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Excise taxes can raise the price of unhealthy products, reducing consumption and associated health risks and costs. Raising state excise taxes on tobacco, alcohol, and sugary drinks and allowing local governments to do the same are win-win strategies for achieving three Healthy North Carolina 2030 health behavior targets while increasing state revenues.

Tobacco use prevalence is higher in rural compared to urban settings, possibly due to differences in tobacco availability, including the option to purchase food and other essential items in stores that do not sell tobacco (tobacco-free food retailers). The goal of this research is to determine whether tobacco-free food retailer availability varies by urbanicity/rurality.Using the 2017 National Establishment Time-Series database, we identified food retailers across all census tracts containing food retailers in the United States (n = 66,053). We used multivariable logistic and linear regression models to test whether tobacco-free food retailer availability varied across 4-levels of census tract urbanicity/rurality (urban, suburban, large town, and small town/rural) for 2 outcomes: (1) the presence of at least 1 tobacco-free food retailer and (2) the percent of all food retailers that were tobacco-free.Compared to urban core census tracts, suburban census tracts had a lower odds (aOR = 0.77, 95% CI = 0.73, 0.81) of having at least 1 tobacco-free food retailer, while small town/rural census tracts had greater odds (aOR = 1.23, 95% CI = 1.15, 1.32). Suburban census tracts (B = -2.29, P.001) and large town census tracts (B = -1.90, P.001) also had a lower percentage of tobacco-free food retailers compared to urban census tracts.Compared to urban cores, tobacco-free food retailers were less prevalent in suburban and large town areas, though similarly or slightly more available in rural areas. Future research should assess whether these differences depend on varying store types.

Toddler milk is an ultra-processed beverage consisting primarily of powdered milk, caloric sweeteners, and vegetable oil. Pediatric health authorities do not support the use of toddler milk, and emerging evidence suggests that toddler-milk marketing practices may mislead consumers. However, studies have not synthesized the extent of toddler-milk marketing practices or how these practices affect parents’ decisions about whether to serve toddler milk. We aimed to summarize the literature about toddler milk to identify what is known about: (1) parents’ toddler-milk purchasing and feeding behaviors, (2) toddler-milk marketing, and (3) how marketing practices influence parents’ beliefs and perceptions about toddler milk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we systematically searched 8 databases (PubMed, APA PsycINFO, Scopus, Cochrane Central, Embase, CINAHL, Communication & Mass Media Complete, and Business Source Premier). We identified 45 articles about toddler milk. Studies were conducted in 25 countries across 6 continents. Five types of findings emerged: (1) consumption and feeding behaviors, (2) demographic correlates of toddler-milk purchasing and consumption, (3) misperceptions and beliefs, (4) increased sales, and (5) increased marketing and responses to marketing. The included articles suggested that toddler-milk sales are growing rapidly worldwide. Findings also revealed that toddler-milk packages (eg, labels, branding) resemble infant formula packages and that toddler-milk marketing practices may indirectly advertise infant formula. Purchasing, serving, and consumption of toddler milk were higher in Black and Hispanic populations than in non-Hispanic White populations, and parents with higher educational attainment and income were more likely to offer toddler milk to their children. Findings suggest a need for policies to prevent cross-marketing of toddler milk and infant formula, reduce provision of toddler milk to infants and toddlers, and prevent caregivers from being misled about toddler-milk healthfulness.

Introduction Studies find differences in tobacco retailer density according to neighborhood sociodemographic characteristics, raising issues of social justice, but not all research is consistent. Aims and Methods This study examined associations between tobacco retailer density and neighborhood sociodemographic characteristics in the United States at four timepoints (2000, 2007, 2012, and 2017) and investigated if associations remained stable over time. Data on tobacco retailers came from the National Establishment Time-Series Database. Adjusted log-linear models examined the relationship between retailer density and census tract sociodemographic characteristics (% non-Hispanic Black [Black], % Hispanic, % vacant housing units, median household income), controlling for percentage of youth, urbanicity, and US region. To examine whether the relationship between density and sociodemographic characteristics changed over time, additional models were estimated with interaction terms between each sociodemographic characteristic and year. Results Tobacco retailer density ranged from 1.22 to 1.44 retailers/1000 persons from 2000 to 2017. There were significant, positive relationships between tobacco retailer density and the percentage of Black (standardized exp(b) = 1.05 [95% CI: 1.04% to 1.07%]) and Hispanic (standardized exp(b) = 1.06 [95% CI: 1.05% to 1.08%]) residents and the percentage of vacant housing units (standardized exp(b) =1.08 [95% CI: 1.07% to 1.10%]) in a census tract. Retailer density was negatively associated with income (standardized exp(b) = 0.84 [95% CI: 0.82% to 0.86%]). From 2000 to 2017, the relationship between retailer density and income and vacant housing units became weaker. Conclusions Despite the weakening of some associations, there are sociodemographic disparities in tobacco retailer density from 2000 to 2017, which research has shown may contribute to inequities in smoking. Implications This study examines associations between tobacco retailer density and neighborhood sociodemographic characteristics in the United States at four timepoints from 2000 to 2017. Although some associations weakened, there are sociodemographic disparities in tobacco retailer density over the study period. Research suggests that sociodemographic disparities in retailer density may contribute to inequities in smoking. Findings from this study may help identify which communities should be prioritized for policy intervention and regulation.

