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Background. While electronic cigarettes (e-cigarettes) may help some smokers quit, some young adult never-smokers are now using e-cigarettes recreationally, potentially increasing their risk for initiation of smoking. We aimed to determine the association between baseline e-cigarette use and subsequent initiation of cigarette smoking among initially never-smoking young adults. Methods. We conducted a prospective cohort study with assessments at baseline (March 2013) and follow-up (October 2014). We used sampling frames representing 97% of the U.S. population to recruit a nationally-representative sample of never-smoking young adults ages 18-30. The independent variable was baseline ever use of e-cigarettes. The main outcome measure was initiation of traditional cigarette smoking between baseline and 18-month follow-up. Results. Baseline surveys were completed by 1506 never-smoking young adults, of whom 915 (60.8%) completed follow-up. There were no demographic differences between responders and non-responders. After applying survey weights—which accounted for both non-response and over or under coverage—2.5% of the represented population of never-smokers (801,010 of 32,040,393) used e-cigarettes at baseline. Cigarette smoking was initiated by 47.7% of e-cigarette users and 10.2% of non-users (P=.001). In fully-adjusted multivariable models, e-cigarette use at baseline was independently associated with initiation of smoking at 18 months (adjusted odds ratio=6.8, 95% confidence interval=1.7–28.3). Results remained similar in magnitude and statistically significant in all sensitivity analyses. Conclusions: Baseline e-cigarette use was independently associated with initiation of traditional cigarette smoking at 18 months. This finding supports policy and educational interventions designed to decrease use of e-cigarettes among non-smokers.

We surveyed a random sample of 852 students at a large university in 2010-2011 to clarify associations between waterpipe tobacco smoking (WTS), ethnicity, and religion. Current (past 30day) WTS was reported by 116 (14%) students, and 331 (39%) reported ever WTS. Middle Eastern ethnicity was associated with current WTS (odds ratio [OR]=2.37; 95% confidence interval [CI]=1.06, 5.34) and ever WTS (OR=2.59; 95% CI=1.22, 5.47). South Asian ethnicity was associated with lower odds for ever WTS (OR=0.42; 95% CI=0.21, 0.86), but there was no significant association between South Asian ethnicity and current WTS. Being an atheist and having lower religiosity were associated with both WTS outcomes. © 2014 Copyright Taylor and Francis Group, LLC.

BACKGROUND: Media literacy programs have shown potential for reduction of adolescent tobacco use. We aimed to determine if an anti-smoking media literacy curriculum improves students' media literacy and affects factors related to adolescent smoking. METHODS: We recruited 1170 9th-grade students from 64 classrooms in 3 public urban high schools. Students were randomized by classroom to a media literacy curriculum versus a standard educational program. In an intent-to-treat analysis, we used multilevel modeling to determine if changes in study outcomes were associated with the curricular intervention, controlling for baseline student covariates and the clustering of students within classrooms. RESULTS: Among participants, mean age was 14.5 years and 51% were male, with no significant differences in baseline characteristics between groups. Smoking media literacy changed more among intervention participants compared with control participants (0.24 vs. 0.08, p < .001). Compared with controls, intervention students exhibited a greater reduction in the perceived prevalence of smoking (-14.0% vs. -4.6%, p < .001). Among those initially susceptible to smoking, intervention participants more commonly reverted to being nonsusceptible post-intervention (24% vs. 16%, p = .08). CONCLUSIONS: A school-based media literacy curriculum is more effective than a standard educational program in teaching media literacy and improving perceptions of the true prevalence of smoking among adolescents. © 2014, American School Health Association.

