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ObjectivesIn this study, we used a discrete choice experiment (DCE) conducted August-October 2017 to examine electronic nicotine delivery systems (ENDS) product preferences in a national sample of adult smokers (N = 1154) who were also using ENDS or had not ruled out future use.MethodsThe DCE evaluated 5 ENDS attributes: relative harm; effectiveness for helping smokers quit; nicotine strength; flavor; and price. We asked participants to choose among their own cigarettes, 2 ENDS products whose attributes varied across tasks, or none. We analyzed ENDS preferences using multinomial, nested, and mixed logit regressions.ResultsSmokers preferred ENDS that are less harmful than cigarettes, are effective in helping smokers quit, are lower priced, and are not menthol-flavored. The marginal willingness to pay for an ENDS product was $8.40 when less harmful than cigarettes, $4.13 when of unknown effectiveness in helping quitting ($13.90 when effective), and $3.37 when ENDS are not menthol-flavored. Furthermore, the overall flavor preference is driven by tobacco smokers, not by menthol cigarette smokers who do prefer menthol-flavored ENDS.ConclusionsPolicies that affect perceptions of ENDS effectiveness in promoting cessation and their relative harm may alter smokers' ENDS preferences. Regulating flavors and price also may influence adult smokers' ENDS preference.

The integration of physical activity into elementary school classrooms, through brief activity breaks (ABs) and lessons that incorporate movement into instruction as active lessons (ALs), are key parts of school physical activity programming and can improve children's health and academic outcomes. With nationally representative survey data from 640 public elementary schools in the United States, we examined the use of these practices and the extent of implementation within classrooms. ALs were used in 71.7% of schools, and ABs were used in 75.6% of schools. In multivariate models, ALs were significantly less likely to be used in majority-Latino schools (adjusted odds ratio = 0.48, 95% confidence interval [0.25, 0.93], p < 0.05) than in predominantly White schools. ABs were significantly less likely to be used in lower socioeconomic schools (adjusted odds ratio = 0.57, 95% confidence interval [0.34, 0.95], p < 0.05) than in higher socioeconomic schools. At schools where ABs were ever used, they were used by 45.6% of teachers, but fewer teachers used them at larger schools (ß = -0.08, p < 0.01) and at lower socioeconomic schools (ß = -0.09, p < 0.05). The reach of ALs and ABs is modest and classroom-level implementation is quite low. Additional dissemination and support is warranted to improve the reach and implementation of these strategies in elementary schools. Such efforts could improve the school-day experience in ways that benefit millions of young children.

The 60% decline in the prevalence of cigarette smoking among U.S. adults over the past 50 years represents a significant public health achievement. This decline was steered in part by national, state, and local tobacco control programs and policies, such as public education campaigns; widespread smoke-free air laws; higher cigarette prices that have been driven by large increases in federal, state, and local cigarette excise taxes; and other tobacco control policy and systems-level changes that discourage smoking. Using the MPOWER framework informed by the Centers for Disease Control and Prevention (CDC) Office on Smoking and Health and the World Health Organization (WHO), this paper reviews these accomplishments and identifies gaps in tobacco control policy implementation and additional research needed to extend these historic successes.

Background: School policies and practices, such as the sharing of school facilities with the surrounding community, support physical activity among students and community members, but are often underutilized. This study examined variations in shared use practices, and associations with perceived barriers. Methods: Surveys were completed by a nationally representative sample of 640 public elementary schools across the United States. Administrators reported on their school's practices related to the shared use of indoor and outdoor facilities, and perceived barriers to sharing. Multivariate logistic regression models were used to examine associations between barriers and practices. Results: Liability or legal concerns, staffing expenses, and facility operation costs were most frequently reported as barriers, while lack of adequate facilities and perceived lack of community interest were less common. Cost concerns and perceived lack of community interest were most strongly associated with lack of sharing. Conclusions: Although liability or legal concerns are common, such concerns are not necessarily associated with less sharing when other factors are taken into account. Administrators' perceptions about lack of community interest were associated with less sharing, but these perceptions may not accurately reflect the community's perspective. Active development of partnerships could increase access to school facilities.