ObjectiveWe sought to conduct a systematic review and meta-analysis of evidence to inform policies that reduce density and proximity of tobacco retailers.Data sourcesTen databases were searched on 16 October 2020: MEDLINE via PubMed, PsycINFO, Global Health, LILACS, Embase, ABI/Inform, CINAHL, Business Source Complete, Web of Science and Scopus, plus grey literature searches using Google and the RAND Publication Database.Study selectionIncluded studies used inferential statistics about adult participants to examine associations between tobacco retailer density/proximity and tobacco use behaviours and health outcomes. Of 7373 studies reviewed by independent coders, 37 (0.5%) met inclusion criteria.Data extractionEffect sizes were converted to a relative risk reduction (RRR) metric, indicating the presumed reduction in tobacco use outcomes based on reducing tobacco retailer density and decreasing proximity.Data synthesisWe conducted a random effects meta-analysis and examined heterogeneity across 27 studies through subgroup analyses and meta-regression. Tobacco retailer density (RRR=2.55, 95% CI 1.91 to 3.19, k=155) and proximity (RRR=2.38, 95% CI 1.39 to 3.37, k=100) were associated with tobacco use behaviours. Pooled results including both density and proximity found an estimated 2.48% reduction in risk of tobacco use from reductions in tobacco retailer density and proximity (RRR=2.48, 95% CI 1.95 to 3.02, k=255). Results for health outcomes came from just two studies and were not significant. Considerable heterogeneity existed.ConclusionsAcross studies, lower levels of tobacco retailer density and decreased proximity are associated with lower tobacco use. Reducing tobacco supply by limiting retailer density and proximity may lead to reductions in tobacco use. Policy evaluations are needed.

Introduction Greater availability of tobacco product retailers in an area may be associated with smoking behaviors, and the majority of people who smoke purchase their cigarettes at gas stations and convenience stores. This cross-sectional study investigates the associations of overall tobacco retailer density and gas/convenience density with adult smoking behaviors. Methods This study built a list of tobacco retailers in 2014 and calculated the county-level number of retailers per 1,000 people. Individual-level smoking behavior data were drawn from the 2014–2015 Tobacco Use Supplement for a sample of adults (n=88,850) residing in metropolitan counties across the U.S. General estimating equation models were fit to investigate the associations between retailer density and cigarette smoking behaviors (smoking status, quit attempt, quit length). Analyses were conducted in 2020. Results A greater number of tobacco retailers (AOR=1.63, 95% CI=1.35, 1.96) and gas stations and convenience stores (AOR=3.29, 95% CI=2.39, 4.52) per 1,000 people were each associated with a higher odds of a respondent smoking every day than the odds of a respondent not smoking. In addition, both measures were associated with a higher odds of a respondent being an every-day than being a some-day smoker. Associations for gas/convenience density were similar in models that additionally controlled for other tobacco retailers (excluding gas/convenience). Study results did not support associations between retailer density and cessation. Conclusions Tobacco retailer density, especially gas/convenience density, is correlated with daily smoking, the most harmful tobacco use behavior. Calculating tobacco retailer density using gas/convenience stores may be a feasible proxy for overall tobacco retailer density.

Introduction Tobacco product retailers provide access to tobacco products and exposure to tobacco marketing. Without a national tobacco retailer licensing system in the United States, there are no estimates of national trends in tobacco retailer numbers and store type over time. Methods We developed a protocol to identify likely tobacco retailers across the United States between 2000 and 2017 using industry codes and retailer names in the annual National Establishment Time Series (NETS) database. We calculated annual counts of tobacco retailers in seven store-type categories and annual numbers of tobacco retailers that opened and closed. Results We estimate that there were 317 492 tobacco product retailers in 2000; the number grew to 412 536 in 2009 before falling to 356 074 in 2017, for a net 12% increase overall. Gas/convenience stores and grocery stores accounted for more than two thirds of all retailers. On average, new openings accounted for 8.0% of the total retailers, whereas 7.3% of retailers closed or stopped selling tobacco each year, with stronger market volatility following the Great Recession. Since 2011, there was a disproportionate reduction in tobacco-selling pharmacies and an increase in both tobacco-specialty shops and tobacco-selling discount stores. Conclusions During two decades when smoking declined, tobacco retailer availability increased in the United States. The economic climate, corporate and public policies, and new tobacco products may all contribute to trends in tobacco retailer availability. State and local jurisdictions considering tobacco retailer policies may find retailer trend information useful for forecasting or evaluating potential policy impacts. Implications This study provides historic data tracking tobacco retailers in the United States between 2000 and 2017, documenting trends that unfolded as the general economic market contracted and grew, with greater regulation of the tobacco retailer environment. These data provide a context for better understanding future changes in the tobacco retailer market. In addition, the protocol established in this study could be applied in any US-based location without tobacco retailer licensing to allow identification of stores and tracking of trends.

Studies document inequitable tobacco retailer density by neighborhood sociodemographics, but these findings may not be robust to different density measures. Policies to reduce density may be less equitable depending on how the presence of store types differs by neighborhood characteristics. We built a 2018 list of probable tobacco retailers in the United States and calculated four measures of density for all census tracts ( N = 71,495), including total count, and number of retailers per 1,000 people, square mile, and kilometers of roadway. We fit multivariable regression models testing associations between each density measure and tract-level sociodemographics. We fit logistic regression models testing associations between sociodemographics and the presence of a tobacco-selling pharmacy or tobacco shop. Across all measures, tracts with a greater percentage of residents living below 150% of the federal poverty level (FPL) had higher density. A higher percentage of Black residents, Hispanic or Latino residents, and vacant housing was inconsistently associated with density across measures. Neighborhoods with a greater percentage of Black residents had a lower odds of having a pharmacy (adjusted odds ratio [a OR] = 0.96, 95% confidence interval [CI; 0.95, 0.97]) and tobacco shop (a OR = 0.87, CI [0.86, 0.89]), while those with a greater percentage of residents living below 150% FPL had greater odds of having a tobacco shop (a OR = 1.18, CI [1.16, 1.20]). Researchers and policymakers should consider how various measures of retailer density may capture different aspects of the environment. Furthermore, there may be an inequitable impact of retailer-specific policies on tobacco availability.