Introduction: Little research has examined whether cardiovascular medications, other than statins, are associated with improved outcomes after pneumonia. Our aim was to examine the association between the use of beta-blockers, statins, angiotensin converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs) with pneumonia-related outcomes. Materials and Methods: We conducted a retrospective population-based study on male patients ≥65 years of age hospitalized with pneumonia and who did not have pre-existing cardiac disease. Our primary analyses were multilevel regression models that examined the association between cardiovascular medication classes and either mortality or cardiovascular events. Results: Our cohort included 21,985 patients: 22% died within 90 days of admission, and 22% had a cardiac event within 90 days. The cardiovascular medications studied that were associated with decreased 90-day mortality included: statins (OR 0.70, 95% CI 0.63-0.77), ACE inhibitors (OR 0.82, 95% CI 0.74-0.91), and ARBs (OR 0.58, 95% CI 0.44-0.77). However, none of the medications were significantly associated with decreased cardiovascular events. Discussion: While statins, ACE inhibitors, and ARBs, were associated with decreased mortality, there was no significant association with decreased CV events. These results indicate that this decreased mortality is unlikely due to their potential cardioprotective effects.

Introduction: While cigarette use is declining, smoking tobacco with a waterpipe is an emerging trend. We aimed to determine the prevalence of waterpipe use in a large diverse sample of U.S. university students and to assess the association of waterpipe use with individual and institution-related characteristics. Methods: We assessed students from 152 U.S. universities participating in the National College Health Assessment during 2008-2009. We used multivariable regression models to determine independent associations between individual and institutional characteristics and waterpipe tobacco use in the past 30 days and ever. Results: Of 105,012 respondents included in the analysis, most were female (65.7%), White (71.2%), and attending public (59.7%) nonreligious (83.1%) institutions. Mean age was 22.1 years. A total of 32,013 (30.5%) reported ever using a waterpipe to smoke tobacco. Rates for current tobacco use were 8.4% for waterpipes, 16.8% for cigarettes, 7.4% for cigars (including cigarillos), and 3.5% for smokeless tobacco. Of current waterpipe users, 51.4% were not current cigarette smokers. Although current waterpipe use was reported across all individual and institutional characteristics, fully adjusted multivariable models showed that it was most strongly associated with younger age, male gender, White race, fraternity/sorority membership, and nonreligious institutions in large cities in the western United States. Conclusions: After cigarettes, waterpipe use was the most common form of tobacco use among university students. Because waterpipe use affects groups with a wide variety of individual and institutional characteristics, it should be included with other forms of tobacco in efforts related to tobacco surveillance and intervention. © The Author 2012. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.

Hookah tobacco smoking is increasing among US college students, including those who would not otherwise use tobacco. Part of hookah's appeal is attributed to the perception that hookah is less harmful than cigarettes. The aims of this study were to assess knowledge of harmful exposures associated with hookah smoking relative to cigarette smoking and to determine associations between this knowledge and hookah smoking outcomes. Students (N=852) at the University of Florida were randomly sampled via e-mail to obtain information on demographics, hookah smoking behavior and knowledge of five exposures (e.g. tar and nicotine). Multivariable logistic regression models assessed independent associations between knowledge and hookah smoking outcomes. Of the five factual knowledge items asked, 475 (55.8%) of the respondents answered none correctly. In multivariable models, correct responses to any knowledge items were not associated with lower odds of hookah smoking or susceptibility to hookah smoking in the future. Although college students are largely unaware of the toxicant exposures associated with hookah smoking, there is little association between knowledge and hookah smoking behavior. © The Author 2012.

Objectives: Although US cigarette smoking is decreasing, hookah tobacco smoking (HTS) is an emerging trend associated with substantial toxicant exposure. We assessed how a representative sample of US tobacco control policies may apply to HTS. Methods: We examined municipal, county, and state legal texts applying to the 100 largest US cities. We developed a summary policy variable that distinguished among cities on the basis of how current tobacco control policies may apply to HTS and used multinomial logistic regression to determine associations between community-level sociodemographic variables and the policy outcome variable. Results: Although 73 of the 100 largest US cities have laws that disallow cigarette smoking in bars, 69 of these cities have exemptions that allow HTS; 4 of the 69 have passed legislation specifically exempting HTS, and 65 may permit HTS via generic tobacco retail establishment exemptions. Cities in which HTS may be exempted had denser populations than cities without clean air legislation. Conclusions: Although three fourths of the largest US cities disallow cigarette smoking in bars, nearly 90% of these cities may permit HTS via exemptions. Closing this gap in clean air regulation may significantly reduce exposure to HTS.