Background: We examined the prevalence of school garden programs at US public elementary schools. The study examined time trends, demographic and regional disparities, and associations with related programs such as farm-to-school. Methods: Annual surveys were gathered from nationally representative samples of elementary schools between 2006-2007 and 2013-2014. Annual samples ranged from 553 to 748 schools. Results: The prevalence of gardens increased steadily from 11.9% in 2006-2007 to 31.2% in 2013-2014 (p < 0.001). In multivariate logistic regressions the prevalence of garden programs varied significantly by school characteristics. Gardens were more prevalent in the west than in other regions. Gardens were less prevalent at schools serving higher proportions of lower-income students, and were more prevalent at urban schools than in suburbs, towns, or rural areas. Gardens were more common at schools with farm-to-school programs. Gardens also were associated with offering formal classroom-based nutrition education. Conclusions: Garden programs in elementary schools have increased over time, but there is room for wider implementation, particularly at schools serving lower-income students. Given the role of childhood in establishing food preferences and dietary consumption habits, such programs are important and can reinforce the messages imparted through nutrition education.

The increases in smoking prevalence among U.S. youth during the 1990's, and the growing evidence that adolescents become regular smokers at earlier ages, have attracted significant attention from public health officials. Preventing experimental young smokers from becoming established smokers may be the most effective way of achieving a long run reductions in smoking in the whole population.The paper addresses the gaps in knowledge about the impact of tobacco control policies on youth smoking uptake by examining the differential effects of cigarette prices, Clean Indoor Air laws, youth access laws, and other socio-economic factors on smoking uptake among nationally representative sample of U.S. high school students. Five clearly defined uptake stage categories are developed in order to classify 16,815 survey participants.The results suggest that cigarette prices are negatively related to moving from lower to higher stages of smoking uptake and that higher prices have an increasing impact as an individual’s risk of smoking uptake gets larger. Youth access laws are significantly and negatively associated with moving to higher stages of smoking uptake. The effect of these restrictions is strongest for students who completed, or almost completed their uptake process as these students are more dependent on commercial sources of cigarettes. Interrupting adolescents' progress on the smoking uptake continuum substantially reduces their probability of becoming daily, addicted smokers.

This paper projects the long term consequences of the rise in youth smoking in the1990s by updating the state estimates for projected smoking-related deaths among youthin the U.S. using information from the Behavioral Risk Factor Surveillance System(BRFSS) 2000 and the U.S. Census 2000. This analysis is similar to that from an earlierstudy published by the Centers for Disease Control and Prevention (CDC), Office onSmoking and Health (MMWR, 45[44], November 8, 1996). The 1996 analysis usedyoung adult smoking prevalence data from 1994 and 1995; whereas, the analysispresented here represents smoking prevalence data from 2000. The overall number ofpotential future smoking-attributable deaths among persons aged 0-17 years in 2000 was6,407,119 for the U.S., up from an estimated 5 million in 1995.Compared with the 1995 estimates, every state except Arizona shows increases inprojected smoking-related deaths among youth for 2000. This upsurge is attributable toboth increases in smoking prevalence among young adults and population aged 0-17years from 1995 to 2000. The increase in smoking prevalence among young adults wasstatistically significant in nine states including Alabama, District of Columbia, Iowa,Kentucky, Nevada, North Dakota, South Carolina, South Dakota, and Vermont.With increasing attention and funding for comprehensive, research-based tobaccocontrol programs in the U.S., one would expect smoking rates to decline over time,resulting in a reduction in projected smoking-related deaths among youth. The analysisreported here does not yet reflect this trend. This study clearly demonstrates that basedon recent smoking patterns, there will continue to be a huge public health toll fromtobacco. The results from this new analysis will be useful to states as they determine theoverall public health benefits from increasing the state excise tax and consider fundingfor comprehensive tobacco control programs.

