessation., Methods: We conducted 18 focus groups (n = 127) with male and female cigarette smokers and nonsmokers in 2 public colleges, 2 high schools, and 1 middle school in Connecticut between November 2012 and April 2013. Participants discussed cigarette smoking cessation in relation to e-cigarettes. Verbatim transcripts were analyzed using thematic analysis., Results: All participants, regardless of age and smoking status, were aware that e-cigarettes could be used for smoking cessation. College and high school participants described different methods of how e-cigarettes could be used for smoking cessation: (a) nicotine reduction followed by cessation; (b) cigarette reduction/dual use; and (c) long-term exclusive e-cigarette use. However, overall, participants did not perceive that e-cigarette use led to successful quitting experiences. Participants described positive attributes (maintenance of smoking actions, "healthier" alternative to cigarettes, and parental approval) and negative attributes (persistence of craving, maintenance of addiction) of e-cigarettes for cessation. Some college students expressed distrust of marketing of e-cigarettes for smoking cessation., Conclusions: Adolescent and young adult smokers and nonsmokers perceive that there are several methods of using e-cigarettes for quitting and are aware of both positive and negative aspects of the product. Future research is needed to determine the role of e-cigarettes for smoking cessation in this population., (© The Author 2015. 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 and Objectives: Electronic cigarette (e-cigarette) use is increasing rapidly among high school (HS) students. Of concern, e-cigarettes can be used to vaporize cannabis, although use rates among adolescents are unknown. We evaluated lifetime rates of using e-cigarettes to vaporize cannabis among all lifetime e-cigarette users (27.9%), all lifetime cannabis users (29.2%), and lifetime users of both e-cigarettes and cannabis (18.8%); common means of vaporizing cannabis including hash oil, wax infused with Δ-9-tetrahydrocannabinol (THC), and dried cannabis; and demographic predictors of using e-cigarettes to vaporize cannabis., Methods: In the spring of 2014, 3847 Connecticut HS students completed an anonymous survey assessing e-cigarette and cannabis use., Results: Vaporizing cannabis using e-cigarettes was common among lifetime e-cigarette users, lifetime cannabis users, and lifetime dual users (e-cigarette 18.0%, cannabis 18.4%, dual users 26.5%). Students reported using e-cigarettes to vaporize hash oil (e-cigarette 15.4%, cannabis 15.5%, dual users 22.9%) and wax infused with THC (e-cigarette 10.0%, cannabis 10.2%, dual users 14.8%) and using portable electronic vaporizers to vaporize dried cannabis leaves (e-cigarette 19.6%, lifetime cannabis 23.1%, lifetime dual users 29.1%). Binary logistic regression indicated that male students (odds ratio [OR] = 2.05), younger students (OR = 0.64), lifetime e-cigarette users (OR = 5.27), and lifetime cannabis users (OR = 40.89) were most likely to vaporize cannabis using e-cigarettes. Rates also differed by HS attended., Conclusions: Rates of vaporizing cannabis using e-cigarettes were high. These findings raise concerns about the lack of e-cigarette regulations and the potential use of e-cigarettes for purposes other than vaping nicotine., (Copyright © 2015 by the American Academy of Pediatrics.)

Introduction: Understanding why young people try and stop electronic cigarette (e-cigarette) use is critical to inform e-cigarette regulatory efforts., Methods: We conducted 18 focus groups (N = 127) in 1 middle school (MS), 2 high schools (HSs), and 2 colleges in Connecticut to assess themes related to e-cigarette experimentation and discontinuation. We then conducted surveys to evaluate these identified themes in 2 MSs, 4 HSs, and 1 college (N = 1,175) to explore whether reasons for e-cigarette experimentation and/or discontinuation differed by school level or cigarette smoking status., Results: From the focus groups, we identified experimentation themes (i.e., curiosity, flavors, family/peer influence, easy access, and perceptions of e-cigarettes as "cool" and as a healthier/better alternative to cigarettes) and discontinuation themes (i.e., health concerns, loss of interest, high cost, bad taste, and view of e-cigarettes as less satisfying than cigarettes). The survey data showed that the top reasons for experimentation were curiosity (54.4%), appealing flavors (43.8%), and peer influences (31.6%), and the top reasons for discontinuation were responses related to losing interest (23.6%), perceiving e-cigarettes as "uncool" (16.3%), and health concerns (12.1%). Cigarette smokers tried e-cigarettes because of the perceptions that they can be used anywhere and to quit smoking and discontinued because they were not as satisfying as cigarettes. School level differences were detected., Conclusions: E-cigarette prevention efforts toward youth should include limiting e-cigarette flavors, communicating messages emphasizing the health risks of use, and changing social norms surrounding the use of e-cigarettes. The results should be interpreted in light of the limitations of this study., (© The Author 2014. 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.)