Background: Although accurate health-related representations of medical situations on television can be valuable, inaccurate portrayals can engender misinformation. Objective: The purpose of this study was to compare sociodemographic and medical characteristics of patients depicted on television vs. actual United States (US) Emergency Department (ED) patients. Methods: Two independently working coders analyzed all 22 programs in one complete year of the popular "emergency room" drama ER. Inter-rater reliability was excellent, and all initial coding differences were easily adjudicated. Actual health data were obtained from the National Heath and Ambulatory Medical Care Survey from the same year. Chi-squared goodness-of-fit tests were used to compare televised vs. real distribution across key sociodemographic and medical variables. Results: Ages at the extremes of age (i.e., ≤ 4 and ≥ 45 years) were less commonly represented on television compared with reality. Characters on television vs. reality were less commonly women (31.2% vs. 52.9%, respectively), African-American (12.7% vs. 20.3%), or Hispanic (7.1% vs. 12.5%). The two most common acuity categories for television were the extreme categories "non-urgent" and "emergent," whereas the two most common categories for reality were the middle categories "semi- urgent" and "urgent." Televised visits compared with reality were most commonly due to injury (63.5% vs. 37.0%, respectively), and televised injuries were less commonly work-related (4.2% vs. 14.8%, respectively). Conclusions: Comparison of represented and actual characteristics of ED patients may be valuable in helping us determine what types of patient misperceptions may exist, as well as what types of interventions may be beneficial in correcting that potential misinformation. © 2012 Elsevier Inc.

Objective To examine the association of race and cultural factors with quality-of-life factors (participation, life satisfaction, perceived health status) in people with spinal cord injury (SCI). Design Cross-sectional multisite study using structured questionnaires. Setting Six National SCI Model Systems centers. Participants People with SCI (N=275; age <16y; SCI with discernable neurologic impairments; used power or manual wheelchair for >1y as primary means of mobility; nonambulatory except for exercise purposes). Interventions None. Main Outcome Measures Participation (Craig Handicap Assessment and Reporting Technique Short Form); satisfaction (Satisfaction With Life Scale); and perceived health status (2 items from 36-Item Short Form Health Survey). Results African American (n=96) with SCI reported more experiences of discrimination in health care, greater perceived racism, more health care system distrust, and lower health literacy than whites (n=156; P range, <.001<.05). Participants who reported experiencing more discrimination in health care reported better occupational functioning (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.072.09; P<.05). Those who perceived more racism in health care settings reported better occupational functioning (OR, 1.65; 95% CI, 1.122.43; P<.05) and greater perceived health (β=.36; 95% CI, .05.68; P<.05). Those who reported more distrust in the health care system reported better current health compared with 1 year ago (β=.38; 95% CI, .06.69; P<.05). Those who reported better communication with their health care provider reported higher levels of mobility (OR, 1.5; 95% CI, 1.052.13; P<.05) and better general health (β=.27; 95% CI, .01.53; P<.05). Conclusions In this cross-sectional study of people with SCI, higher levels of perceived discrimination and racism and better communication with health care providers were associated with an increase in participation and functioning and improvements in perceptions of well-being.

Background: Although processes of care are common proxies for health care quality, their associations with medical outcomes remain uncertain. Methods: For 2076 patients hospitalized with pneumonia from 32 emergency departments, we used multilevel logistic regression modeling to assess independent associations between patient outcomes and the performance of 4 individual processes of care (assessment of oxygenation, blood cultures, and rapid initiation [<4 hours] and appropriate selection of antibiotic therapy) and the cumulative number of processes of care performed. Results: Overall, 141 patients (6.8%) died. Mortality was 0.3% to 1.7% lower for patients who had each of the individual processes of care performed (P <.13 for each comparison); mortality was 7.5% for patients who had 0 to 2 processes of care, 7.2% for those with 3 processes of care, and 5.8% for those with all 4 processes of care performed (P =.39). Mortality was not significantly associated with either individual or cumulative process measures in multivariable models. Conclusion: Neither the individual processes of care nor the cumulative number performed is associated with short-term mortality for pneumonia. ©.