Written language is the primary means by which scientific research findings are disseminated. Yet in the era of information overload, dissemination of a field of research may require additional efforts given the sheer volume of material available on any specific topic. Topic models are unsupervised natural language processing methods that analyze nonnumeric data (i.e., text data) in abundance. These tools aggregate, and make sense of, those data making them interpretable to interested audiences. In this perspective piece, we briefly describe topic models, including their purpose, function, and applicability for health education researchers and practitioners. We note how topic models can be applied in several contexts, including social media–based analyses, and mapping trends in scientific literature over time. As a tool for studying words, and patterns of words, topic models stand to improve our understanding of events prior and those occurring in the moment and help us look ahead into the future.

This study documents all tobacco control proposals (bills) introduced in the United States into all 50 state legislatures from the start of 2010 through 2015 and assesses associations between tobacco-related strategies and tobacco product types with enactment of the bills into law. In total, members of state legislatures introduced 2801 tobacco control bills, and state legislatures enacted 17.4%. Bills most introduced addressed clean air (n = 696) and tax or price bills (n = 582), yet both had lower likelihood of enactment (each OR, 0.51; 95% CI 0.38–0.69) compared to bills on any other tobacco control strategy. Legislators introduced only 147 product manufacturing bills, but these had the highest odds of enactment (OR, 3.70, 95% CI 2.52–5.44) compared to any other intended strategy, followed by tax evasion (OR, 3.08; 95% CI 2.33–4.08) and retailer licensing or location (OR, 1.73; 95 CI 1.24–2.41). Compared to other products, bills regulating e-cigarettes had the highest enactment rate (21.2%). Despite introduction of many bills promoting traditional, evidence-based tobacco control strategies, these had less likelihood of enactment than others.

Introduction Minimum floor price laws (MFPLs) are an emerging tobacco control policy that sets a minimum price below which a specific tobacco product cannot be sold. MFPLs target cheaper products and may disproportionately impact consumers choosing low price brands or using discounts to reduce prices. We developed a static microsimulation model for California, United States to project short-term effects of different MFPL options for a 20-stick pack of cigarettes on adult smoking behaviors. Aims and Methods We simulated 300 000 individuals defined by race and ethnicity, sex, age, and poverty status. Smoking behaviors and cigarette prices were assigned based on demographic distributions in the 2014–2016 California Behavioral Risk Factor Surveillance System. We drew 100 random samples (n = 30 000), weighted to state-level California demographic characteristics. We simulated six MFPL options and modeled impacts on smoking prevalence and cigarette consumption, in general, and separately for those in households below or above 250% of the federal poverty level, assuming a price elasticity of −0.4. Results Predicted changes in prices, prevalence, and consumption increased exponentially as the floor price increased from $7.00 to $9.50. Assuming 15% policy avoidance, projected increases in average cigarette prices ranged from $0.19 to $1.61. Decreases in smoking prevalence ranged from 0.05 to 0.43 percentage points, and decreases in average monthly cigarette consumption ranged from 1.4 to 12.3 cigarettes. Projected prices increased, and prevalence and consumption decreased, more among individuals in households below 250% federal poverty level. Conclusions MFPLs are a promising tobacco control strategy with the potential to reduce socioeconomic disparities in cigarette smoking prevalence and consumption. Implications Despite reductions in adult smoking prevalence, significant socioeconomic disparities remain, with lower-income groups smoking at substantially higher levels than higher-income groups. Policies that set a floor price below which a tobacco product cannot be sold could reduce socioeconomic disparities in smoking, depending on variation in prices paid by smokers prepolicy. By using a microsimulation model to predict changes in smoking for different population groups in California under several floor price scenarios, this study demonstrates that MFPLs have the potential to reduce adult smoking prevalence overall, and especially for lower-income tobacco users.

ObjectivesDevelop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies.MethodsWe developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies.ResultsThe CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking.ConclusionsThe CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

IntroductionIn March 2017, the US Department of Defense (DoD) implemented a policy requiring all military stores to set tobacco prices equal to ‘prevailing prices’ in the ‘local community’ adjusted for state and local taxes. We compared tobacco product prices in a sample of retailers located on five Air Force Bases (AFBs) in Texas and Mississippi with those sold in nearby off-base stores.MethodsWe constructed a list of on-base and off-base tobacco retailers. Off-base retailers included stores that were located within a 1.5-mile road network service area from main AFB gates. Between July and September 2019, a trained auditor visited 23 on-base and 50 off-base retailers to confirm tobacco product sales, and documented the price of cigarettes and Copenhagen smokeless tobacco. For each area, the median price for each product, as well as the difference in median prices by on-base versus off-base status, was calculated.ResultsThe median price of cigarettes and smokeless products was cheaper at on-base retailers. All products were cheaper at on-base stores in Fort Sam Houston and Lackland AFB. Similarly, all products were cheaper in on-base stores at Keesler AFB, with the exception of Marlboro Red packs ($0.22 more), and at Sheppard AFB with the exception of cheapest cigarette cartons ($6.26 more).ConclusionDespite the implementation of the new DoD policy, tobacco products are cheaper in on-base retailers compared with off-base retailers. Refining of the definitions used and improved compliance with the new DoD policy are needed.