Introduction: There is limited evidence on electronic cigarette (e-cigarette) use among U.S. adolescents., Methods: Cross-sectional, anonymous surveys conducted in 4 high schools (HS; n = 3,614) and 2 middle schools (MS; n = 1,166) in Connecticut in November 2013 examined e-cigarette awareness, use patterns, susceptibility to future use, preferences, product components used (battery type, nicotine content, flavors), and sources of marketing and access., Results: High rates of awareness (MS: 84.3%; HS: 92.0%) and of lifetime (3.5% MS, 25.2 % HS) and current (1.5% MS, 12% HS) use of e-cigarettes was observed. Among those who had not tried e-cigarettes, 26.4% of MS and 31.7% of HS students reported being susceptible to future use. Males (OR = 1.70, p < .01), older students (OR = 1.39, p < .05), Caucasians (OR = 2.01, p < .001), ever cigarette smokers (OR = 13.04, p < .001), and current cigarette smokers (OR = 65.11, p < .001) were more likely to be lifetime e-cigarette users and to report greater future susceptibility (males: OR = 1.30; Caucasians: OR = 1.14; ever cigarette smokers; OR = 3.85; current cigarette smokers; OR = 9.81; ps < .01-.001). Among MS students who were lifetime e-cigarette users, 51.2% reported that e-cigarette was the first tobacco product they had tried. E-cigarettes that were rechargeable and had sweet flavors were most popular. Smokers preferred e-cigarettes to cigarettes. Current cigarette smokers were more likely to initiate with nicotine-containing e-cigarettes, and ever and never cigarette smokers to initiate with e-cigarettes without nicotine. Primary sources for e-cigarette advertisements were televisions and gas stations and, for acquiring e-cigarettes, were peers., Conclusions: Longitudinal monitoring of e-cigarette use among adolescents and establishment of policies to limit access are imperatively needed., (© The Author 2014. 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 and Aims: Smoking is associated with more severe/extensive gambling in adults. The purpose of this study was to examine relationships between smoking and gambling in adolescents., Methods: Analyses utilized survey data from 1591 Connecticut high-school students. Adolescents were classified by gambling (Low-Risk Gambling [LRG], At Risk/Problem Gambling [ARPG]) and smoking (current smoker, non-smoker). The main effects of smoking and the smoking-by-gambling interactions were examined for gambling behaviors (e.g., type, location), and gambling attitudes. Data were analyzed using chi-square and logistic regression; the latter controlled for gender, race/ethnicity, grade, and family structure., Results: For APRG adolescents, smoking was associated with greater online, school, and casino gambling; gambling due to anxiety and pressure; greater time spent gambling; early gambling onset; perceived parental approval of gambling; and decreased importance of measures to prevent teen gambling. For LRG adolescents, smoking was associated with non-strategic gambling (e.g., lottery gambling); school gambling; gambling in response to anxiety; gambling for financial reasons; greater time spent gambling; and decreased importance of measures to prevent teen gambling. Stronger relationships were found between smoking and casino gambling, gambling due to pressure, earlier onset of gambling, and parental perceptions of gambling for ARPG versus LRG adolescents., Discussion: Smoking is associated with more extensive gambling for both low- and high-risk adolescent gamblers., Conclusion: Smoking may be a marker of more severe gambling behaviors in adolescents and important to consider in gambling prevention and intervention efforts with youth., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

The treatment of adolescent tobacco dependence is an imperative public health goal. Adolescent-focused smoking cessation interventions have shown modest results at most, indicating the need for the development of innovative and effective interventions for this vulnerable population. This review aims to provide an update of smoking cessation interventions for youth by reviewing the literature published between 2009 and November 2014 evaluating psychosocial and pharmacological interventions. Based on this examination, future directions for research in advancing the development of adolescent-focused tobacco treatments are provided.