Background. African-Americans admitted to U.S. hospitals with community-acquired pneumonia (CAP) are more likely than Caucasians to experience prolonged hospital length of stay (LOS), possibly due to either differential treatment decisions or patient characteristics. Methods. We assessed associations between race and outcomes (Intensive Care Unit [ICU] variables, LOS, 30-day mortality) for African-American or Caucasian patients over 65 years hospitalized in the Veterans Health Administration (VHA) with CAP (2002-2007). Patients admitted to the ICU were analyzed separately from those not admitted to the ICU. VHA patients who died within 30 days of discharge were excluded from all LOS analyses. We used chi-square and Fisher's exact statistics to compare dichotomous variables, the Wilcoxon Rank Sum test to compare age by race, and Cox Proportional Hazards Regression to analyze hospital LOS. We used separate generalized linear mixed-effect models, with admitting hospital as a random effect, to examine associations between patient race and the receipt of guideline-concordant antibiotics, ICU admission, use of mechanical ventilation, use of vasopressors, LOS, and 30-day mortality. We defined statistical significance as a two-tailed p 0.0001. Results. Of 40,878 patients, African-Americans (n = 4,936) were less likely to be married and more likely to have a substance use disorder, neoplastic disease, renal disease, or diabetes compared to Caucasians. African-Americans and Caucasians were equally likely to receive guideline-concordant antibiotics (92% versus 93%, adjusted OR = 0.99; 95% CI = 0.81 to 1.20) and experienced similar 30-day mortality when treated in medical wards (adjusted OR = 0.98; 95% CI = 0.87 to 1.10). African-Americans had a shorter adjusted hospital LOS (adjusted HR = 0.95; 95% CI = 0.92 to 0.98). When admitted to the ICU, African Americans were as likely as Caucasians to receive guideline-concordant antibiotics (76% versus 78%, adjusted OR = 0.99; 95% CI

The Ragins and McFarlin Mentor Role Instrument (RMMRI) was originally developed to measure perceptions of mentoring relationships in research and development organizations. The current study was designed to evaluate the RMMRI's reliability and validity when the instrument was administered to clinical and translational science trainees at an academic medical center. The 33-item RMMRI was administered prospectively to a cohort of 141 trainees at the University of Pittsburgh in 2007-2008. Likert-scale items focused on perceptions of five mentoring roles in the career dimension (sponsor, coach, protector, challenger, and promoter) and six mentoring roles in the psychosocial dimension (friend, social associate, parent, role model, counselor, and acceptor). Outcome items included overall perceptions of mentoring satisfaction and effectiveness. Of 141 trainees, 53% were male, 66% were white, 22% were Asian, and 59% were medical doctors. Mean age was 32 years. Analyses showed strong within-factor inter-item correlations (Pearson coefficients of 0.57-0.93); strong internal consistency (Cronbach alphas of 0.82-0.97); confirmatory factorial validity, as demonstrated by confirmatory factor analysis of the two mentoring dimensions, 11 mentoring roles, and 33 RMMRI items; and concurrent validity, as demonstrated by strong correlations (Pearson coefficients of 0.56-0.71) between mentoring dimensions, satisfaction, and effectiveness. This article concludes that the RMMRI shows reliability and validity in capturing the multidimensional nature of mentoring when administered to clinical and translational science trainees in the academic setting.