Introduction Five U.S. states have proposed policies to require health warnings on sugar-sweetened beverages, but warnings’ effects on actual purchase behavior remain uncertain. This study evaluated the impact of sugar-sweetened beverage health warnings on sugar-sweetened beverage purchases. Study design Participants completed one study visit to a life-sized replica of a convenience store in North Carolina. Participants chose six items (two beverages, two foods, and two household products). One item was randomly selected for them to purchase and take home. Participants also completed a questionnaire. Researchers collected data in 2018 and conducted analyses in 2019. Setting/participants Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened beverage consumers (usual consumption ≥12 ounces/week). Intervention Research staff randomly assigned participants to a health warning arm (sugar-sweetened beverages in the store displayed a front-of-package health warning) or a control arm (sugar-sweetened beverages displayed a control label). Main outcome measures The primary trial outcome was sugar-sweetened beverage calories purchased. Secondary outcomes included reactions to trial labels (e.g., negative emotions) and sugar-sweetened beverage perceptions and attitudes (e.g., healthfulness). Results All 400 participants completed the trial and were included in analyses. Health warning arm participants were less likely to be Hispanic and to have overweight/obesity than control arm participants. In intent-to-treat analyses adjusting for Hispanic ethnicity and overweight/obesity, health warnings led to lower sugar-sweetened beverage purchases (adjusted difference, −31.4 calories; 95% CI= −57.9, −5.0). Unadjusted analyses yielded similar results (difference, −32.9 calories; 95% CI= −58.9, −7.0). Compared with the control label, sugar-sweetened beverage health warnings also led to higher intentions to limit sugar-sweetened beverage consumption and elicited more attention, negative emotions, thinking about the harms of sugar-sweetened beverage consumption, and anticipated social interactions. Trial arms did not differ on perceptions of sugar-sweetened beverages’ added sugar content, healthfulness, appeal/coolness, or disease risk. Conclusions Brief exposure to health warnings reduced sugar-sweetened beverage purchases in this naturalistic RCT. Sugar-sweetened beverage health warning policies could discourage sugar-sweetened beverage consumption. Trial registration This study is registered at www.clinicaltrials.gov NCT03511937.

Introduction: Young adulthood is a critical time for the emergence of risk behaviors including smoking. Psychological health is associated with smoking, but studies rarely track both over time. We used longitudinal data to assess whether average patterns of psychological health influenced average patterns of smoking and whether short-term fluctuations in psychological health influenced fluctuations in smoking. Method: Young adults aged 18–30 from the Panel Study of Income Dynamics were followed from 2007 to 2013, and mean trajectories of smoking were modeled. Psychological health variables included ever having a mental health diagnosis and time-varying distress. Results: In regression models, individuals with poorer psychological health (higher distress or a diagnosis) were more likely to be smokers and to smoke greater number of cigarettes. The association of diagnosis with number of cigarettes smoked increased with age. Conclusions: Smoking-related interventions should target individuals with poorer psychological health, even if they have no formal mental health diagnosis.

Cancer survivors who smoke cigarettes face health risks from continued smoking. Some smokers use e-cigarettes to reduce combustible cigarette use, but research on whether cancer survivors do the same is limited. Research is needed to understand whether smokers who are cancer survivors use e-cigarettes at higher rates than smokers never diagnosed with cancer, to inform provider-patient discussions about e-cigarettes. Using cross-sectional data from current cigarette smokers in Wave 1 (2013–2014) of the Population Assessment of Tobacco Health (PATH) study, we compared cancer survivors (n = 433) and those without a prior cancer diagnosis (n = 10,872) on e-cigarette use and reasons for use. Among smokers, 59.4% of cancer survivors and 63.2% of those without a cancer diagnosis had ever used e-cigarettes, and nearly one-quarter of both groups (23.1% and 22.3%, respectively) reported being current users. Multivariate results, however, suggest that cancer survivors might be more likely to be ever (OR = 1.28; p = .05) or current (OR = 1.25; p = .06) e-cigarette users compared to those never diagnosed, although results were marginally significant. The majority of both groups (> 71%) reported using e-cigarettes for perceived health-related reasons—including smoking reduction. Our study found that among smokers, cancer survivors were using e-cigarettes at similar rates as never-diagnosed smokers and both groups used e-cigarettes largely for perceived health-related reasons. Clinicians who treat cancer survivors may need to routinely ask their patients who smoke about e-cigarette use and address the limited research on the efficacy of e-cigarettes as a cessation aid as compared to other evidence-based options.

Introduction Minimum price laws, which set a price below which a product cannot be sold, are a promising but understudied strategy for reducing the consumption of sugar-sweetened beverages. New York City has implemented a minimum price law for tobacco products and could consider this policy for sugar-sweetened beverages. This study projects the impacts of a sugar-sweetened beverage minimum price law among New York City adults, with effects of a sugar-sweetened beverage excise tax examined for comparison. Methods In 2020–2021, a microsimulation model of dietary behaviors and body weight was developed using population-based survey data, research on responsiveness to and avoidance of price increases, and a validated weight change model. Analyses applied the model to simulate the impacts of implementing a minimum price law (8 or 10 cents/ounce price floors) or an excise tax (1 or 2 cents/ounce tax rates) on diet and body weight among New York City adults for more than 5 years. Sensitivity analyses varied assumptions about price responsiveness, caloric compensation, and avoidance. Results A sugar-sweetened beverage minimum price law with an 8 cents/ounce floor would reduce average sugar-sweetened beverage intake by 16.5 calories/day (95% uncertainty interval= −17.2, −15.8) and obesity prevalence by 0.86 percentage points (95% uncertainty interval= −1.03, −0.69). Benefits were similar for a minimum price law with a 10 cents/ounce floor and for 1 and 2 cents/ounce taxes (range of obesity reductions: −0.84 to −1.24 percentage points). Benefits persisted in sensitivity analyses and were larger for Black and Hispanic than for White and Asian adults and for adults with lower than for those with higher income. Conclusions Excise taxes and minimum price laws for sugar-sweetened beverages could both reduce New York City adults’ sugar-sweetened beverage consumption and obesity prevalence and narrow sociodemographic disparities in obesity.