Background: Impulsive adolescents have difficulty quitting smoking. We examined if treatments that provide behavioral incentives for abstinence improve treatment outcomes among impulsive adolescent smokers, who have been shown to be highly sensitive to reward., Methods: We ran secondary data analyses on 64 teen smokers (mean age=16.36 [1.44]; cigarettes/day=13.97 [6.61]; 53.1% female; 90.6% Caucasian) who completed a four-week smoking cessation trial to determine whether impulsive adolescents differentially benefit from receiving cognitive behavioral therapy (CBT), contingency management (CM), or the combination of the two (CM/CBT). Indices of treatment efficacy included self-report percent days abstinent and end of treatment biochemically-confirmed 7-day point prevalence abstinence (EOT abstinence). We assessed self-reported impulsivity using the Brief Barratt Impulsiveness Scale. We used univariate Generalized Linear Modeling to examine main effects and interactions of impulsivity and treatment condition as predictors of self-reported abstinence, and exact logistic regression to examine EOT abstinence., Results: CM/CBT and CM were comparably effective in promoting abstinence, so analyses were conducted comparing the efficacy of CBT to treatments with a CM component (i.e., CM and CM/CBT). CBT and deficient self-regulation predicted lower self-reported abstinence rates within the total analytic sample. Treatments containing CM were more effective than CBT in predicting 1) self-reported abstinence among behaviorally impulsive adolescents (% days abstinent: CM 77%; CM/CBT 81%; CBT 30%) and 2) EOT point prevalence abstinence among behaviorally impulsive adolescents and adolescents with significant deficits in self-regulation., Conclusion: CM-based interventions may improve the low smoking cessation rates previously observed among impulsive adolescent smokers., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: Smoking and gambling are two significant public health concerns. Little is known about the association of smoking and gambling in adolescents. The current study of high-school adolescents examined: (1) smoking behavior by problem-gambling severity and (2) health-related variables by problem-gambling severity and smoking status., Methods: Analyses utilized survey data from 1591 Connecticut high-school students. Adolescents were classified by problem-gambling severity (Low-Risk Gambling [LRG], At-Risk/Problem Gambling [ARPG]) and smoking status (current smoker, non-smoker). Analyses examined the smoking behavior of ARPG versus LRG adolescents as well as the smoking-by-problem-gambling-severity interactions for health and well-being measures (e.g., grades, substance use). Chi-square and logistic regression analyses were used; the latter controlled for gender, race/ethnicity, school grade, and family structure., Results: More adolescents with ARPG than LRG reported regular smoking, heavy smoking, early smoking onset, no smoking quit attempts, and parental approval of smoking. ARPG and LRG adolescents who smoked were more likely to report poor grades, lifetime use of marijuana and other drugs, current heavy alcohol use, current caffeine use, depression, and aggressive behaviors and less likely to report participation in extracurricular activities. The association between not participating in extracurricular activities and smoking was statistically stronger in the LRG compared to the ARPG groups. Post-hoc analyses implicated a range of extracurricular activities including team sports, school clubs, and church activities., Conclusions: Smoking was associated with poorer health-related behaviors in both ARPG and LRG groups. Interventions with adolescents may benefit from targeting both smoking and gambling.

Background: The objective of this study was to determine the effects of the N-methyl-d-aspartate (NMDA) receptor antagonist, memantine (0, 20, 40 mg/d), upon alcohol drinking and craving in heavy drinkers with or without a family history (FH) of alcoholism, and to explore the modulatory influence of the presence of impulsivity on these outcomes., Methods: Ninety-two, nontreatment-seeking, heavy drinkers received memantine or placebo for 8 days. On the eighth day, they received a priming dose of alcohol followed by a 3-hour period of alcohol access., Results: Memantine at a dose of 20 mg reduced alcohol craving but did not influence alcohol drinking. No effects of FH were observed. In participants with higher baseline levels of impulsivity, 40 mg of memantine reduced alcohol craving but increased alcohol drinking and alcohol-induced stimulation., Conclusions: NMDA receptor signaling may play divergent roles in mediating alcohol cue-induced craving and alcohol drinking in heavy drinkers. The potential efficacy of memantine as monotherapy for alcohol use disorders may be limited by its tendency to disinhibit drinking in some individuals., (Copyright © 2015 by the Research Society on Alcoholism.)

Background: This pilot study conducted a preliminary examination of whether Cognitive Bias Modification (CBM), a computerized task to retrain cognitive-approach biases towards smoking stimuli (a) changed approach bias for cigarettes, and (b) improved smoking cessation outcomes in adolescent smokers., Methods: Sixty adolescent smokers received four weeks of Cognitive Behavioral Therapy (CBT) for smoking cessation, with CBM (90% avoidance/10% approach for smoking stimuli and 10% avoidance/90% approach for neutral stimuli) or sham (50% avoidance/50% approach for smoking and neutral stimuli) training in the Netherlands (n = 42) and the United States (n = 18)., Results: While we did not observe changes in action tendencies related to CBM, adolescents with higher smoking approach biases at baseline had greater decreases in approach biases at follow-up, compared to adolescents with smoking avoidance biases, regardless of treatment condition (p = 0.01). Intent-to-treat (ITT) analyses showed that CBM, when compared with sham trended toward higher end-of-treatment, biochemically-confirmed, seven-day point prevalence abstinence, (17.2% vs. 3.2%, p = 0.071). ITT analysis also showed that regardless of treatment condition, cotinine level (p = 0.045) and average number of cigarette smoked (p ≤ 0.001) significantly decreased over the course of treatment., Conclusions: The findings from this pilot study suggests that re-training approach biases toward cigarettes shows promise for smoking cessation among adolescent smokers. Future research should utilize larger samples and increased distinction between CBM and sham conditions, and examine mechanisms underlying the CBM approach.