Purpose: Tobacco use using a waterpipe is an emerging trend among college students. Although cigarette smoking is low among college athletes, waterpipe tobacco smoking may appeal to this population. The purpose of this study was to compare cigarette and waterpipe tobacco smoking in terms of their associations with organized sport participation. Methods: In the spring of 2008, we conducted an online survey of 8,745 college students at eight institutions as part of the revised National College Health Assessment. We used multivariable regression models to assess the associations between tobacco use (cigarette and waterpipe) and organized sports participation. Results: Participants reported participation in varsity (5.2%), club (11.9%), and intramural (24.9%) athletics. Varsity athletes and individuals who were not varsity athletes had similar rates of waterpipe tobacco smoking (27.6% vs. 29.5%, p = .41). However, other types of athletes were more likely than their counterparts to have smoked waterpipe tobacco (35.1% vs. 28.7%, p < .001 for club sports and 34.8% vs. 27.7%, p < .001 for intramural sports). In fully-adjusted multivariable models, sports participants of any type had lower odds of having smoked cigarettes, whereas participants who played intramural sports (odds ratio = 1.15, 95% confidence interval = 1.03, 1.29) or club sports (odds ratio = 1.15, 95% confidence interval = 1.001, 1.33) had significantly higher odds of having smoked waterpipe tobacco. Conclusions: College athletes are susceptible to waterpipe tobacco use. In fact, compared with their nonathletic counterparts, club sports participants and intramural sports participants generally had higher odds of waterpipe tobacco smoking. Allure for waterpipe tobacco smoking may exist even for individuals who are traditionally considered at low risk for tobacco use. © 2010 Society for Adolescent Medicine.

Organizations recommend media literacy to reduce tobacco use, and higher media literacy has been associated with lower smoking among high school students. The relationship between smoking media literacy and tobacco use, however, has not been systematically studied among college students. The purpose of this study was to determine the association between smoking and smoking media literacy among college students. We conducted the National College Health Assessment (NCHA) at a large, urban university, adding six items measuring smoking media literacy. A total of 657 students responded to this random sample e-mail survey. We used multiple logistic regression to determine independent associations between smoking media literacy items and current smoking. The media literacy scale was internally consistent (α=0.79). Of the respondents, 21.5% reported smoking cigarettes over the past 30 days. In a fully adjusted multivariate model, participants with medium media literacy had an odds ratio (OR) for current smoking of 0.45 (95% CI=0.29, 0.70), and those with high media literacy had an OR for current smoking of 0.38 (95% CI=0.20, 0.70). High smoking media literacy is independently associated with lower odds of smoking. Smoking media literacy may be a valuable construct to address in college populations.

We aimed to determine which media exposures are most strongly associated with marijuana and alcohol use among adolescents. In 2004, we surveyed 1,211 students at a large high school in suburban Pittsburgh regarding substance use, exposure to entertainment media, and covariates. Of the respondents, 52% were female, 8% were non-White, 27% reported smoking marijuana, and 60% reported using alcohol. They reported average exposure to 8.6 hr of media daily. In adjusted models, exposure to music was independently associated with marijuana use, but exposure to movies was independently associated with alcohol use. Implications, limitations, and suggestions for further research are discussed.

Background: Two thirds of all sexual references in music are degrading in nature, yet it remains uncertain whether these references promote earlier sexual activity. The purpose of this study was to determine if exposure to lyrics describing degrading sex in popular music is independently associated with sexual behavior in a cohort of urban adolescents. Methods: All ninth-grade health students at three large urban high schools completed in-school surveys in 2006 and 2007. Participants' exposure to lyrics describing degrading sex was computed with overall music exposure and content analyses of their favorite artists' songs. Outcomes included sexual intercourse and progression along a noncoital sexual continuum. Multivariable regression was used to assess independent associations between exposure to lyrics describing degrading sex and outcomes. Results: The 711 participants were exposed to 14.7 hours each week of songs with lyrics describing degrading sex (SD=17.0). Almost one third of participants (n=216) had previously been sexually active. Compared to those with the least exposure to lyrics describing degrading sex, those with the most exposure were more than twice as likely to have had sexual intercourse (OR=2.07; 95% CI=1.26, 3.41), even after adjusting for all covariates. Similarly, among those who had not had sexual intercourse, those in the highest tertile of exposure to lyrics describing degrading sex were nearly twice as likely to have progressed along a noncoital sexual continuum (OR=1.88; 95% CI=1.23, 2.88) compared to those in the lowest tertile. Finally, the relationships between exposure to lyrics describing nondegrading sex and sexual outcomes were not significant. Conclusions: This study supports an association between exposure to lyrics describing degrading sex in popular music and early sexual experience among adolescents. © 2009 American Journal of Preventive Medicine.