Smoking among youths and young adults has been rising throughout the 1990’s. Numerous policies have been enacted to try to reverse this trend. However, little is known about the impact that these policies have on the smoking behavior of young adults. This study uses a dichotomous indicator of daily smoking participation in the past thirty days, an ordered measure representing the frequency of cigarette consumption and a quasi-continuous measure of the number of cigarettes smoked per day on average to examine the impact of cigarette prices, clean indoor air laws and campus level smoking policies on the smoking behaviors of a 1997 cross section of college students. The results of the analysis indicate that higher cigarette prices are associated with lower smoking participation and lower levels of use among college student smokers. Local and state level clean indoor air restrictions have a cumulative impact on the level of smoking by current smokers. Complete smoking bans on college campuses are associated with lower levels of smoking among current smokers but have no significant impact on smoking participation. Bans on cigarette advertising on campus as well as bans on the sale of cigarettes on campus have no significant effect on the smoking behavior of college student smoking behavior.

Prior economic research provides mixed evidence on the impact of cigarette prices on youth smoking. This paper empirically tests the effects of various price measures on youth demand for cigarettes using data collected in a recent nationally representative survey of 17,287 high school students. In addition to commonly used cigarette price measures, the study also examined the effect of price as perceived by the students. This unique information permits the study of the effect of teen-specific price on cigarette demand. The analysis employed a two-part model of cigarette demand based on a model developed by Cragg (1971) in which the propensity to smoke and the intensity of the smoking habit are modeled separately. The results confirm that higher cigarette prices, irrespective of the way they are measured, reduce youth cigarette smoking. The split of the price effect on smoking probability and on smoking intensity depends on the price measure used in the model. The largest impact on cigarette demand has the teenspecific, perceived price of cigarettes.

Objectives: Data from the 1992, 1993, and 1994 Monitoring the Future Surveys were used to investigate the differential effects of cigarette price on the intensity of youth cigarette smoking.Methods: Respondents are classified into nonsmokers; individuals who smoked less than one cigarette per day; individuals who smoked one to five cigarettes per day; individuals who smoked one-half pack a day; and individuals who smoked one pack or more a day. A Threshold of Change Model was estimated with information on cigarette prices as the main explanatory variables.Results: Dummy variables indicating medium and high prices were found to have varying effects on different levels of smoking intensity, even though higher prices were associated with lower smoking in all cases. The differences are more striking in the high price case. The effects of higher prices are largest at the heaviest smoking levels.Conclusion: Cigarette prices an effective tool to discourage youth smoking. The differential effects of cigarette price on smoking intensity warrant further investigation.

Objectives - To determine the relationship between brand-specific advertising and promotions in convenience stores for Marlboro and Camel cigarettes and choice of usual brand among school students.Design - Cross-sectional survey with merged records of store tobacco advertising and promotions.Setting – United States.Participants – 3,890 high school smokers with a usual brand, matched to 196 convenience stores.Main outcome measures – Choice of Marlboro as a usual brand ; choice of Camel as a usual brand.Results – Choice of Marlboro as a usual brand was associated with presence of a Marlboro gift with purchase (p.05) and negatively associated with a greater share of exterior advertising voice for Camel (p

Objective—This study aimed to assess the effect of the Master Settlement Agreement’s (MSA) 24 April 1999 ban on billboard tobacco advertising on the tobacco industry’s point-of-purchase marketing strategies.Methods—Observations were conducted from 16 February through 23 June 1999 in 3,464 tobacco-selling retail stores in a total of 191 communities across the nation. Communities were determined by the location of schools in a nationally representative sample of students in grades 8, 10, and 12 in the United States. At each store, information was collected on the extent of interior and exterior tobacco advertising, extent of tobacco functional objects, presence of tobacco promotions, and placement of tobacco and low-height advertisements. Logistic regression and cumulative logit analyses were used to assess changes in pre- and post-ban retail environments, after adjusting for store type, store size, presence of state tobacco control program and urbanicity.Results—After adjustment for covariates, there were significant post-ban increases in the presence of tobacco sales promotions, the presence and extent of functional objects, the presence of exterior and interior store advertising, and the extensiveness of exterior store advertising.Conclusions—The observed increase in point-of-purchase marketing in the period following the billboard advertising ban suggests that the tobacco industry may be shifting at least some of the expenditures once spent on billboard advertising to the advertising and promotion at the point-ofpurchase. To the extent that this is so, the intended effects of the MSA billboard ban may not be fully realized.