ObjectivesTo advance understanding of how message framing can be used to maximise public support across different pricing policies for alcohol, tobacco and sugary drinks/foods that prevent consumption of cancer-causing products.DesignWe designed a 3×4×3 randomised factorial experiment to test responses to messages with three pricing policies, four message frames and three products.SettingOnline survey panel (Qualtrics) in 2019.ParticipantsAdults (N=1850) from the UK and USA.InterventionsParticipants randomly viewed one of 36 separate messages that varied by pricing policy (increasing taxes, getting rid of price discounts, getting rid of low-cost products), four frames and product (alcohol, tobacco, sugary drinks/foods).Primary and secondary outcome measuresWe assessed the relationship between the message characteristics and four dependent variables. Three were related to policy support: (1) increasing taxes on the product mentioned in the message, (2) getting rid of price discounts and special offers on the product mentioned in the message and (3) getting rid of low-cost versions of the product mentioned in the message. One was related to reactance, a psychological response to having one’s freedom limited.ResultsWe found no effect for pricing policy in the message. Frames regarding children and reducing cancer risk moderated some outcomes, showing promise for real-world use. We found differences in support by product and reactance with greatest support and least reactance for tobacco policies, less support and more reactance for alcohol policies, and the least support and most reactance for sugary drinks/foods policies.ConclusionsCancer prevention efforts using policy interventions can be informed by the message framing literature. Our results offer insights for cancer prevention advocacy efforts across the UK and USA and highlight that tax versus non-tax approaches to increasing the cost of cancer-causing products result in similar responses from consumers.

Brief interventions to reduce frequent alcohol use among persons with HIV (PWH) are evidence-based, but resource-constrained settings must contend with competition for health resources. We evaluated the cost-effectiveness of two intervention arms compared to the standard of care (SOC) in a three-arm randomized control trial targeting frequent alcohol use in PWH through increasing the percent days abstinent from alcohol and viral suppression. We estimated incremental cost per quality-adjusted life year [QALY] gained from a modified societal perspective and a one-year time horizon using a Markov model of health outcomes. The two-session brief intervention (BI), relative to the six-session combined intervention (CoI), was more effective and less costly; the estimated incremental cost-effectiveness of the BI relative to the SOC, was $525 per QALY gained. The BI may be cost-effective for the HIV treatment setting; the health utility gained from viral suppression requires further exploration.

Background Hazardous alcohol use is detrimental to persons with HIV (PWH), impacting medication adherence and liver function, yet globally resources to target alcohol use behavior in this population are limited. Few studies have identified the costs of integrating alcohol reduction interventions into HIV care. Objective To estimate the costs of implementing and delivering two evidence-based behavioral counseling interventions targeting hazardous alcohol use among persons with HIV and to estimate the costs of scale-up in ART clinics in Thai Nguyen, Vietnam. Methods We undertook a micro-costing approach to determine the costs of delivering two adapted evidence-based interventions to reduce alcohol use: an intensive combined cognitive behavioral therapy and motivational enhancement therapy-informed intervention (CoI) and an abbreviated brief alcohol intervention (BI). A total of 294 participants with hazardous alcohol use were identified through a brief screening tool and received the CoI (n = 147) and the BI (n = 147) over 3 months. We estimated costs using time and motion studies, budget analysis, staff interviews, and participant questionnaires. Data were collected from 2016 to 2018 in VND and converted to USD. Results The total cost of implementation and administration of the intervention to 147 participants receiving the CoI was $13,900 ($95 per participant) and to 147 participants receiving the BI was $5700 ($39 per participant). Implementation and startup costs including training accounted for 27% of costs for the CoI and 28% for the BI. Counselor costs accounted for a large proportion of both the CoI (41%) and the BI (30%). Conclusions Implementing and delivering alcohol reduction interventions to people with HIV in Vietnam with appropriate fidelity is costly. These costs may be reduced, particularly counselor labor costs, by using an evidence-based brief intervention format. Future research should explore the budgetary impact of brief and combined interventions to reduce hazardous alcohol use, particularly among vulnerable populations.

Combining geospatial data on residential and tobacco retailer density in 30 big US cities, we find that a large majority of urban residents live in tobacco swamps - neighborhoods where there is a glut of tobacco retailers. In this study, we simulate the effects of tobacco retail reduction policies and compare probable changes in resident-to-retailer proximity and retailer density for each city. While measures of proximity and density at baseline are highly correlated, the results differ both between effects on proximity and density and across the 30 cities. Context, particularly baseline proximity of residents to retailers, is important to consider when designing policies to reduce retailer concentration.