Context: Although certain media exposures have been linked to the presence of psychiatric conditions, few studies have investigated the association between media exposure and depression. Objective: To assess the longitudinal association between media exposure in adolescence and depression in young adulthood in a nationally representative sample. Design: Longitudinal cohort study. Setting and Participants: We used the National Longitudinal Survey of Adolescent Health (Add Health) to investigate the relationship between electronic media exposure in 4142 adolescents who were not depressed at baseline and subsequent development of depression after 7 years of follow-up. Main Outcome Measure: Depression at follow-up assessed using the 9-item Center for Epidemiologic Studies-Depression Scale. Results: Of the 4142 participants (47.5% female and 67.0% white) who were not depressed at baseline and who underwent follow-up assessment, 308 (7.4%) reported symptoms consistent with depression at follow-up. Controlling for all covariates including baseline Center for Epidemiologic Studies-Depression Scale score, those reporting more television use had significantly greater odds of developing depression (odds ratio [95% confidence interval], 1.08 [1.01-1.16]) for each additional hour of daily television use. In addition, those reporting more total media exposure had significantly greater odds of developing depression (1.05 [1.0004-1.10]) for each additional hour of daily use. We did not find a consistent relationship between development of depressive symptoms and exposure to videocassettes, computer games, or radio. Compared with young men, young women were less likely to develop depression given the same total media exposure (odds ratio for interaction term, 0.93 [0.88-0.99]). Conclusion: Television exposure and total media exposure in adolescence are associated with increased odds of depressive symptoms in young adulthood, especially in young men. © 2009 American Medical Associati

Objective: To assess the association between adolescent smoking and volume of exposure to various forms of media after controlling for multiple relevant covariates. Methods: A survey of all adolescents at a large suburban high school assessed: (1) current smoking and susceptibility to future smoking; (2) volume of exposure to various media; and (3) covariates related to smoking. Multivariate logistic regression models assessed relationships between each of the independent variables (media exposures) and the two smoking outcomes after controlling for covariates. Results: Of the 1138 respondents, 19% (n=216) reported current smoking. Forty percent (n=342) of the non-smokers (n=922) were susceptible to future smoking. Students reported exposure to an average of 8.6 (standard deviation 5.1) h of media daily, including 2.6 h of music. Those with high exposure to films and music were more likely to be smokers (Ptrend=0.036 and Ptrend<0.001, respectively), and those with high exposure to books were less likely to be smokers (Ptrend<0.001). After controlling for all relevant covariates, those with high exposure to music had greater odds of being smokers than those with low exposure [odds ratio (OR) 1.90, 95% confidence intervals (CI) 1.10-3.30], and those with high exposure to books had lower odds of being current smokers (OR 0.55, 95% CI 0.33-0.94). Conclusion: Exposure to films and music are associated with smoking, but only the relationship between music exposure and smoking persists after rigorous covariate control. Exposure to books is associated with lower odds of smoking. © 2008 The Royal Institute of Public Health.