Objectives - To determine the relationship between extent of restrictions on smoking at home, at school and in public places, and smoking uptake, smoking prevalence and monthly cigarette consumption by school students.Design - Cross-sectional survey with merged records of extent of restrictions on smoking in public places.Setting – United States.Participants – 17,287 high school students.Main outcome measures – Five-point scale of smoking uptake; 30-day smoking prevalence; monthly cigarette consumption among current smokers.Results – More restrictive arrangements on smoking at home were associated with a greater likelihood of being in an earlier stage of smoking uptake (p

This review focuses on the extent to which comprehensive, statewide, tobacco control programs in the United States have induced change in teenage smoking or made progress towards this goal and under what circumstances such programs are likely to be most effective. The sources for this review include published journal articles, reports and documents, rather than any primary data analysis. We review evidence for the extent to which individual strategies that comprise a comprehensive tobacco control program are related to reducing teenage tobacco use, thereby providing a rationale as to why such comprehensive programs might be expected to reduce adolescent smoking when implemented on a statewide basis. This evidence suggests that school-based smoking prevention programs using the social influences approach, public education through counteradvertising, strongly enforced measures to: prevent youth from purchasing cigarettes, ban smoking in public places and ban tobacco advertising; and real increases in the price of cigarettes, all lead to reductions in teenage tobacco smoking.When implemented as part of statewide programs, however, effects are difficult to assess and unwary legislators risk being poorly informed about the impact of comprehensive programs on teenage smoking. We identify five factors that can mislead: 1) changing population smoking prevalence is likely to be a relatively slow process, even in response to comprehensive programs; 2) smoking prevalence is usually only measured yearly or less frequently and sampling variation and different survey methodologies make these measures insensitive tools for assessing early change; 3) changes in smoking behavior and prevalence can reflect underlying societal influences unrelated to new tobacco control programs; 4) actual implementation of program strategies may differ substantially from intended implementation and the extent of disparity may vary over time and between programs; and 5) tobacco industry activities may undermine tobacco control programs and falsely suggest the programs are ineffective when, in fact, they could be very effective in the absence of industry efforts. For all these reasons, assessment of progress requires much more than a cursory look at teenage smoking prevalence. We argue for taking a larger view that takes account of the extent of program implementation and expenditure, and evaluates markers of progress in factors known to mediate teenage tobacco smoking, as well as change in tobacco smoking itself. Against this background, the report focuses mainly upon five states that have received funding for comprehensive programs: California, Massachusetts, Arizona, Oregon and Florida.California: The California Tobacco Control Program, commenced in 1989, found the early program period to be associated with reduced aggregate cigarette consumption beyond what would have been expected from a price increase alone, an excess decline in adult smoking prevalence and stabilization of teenage smoking prevalence at a time when it increased in the rest of the nation. Since 1994 however, effects on both teenage and adult smoking prevalence appear to have been lost, or diminished, coincident with reduced program expenditure in this period. Importantly, these findings are largely supported in these time periods by concomitant change, or lack of it, in teenage tobacco-related beliefs and attitudes, perceptions of ease of access to tobacco, and compliance with school smoking restrictions, as well as an increase in the later period in tobacco advertising and promotion, as evidenced by tobacco industry expenditures and adolescent reports of exposure.Massachusetts: Overall, evidence that the Massachusetts Tobacco Control Program (launched in 1993 ), was associated with influencing youth tobacco use is positive and consistent. This is especially true given that trends in prevalence are contrary to those observed nationally since the program’s inception. Evidence of decline in per capita consumption is particularly strong and available research suggests that some of this decline applied to adolescent smokers. Intermediate markers of progress are consistent with high levels of media message recall, acceptance by teenagers of the health risks of smoking and increased restrictions on smoking in public places. Like California, however, compliance with bans on smoking at school has not changed. Accessing tobacco at retail outlets appears more difficult, but most teenagers reported that cigarettes were still easy to obtain. Evidence suggests that social contacts are increasingly more likely to be sources for cigarettes.Arizona: Information available to date from the Arizona Tobacco Education Program suggests that after a slow start in the development of the program, the predominantly youth-directed media campaign has been very intensive and well-recalled by adolescents. Effects on aggregate cigarette consumption were in line with expectations