BACKGROUND: In 2015, the US Preventive Services Task Force (USPSTF) revised clinical recommendations to more broadly recommend abnormal blood glucose screening and more clearly recommend referral to behavioral interventions for adults with prediabetes. OBJECTIVE: To assess the effects of the 2015 USPSTF recommendation changes on abnormal blood glucose screening and referral to behavioral interventions, and to examine physicians’ perceptions of the revised recommendation. DESIGN: We utilized a sequential, dependent mixed-methods triangulation design. PARTICIPANTS: A total of 33,444 patients meeting USPSTF abnormal blood glucose screening criteria within 15 health system–affiliated primary care practices and 20 primary care physicians in North Carolina. MAIN MEASURES: We assessed monthly abnormal blood glucose screening rate and monthly referral rate to behavioral interventions. To estimate trend changes in outcomes, we used segmented linear regression analysis of interrupted time-series data. We gathered physicians’ perspectives on the 2015 USPSTF abnormal blood glucose recommendation including awareness of, agreement with, adoption of, and adherence to the recommendation. To analyze qualitative data, we used directed content analysis. KEY RESULTS: There was a slight significant change in trend in abnormal blood glucose screening rates post-recommendation. There was a slight, statistically significant decrease in referral rates to behavioral interventions post-recommendation. Physicians were generally unaware of the revisions to the 2015 USPSTF abnormal blood glucose recommendation; however, once the recommendations were described, physicians agreed with the screening recommendation but felt that the behavioral intervention referral recommendation was hard to implement. CONCLUSION: The 2015 USPSTF abnormal blood glucose guideline had little to no effect on abnormal blood glucose screening or referral to behavioral interventions in North Carolina practices. Potential interventions to improve these rates could include clinical decision tools embedded in the electronic health record and better referral systems for community-based diabetes prevention programs.

The projected three-fold increase in diabetes burden by 2060 in the United States will affect certain race and gender groups disproportionately. The objective of this mixed-methods study was to assess differences in prediabetes screening and clinician response to prediabetes by patient race and gender. We utilized data from 18,742 patients seen between 11/1/15 and 4/30/17 who met criteria for blood glucose screening by the 2015 US Preventive Service Task Force recommendation and had at least one visit to a primary care practice within a large, academic health system located in North Carolina. We utilized generalized estimating equations with logistic regression to assess race and gender differences in two outcomes: prediabetes screening and clinician response to prediabetes. We conducted twenty in-depth interviews (October 2018–May 2019) with physicians to assess their approach to screening for and treating prediabetes. Black patients had 11% higher odds (95% CI:1.02–1.20) of being screened for prediabetes than White patients. Men had 19% higher odds (95% CI:1.09–1.30) of being screened for prediabetes than women. There were no significant differences in clinician response to prediabetes by patient race or gender. Qualitatively, physicians reported a non-systematic approach to prediabetes screening and follow-up care related to: 1) System-level barriers to screening and treatment; 2) Implicit bias; 3) Patient factors; and 4) Physician preferences for prediabetes treatment. Targeted risk-based screening for prediabetes along with increased treatment for prediabetes are critical for preventing diabetes and reducing diabetes-related disparities.

This study documents all tobacco control proposals (bills) introduced in the United States into all 50 state legislatures from the start of 2010 through 2015 and assesses associations between tobacco-related strategies and tobacco product types with enactment of the bills into law. In total, members of state legislatures introduced 2801 tobacco control bills, and state legislatures enacted 17.4%. Bills most introduced addressed clean air (n = 696) and tax or price bills (n = 582), yet both had lower likelihood of enactment (each OR, 0.51; 95% CI 0.38-0.69) compared to bills on any other tobacco control strategy. Legislators introduced only 147 product manufacturing bills, but these had the highest odds of enactment (OR, 3.70, 95% CI 2.52-5.44) compared to any other intended strategy, followed by tax evasion (OR, 3.08; 95% CI 2.33-4.08) and retailer licensing or location (OR, 1.73; 95 CI 1.24-2.41). Compared to other products, bills regulating e-cigarettes had the highest enactment rate (21.2%). Despite introduction of many bills promoting traditional, evidence-based tobacco control strategies, these had less likelihood of enactment than others.

Policy Points: Policymakers in the United States should consider expanding pharmacy practice laws to allow pharmacists to vaccinate adolescents as a way to improve geographic access to adolescent vaccines, particularly for human papillomavirus (HPV) vaccine, which has low uptake. Our state-level analysis showed that pharmacists are more geographically dispersed than primary care physicians in the US state of Texas. Including pharmacists among available adolescent vaccine providers would improve the geographic distribution of vaccine providers, especially in areas with an inadequate number of primary care physicians. Context The largest disparities in human papillomavirus (HPV) vaccination in the United States are due to geography. One potential way of addressing these disparities is by improving geographic access to HPV vaccination. Two federal panels have recommended including community pharmacists as HPV vaccine providers as a strategy to improve opportunities for HPV vaccination for adolescents. We sought to evaluate whether community pharmacists can improve the number of vaccine providers in areas with primary care physician shortages in the US state of Texas. Methods We gathered publicly available physician and pharmacist 2016 workforce data from the Texas Medical Board and Board of Pharmacy. We conducted geospatial analysis of census tracts to analyze the distribution of physicians and pharmacists and how pharmacists change vaccine provider coverage across the state. Findings Census tracts with high numbers of physicians per capita tended to be located near one another, in 5 of 5 analyses of Moran's I (median = .04). In contrast, pharmacist rates were not spatially dependent on census tract in any of our analyses. If pharmacists were added to primary care physicians as vaccine providers, 35% of urban census tracts that previously had inadequate coverage would be adequately covered, while 18% of inadequately covered rural census tracts would become adequately covered. Overall, when pharmacists were included with primary care physicians as vaccine providers, vaccine providers per capita increased in 2,413 of the 4,508 urban census tracts (54%), while the rate increased in 223 of 746 rural census tracts (30%). Conclusions Pharmacists are more geographically dispersed across census tracts than primary care physicians. As a result, adding pharmacists to the workforce would increase the availability of vaccine providers in areas with inadequate primary care provider coverage.