Objective: To perform a comprehensive content analysis of substance use in contemporary popular music. Design: We analyzed the 279 most popular songs of 2005 according to Billboard magazine. Two coders working independently used a standardized data collection instrument to code portrayals of substance use. Outcome Measures: Presence and explicit use of substances and motivations for, associations with, and consequences of substance use. Results: Of the 279 songs, 93 (33.3%) portrayed substance use, with an average of 35.2 substance references per song-hour. Portrayal of substance use varied significantly (P <.001) by genre, with 1 or more references in 3 of 35 pop songs (9%), 9 of 66 rock songs (14%), 11 of 55 R&B/hip-hop songs (20%), 22 of 61 country songs (36%), and 48 of 62 rap songs (77%). While only 2.9% of the 279 songs portrayed tobacco use, 23.7% depicted alcohol use, 13.6% depicted marijuana use, and 11.5% depicted other or unspecified substance use. In the 93 songs with substance use, it was most often motivated by peer/social pressure (45 [48%]) or sex (28 [30%]); use was commonly associated with partying (50 [54%]), sex (43 [46%]), violence (27 [29%]), and/or humor (22 [24%]). Only 4 songs (4%) contained explicit antiuse messages, and none portrayed substance refusal. Most songs with substance use (63 [68%]) portrayed more positive than negative consequences; these positive consequences were most commonly social, sexual, financial, or emotional. Conclusions: The average adolescent is exposed to approximately 84 references to explicit substance use daily in popular songs, and this exposure varies widely by musical genre. The substance use depicted in popular music is frequently motivated by peer acceptance and sex, and it has highly positive associations and consequences. ©2008 American Medical Association. All rights reserved.

Objective. African Americans currently bear the greatest burden of morbidity and mortality due to smoking, and exposure to pro-tobacco media messages predicts smoking. This study compared the concentration (proportion of media messages that are for tobacco) and density (pro-tobacco media messages per person) of pro-tobacco media messages between African American and Caucasian markets. Methods. We searched Medline (1966 to June 2006), PsychINFO (1974 to June 2006), and CINAHL (1982 to June 2006) for studies from peer-reviewed journals directly comparing the volume of pro-tobacco media messages in African American and Caucasian markets. From each study, we extracted the number of total media messages, the number of tobacco-related messages, and the number of residents living in each market area. We calculated the concentration and density of tobacco advertising in each market. Results. Out of 131 studies identified, 11 met eligibility criteria, including seven comparing billboard/signage in African American and Caucasian markets and four comparing magazine advertising in African American and Caucasian markets. Meta-analysis estimated a pooled odds ratio of 1.7 (95% confidence interval [CI] 1.1, 2.6) for a given billboard being smoking-related in African American vs. Caucasian market areas (i.e., concentration). The pooled rate ratio of the density of smoking-related billboards was 2.6 (95% CI 1.5, 4.7) in African American vs. Caucasian market areas. Magazine data were insufficient for meta-analysis. Conclusion. Available data indicated that African Americans are exposed to a higher volume of pro-tobacco advertising in terms of both concentration and density. These findings have important implications for research, policy measures, and educational interventions involving racial disparities due to tobacco. ©2007 Association of Schools of Public Health.

Objectives: To develop a smoking media literacy (SML) scale by using empiric survey data from a large sample of high school students and to assess reliability and criterion validity of the scale. Design: On the basis of an established theoretical framework, 120 potential items were generated, and items were eliminated or altered on the basis of input from experts and students. Cross-sectional responses to scale items, demographics, smoking-related variables, and multiple covariates were obtained to refine the scale and determine its reliability and validity. Setting: One large Pittsburgh, Pa, high school. Participants: A total of 1211 high school students aged 14 to 18 years. Main Outcome Measures: Current smoking, susceptibility to smoking, attitudes toward smoking, and smoking norms. Results: Factor analysis demonstrated a strong 1-factor scale with 18 items (α=0.87). After controlling for all covariate data, SML had a statistically significant and independent association with current smoking (P=.01), susceptibility (P<.001), and attitudes (P<.001), but not norms (P=.42). Controlling for all covariates, an increase of 1 point on the 10-point SML scale was associated with a 22% decrease in the odds of being a smoker and a 31% decrease in the odds of being susceptible to smoking. Conclusions: Smoking media literacy can be measured with excellent reliability and concurrent criterion validity. Given the independent association between SML and smoking, media literacy may be a promising tool for future tobacco control interventions. ©2006 American Medical Association. All rights reserved.