based on the extent of the 1994 price increase. Markers of progress with respect to youth attitudes, exposure to smoking restrictions, reduced youth access and smoking behavior will need to await completion of follow-up surveys later in the year. In addition, the adult-focused campaign which began in 1998 remains to be evaluated and a planned population survey of adults will provide important information about its impact.Oregon: Since the Oregon Tobacco Prevention and Education Program has been in the field for only two full years, relatively limited data are available to assess progress. However, early reports suggest that media messages have reached both adults and teenagers. To date, there are no published measures of changes in tobacco-related knowledge or attitudes, restrictions on smoking in public places, youth access, or tobacco industry promotional activity, although these data are being collected. However, the decline in per capita consumption since the program’s inception is highly consistent with what was observed in California and Massachusetts, being greater than expected from a price increase alone. Similarly, the observed reduction in adult smoking prevalence mirrors that found in Massachusetts and the early program period in California. However, final judgement will need to await release of comparable national data.Florida: Despite being in the field for only one year, the Florida Tobacco Pilot Program has been extremely proactive in its use of media counteradvertising, choosing to focus upon further discrediting the tobacco industry as the prime strategy to discourage adolescents from smoking. In addition, the program has been active in developing programs at the community level. The media campaign is being seen and remembered by teens, and there is evidence that it has increased negative attitudes towards the industry. The indication from the school-based surveys in Florida that teen prevalence significantly declined between 1998 and 1999 is notable, but must await comparison with national trends to determine whether these changes were part of underlying change in teenage smoking patterns.Each of the programs underway in the five states differ by virtue of: their length of time in the field and per capita expenditure on tobacco control; background circumstances under which they were initiated; background trends in teenage smoking prevalence against which they will be judged; the relative allocation of funding to general tobacco control strategies as opposed to youth-specific approaches; selection of messages and strategies within each program component; extent of actual compared with intended implementation; and measures used to assess progress. When appraised individually, it is difficult to draw firm conclusions about the effectiveness of particular mixes of program inputs in reducing teenage tobacco use. However, when taken together, a number of consistent findings emerge. First, we find that one of the single most critical factors in program success seems to be the extent of implementation, and the degree to which this is undermined by the tobacco industry and other competitors for funding. More fully implemented programs lead to increased counteradvertising and community initiatives; a greater capacity to implement school-based smoking prevention programs; and an increase in the passage of local ordinances that create smoke-free indoor environments and reduce youth access. These factors create an environment more favorable for reduced teenage tobacco use. There is strong evidence from these comprehensive programs, coupled with other research, that price increases influence overall and adolescent tobacco use and that the addition of program activity reduces consumption more than expected due to price alone.There is consistent evidence the programs are associated with a decline in adult smoking prevalence, with these effects observed to date in California, Massachusetts and Oregon.These changes in the normative environment for smoking, coupled with reduced opportunities to smoke and the message of social undesirability offered by increased bans on smoking, are likely to be an important influence on youth smoking. Arizona and Florida -- conducting more youth-focused campaigns -- have yet to examine change in adult prevalence associated with program exposure. Finally, despite the different strengths and combinations of program messages and strategies used in these comprehensive programs, the evidence that they lead to markers of change in factors that influence teenage smoking, and to reductions in teenage smoking prevalence and uptake, is compelling. Plainly, for programs like Arizona, which has yet to report follow-up data, and Florida, which is early in its development, more research is needed to clarify and confirm important early indications of positive progress. Notwithstanding these cautions, we find that the weight of evidence falls in favor of comprehensive tobacco control programs being able to reduce teenage tobacco use.As states decide what level of funding from their tobacco settlement money should be allocated to programs to reduce teenage tobacco use, legislators should not use ‘lack of evidence for benefit’ as an argument to avoid making such allocations. Given progress made by programs in the field, research findings that strongly link tobacco policy advances, counteradvertising and school-based tobacco education programs to reduced youth smoking, and our theoretical understanding of factors that shape teenage tobacco use, comprehensive tobacco control programs are in fact the ‘best buy’ for reducing teenage smoking.