Tobacco use remains the leading cause of preventable death in the United States. Tobacco industry reports document the systematic targeting of menthol cigarettes in Black communities, and 84.6% of ...

Objectives We examined effects of e-cigarette ad messages and visual cues on outcomes related to combustible cigarette smoking cessation: smoking cessation intention, smoking urges, and immediate smoking behavior. Methods US adult smokers (N = 3293) were recruited through Amazon Mechanical Turk and randomized to condition in a 3 (message: e-cigarette use anywhere, harm reduction, control) × 2 (e-cigarette cue presence or absence) between-subjects experiment. Stimuli were print ads for cigarette-like e-cigarettes ("cigalikes") that were manipulated for the experimental conditions. We conducted ANOVA and logistic regression analyses to investigate effects of the manipulations. Results Message effects on cessation intention and smoking urges were not statistically significant. There was no evidence of cue effects or message × cue interactions across outcomes. Contrary to expectations, e-cigarette use anywhere and harm reduction messages were associated with lower odds of immediate smoking than the control message (AOREUA = 0.75, 95%CI = 0.58, 0.97, p = .026; AORHR = 0.72, 95%CI = 0.55, 0.93, p = .013). Conclusions E-cigarette use anywhere and harm reduction messages may encourage smoking cessation, given the observed reduction in immediate smoking. E-cigarette cues may not influence smoking cessation outcomes. Future studies should investigate whether message effects are a result of smokers believing e-cigarettes to be effective cessation aids.

We apply a spatial perspective to measure the extent to which the 2018 U.S. racial, ethnic, and socioeconomic composition of census tracts were each associated with tobacco retailer density within a tract and in its neighboring tracts (n = 71,409). A 10-percentage point increase in the Black population was associated with 0.07 (p 0.05) more retailers per square mile within a focal tract and 0.35 (p 0.001) more retailers per square mile in its neighbors on average. A greater percent of Hispanic/Latino residents was associated with more retailers per square mile, both within a focal tract (b = 0.95, p 0.001) and in its neighbors 0.39 (p 0.001). Inverse associations were observed for percent white. We also observed inequities by socioeconomic status. The overall magnitude of inequities may be underestimated if the spatial dependence between focal tracts and their neighbors are not taken into consideration. Policymakers should prioritize interconnected geographic areas experiencing high racialized and socioeconomic segregation when designing and implementing policies to reduce retail tobacco product availability.

INTRODUCTION: Social interactions are a key mechanism through which health communication efforts, including pictorial cigarette pack warnings, may exert their effects. We sought to better understand social interactions elicited by pictorial cigarette pack warnings. METHODS: A controlled trial randomly assigned US adult smokers (n = 2149) to have their cigarette packs labeled with pictorial or text-only warnings for 4 weeks. Smokers completed surveys during the baseline visit and each of the subsequent 4 weekly visits. RESULTS: Smokers with pictorial warnings on their packs had more conversations throughout the trial compared to those with text-only warnings (8.2 conversations vs 5.0, p

Background One-third of the burden of cancer is associated with four health harming behaviours - tobacco use, alcohol consumption, poor diet and physical inactivity. The growing evidence base supporting price-related policies to curb over consumption is of interest to governments globally. However, implementation requires public and policy-maker support. The aim of this study is to enhance our understanding of the features of message framing that influence public support for price-related policies in relation to tobacco, alcohol, and sugar. Methods We conducted 18 semi-structured interviews (9 UK and 9 USA) exploring knowledge, attitudes, and beliefs of 4 price policies in relation to tobacco, alcohol and sugar. Interviewees included cancer policy advocates, cancer survivors and members of the public. We used NVivo 12 to organise the data for inductive and deductive thematic analysis. Results Common supportive features included: (i) highlighting the health benefit (eg reduced cancer risk), arising from impact on purchasing behaviour; (ii) indirectly making the health harm associated with consumption clear. Common unsupportive features included: (i) policy effectiveness will depend on size of the financial penalty and consumer response; (ii) such policies are unfair on sensible consumers and potentially regressive. Interviewees were more supportive of price-related policies for products containing tobacco where they perceived a stronger association with cancer risk. Conclusions This study reveals important differences in levels of persuasiveness arising from the framing of messages to promote price-related policies. The results informed the identification of 4 frames to be tested in a multi-factorial quantitative study, currently under way. These frames can be characterised as: F1 - To reduce the financial strain on healthcare systems; F2 - For the protection of children; F3 - To reduce cancer risk; and F4 - To reduce the risk of other non-communicable diseases. Key messages Tailoring the framing of price-related policies in relation to the product they are applied to may increase public acceptability. This may in turn facilitate their implementation.

Introduction Overconsumption of sugar-sweetened beverage (SSB) is a significant contributor to obesity. Policymakers have proposed requiring health warnings on SSBs to reduce SSB consumption. Randomized trials indicate that SSB warnings reduce SSB purchases, but uncertainty remains about how warnings affect population-level dietary and health outcomes. Methods This study developed a stochastic microsimulation model of dietary behaviors and body weight using the 2005–2014 National Health and Nutrition Examination Surveys, research on SSB health warnings, and a validated model of weight change. In 2019, the model simulated a national SSB health warning policy's impact on SSB intake, total energy intake, BMI, and obesity among U.S. adults over 5 years. Sensitivity analyses varied assumptions about: (1) how warning efficacy changes over time, (2) the magnitude of warnings’ impact on SSB intake, and (3) caloric compensation. Results A national SSB health warning policy would reduce average SSB intake by 25.3 calories/day (95% uncertainty interval [UI]= −27.0, −23.6) and total energy intake by 31.2 calories/day (95% UI= −32.2, −30.1). These dietary changes would reduce average BMI by 0.64 kg/m2 (95% UI= −0.67, −0.62) and obesity prevalence by 3.1 percentage points (95% UI= −3.3%, −2.8%). Obesity reductions persisted when assuming warning efficacy wanes over time and when using conservative estimates of warning impact and caloric compensation. Benefits were larger for black and Hispanic adults than for white adults, and for adults with lower SES than for those with higher SES. Conclusions A national SSB health warning policy could reduce adults’ SSB consumption and obesity prevalence. Warnings could also narrow sociodemographic disparities in these outcomes.