Aims To validate a model for quantifying the prognosis of patients with pulmonary embolism (PE). The model was previously derived from 10 534 US patients. Methods and results We validated the model in 367 patients prospectively diagnosed with PE at 117 European emergency departments. We used baseline data for the model's 11 prognostic variables to stratify patients into five risk classes (I-V). We compared 90-day mortality within each risk class and the area under the receiver operating characteristic curve between the validation and the original derivation samples. We also assessed the rate of recurrent venous thrombo-embolism and major bleeding within each risk class. Mortality was 0% in Risk Class I, 1.0% in Class II, 3.1% in Class III, 10.4% in Class IV, and 24.4% in Class V and did not differ between the validation and the original derivation samples. The area under the curve was larger in the validation sample (0.87 vs. 0.78, P=0.01). No patients in Classes I and II developed recurrent thrombo-embolism or major bleeding. Conclusion The model accurately stratifies patients with PE into categories of increasing risk of mortality and other relevant complications. Patients in Risk Classes I and II are at low risk of adverse outcomes and are potential candidates for outpatient treatment.

Purpose: To determine whether media literacy concerning tobacco use is independently associated with two clinically relevant outcome measures in adolescents: current smoking and susceptibility to smoking. Methods: We asked high school students aged 14-18 years to complete a survey that included a validated 18-item smoking media literacy (SML) scale, items assessing current smoking and susceptibility to future smoking, and covariates shown to be related to smoking. We used logistic regression to assess independent associations between the two outcome measures and SML. Results: Of the 1211 students who completed the survey, 19% reported current smoking. Controlling for all potential confounders of smoking, we found that an increase of one point (out of 10) in SML was independently associated with an odds ratio for smoking of .84 (95% confidence interval [CI] .71-.99). Compared with students below the median score on the SML scale, students above the median had an odds ratio for smoking of .57 (95% CI .37-.87). Of the students who were nonsmokers, 40% were classified as susceptible to future smoking. Controlling for all potential confounders of smoking, we found that an increase of one point (out of 10) was independently associated with and an odds ratio for smoking susceptibility of .68 (95% CI .58-.79). Compared with students below the median SML, students above the median SML had an odds ratio for smoking susceptibility of .49 (95% CI .35-.68). Conclusions: In this sample of high school students, higher SML is independently associated with reduced current smoking and reduced susceptibility to future smoking. © 2006 Society for Adolescent Medicine.

Background: Long-term patient-centered outcomes after acute illness may be associated with baseline health status, the development of acute organ dysfunction (AOD), or both. Study objective: To determine whether AOD (occurring in the first 30 days) was independently associated with 90-day survival, functional status, and health-related quality of life (HRQL) after controlling for baseline health status in patients who were hospitalized with community-acquired pneumonia (CAP) and survived to day 30. Design: Prospective observational study. Setting: Four hospitals in Pennsylvania, Massachusetts, and Nova Scotia, Canada, between October 1991 and March 1994. Patients: One thousand three hundred thirty-nine patients who were hospitalized with CAP. Interventions: Baseline and 90-day quality-of-life and functional status questionnaires. Measurements and results: We determined the 90-day survival rate in all patients (n = 1,339) and the functional status and HRQL in subsets of 261 and 219 patients, respectively. AOD occurred in one or more organ system in 639 patients (47.7%) and in two or more organ systems in 255 patients (19.1%). In univariate analyses, greater AOD was associated with a higher mortality rate (p < 0.0001), a lower HRQL (p = 0.006), and lower functional status (p = 0.009) at 90 days. However, after adjusting for baseline HRQL, AOD was not associated with mortality (p = 0.47) or HRQL (p = 0.14) at 90 days and was only weakly associated with 90-day functional status (p = 0.02). Conclusions: Although patients who develop AOD are at risk for late adverse outcomes, their risk is due predominantly to poor baseline status prior to illness and not to the organ dysfunction per se. Therefore, AOD does not appear to have significant long-term ramifications for patient-centered outcomes. © 2002 Elsevier Science Ltd. All rights reserved.