Introduction Between 2012 and 2016, sales of cigars increased by 29% in the United States. In small local studies, greater little cigar and cigarillo (LCC) availability and marketing has been documented in neighborhoods with a greater proportion of Hispanic or Latino and black residents, and near schools. This national study of cigarette retailers assesses whether LCC availability and marketing at the point of sale is associated with neighborhood racial, ethnic, income, and percent youth demographics. Methods In 2015, we collected LCC availability and marketing data through retailer audits of a nationally representative sample of 2128 cigarette retailers. Using 2011–2015 American Community Survey census tract estimates, we modeled associations of neighborhood demographics (in quartiles) with availability of LCC-flavored products, and presence of exterior advertisements, youth marketing, and promotions. Results Nearly 90% of retailers sold LCCs, 83.0% sold flavored LCCs, and 30.9% had youth marketing. Controlling for retailer type and other neighborhood characteristics, neighborhoods with the highest proportion of black residents had significantly higher odds of flavored LCC availability (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.52, 3.30); exterior advertisements (AOR = 2.84, 95% CI = 1.94, 4.16); price promotions (AOR = 1.62; 95% CI = 1.07–2.45), and youth appeal (AOR = 1.49, 95% CI 1.08–2.08) compared to the lowest. Disparities in flavored LCC availability, exterior advertising, and youth appeal were also present for lower income neighborhoods. Conclusion Neighborhoods with a greater proportion of black or lower income residents have greater flavored LCCs availability and LCC marketing. Without stronger LCC regulation, residents of these neighborhoods may be at a greater risk of LCC use. Implications LCCs are harmful combustible tobacco products that are less regulated than cigarettes (eg, lower taxation, cheaper outlay due to small package sizes, availability of flavors), which makes them an affordable and appealing product to youth. This study documents greater availability, advertising, and marketing of LCCs in neighborhoods with a higher proportion of black or lower-income residents, potentially putting these populations at a greater risk of using or switching to these products in the face of increasing cigarette regulations. These findings underscore the need for local, state, and federal LCC regulatory action.

Background One-third of the burden of cancer is associated with four health harming behaviours – tobacco use, alcohol consumption, poor diet and physical inactivity. These individual behaviours are influenced by a complex array of socio-political factors, including industry interests. The growing evidence base supporting the use of price-related policies to curb over consumption of unhealthy products is of interest to governments around the world. However, the implementation of such policies requires public and policy-maker support. The aim of this study is to enhance our understanding of the features of message framing that influence public support in relation to four price-related policies (1-tax, 2-mitigation fee, 3-discounting ban and 4-minimum pricing); across three products (tobacco, alcohol and sugar); and two countries (USA and UK). Methods We conducted 18 semi-structured interviews exploring knowledge, attitudes, and beliefs of the four pricing policies in relation to tobacco, alcohol and sugar products in 2018. Nine in the USA and nine in the UK. Interviewees included cancer policy advocates, cancer survivors and members of the general public. NVivo 12 was used to organise the data for inductive and deductive thematic analysis. Results Common supportive features across all four policies included (i) highlighting the health benefit (including reduced cancer risk), particularly for young people and those on low income, arising from impact on purchasing behaviour and (ii) making the cost of consumption in terms of health harm clear. Common unsupportive features across policies included (i) that effectiveness will depend on size of the financial penalty and consumer response and (ii) such policies are unfair on sensible consumers and potentially regressive. Interviewees’ were more supportive of price-related policies for tobacco containing products where they perceived a strong association between tobacco use and cancer risk. Some differences in views arose between products, particularly around the addictive nature of alcohol and tobacco that did not apply to sugar consumption. Conclusion This study reveals important differences in levels of persuasiveness arising from the framing of messages designed to promote price-related policies as a health promotion strategy. The results have informed the identification of four frames to be tested in a multi-factorial quantitative study, currently under way. These frames can be characterised as: F1 - To reduce the financial strain on the health care system; F2 - For the protection of children and young people; F3 - To reduce cancer risk; and F4 - To reduce the risk of other non-communicable diseases.

The United States (US) has identified income-based disparities in smoking as a critical public health issue, but the extent to which these disparities are changing over time within states is not well documented. This study examined recent trends in current cigarette smoking in each state and the District of Columbia by self-reported annual household income. Data came from the Behavioral Risk Factor Surveillance System, a state-representative survey of US adults. Sample sizes for each state and year ranged from 2,914 to 36,955 participants. We fit logistic regression models to examine linear time trends in cigarette smoking status in each state between 2011 and 2017. In every state, the odds of smoking were 1.4 to 3.0 times greater in the lower-income group as compared to the higher-income group in 2017. Among 47 states, linear time trends in smoking did not significantly differ by income group, suggesting no change in income-based disparities. In three states (Florida, Maine, West Virginia) disparities widened, primarily because smoking prevalence only dropped among higher-income groups. Disparities declined in only one state. In New York, smoking prevalence declined more for lower-income groups compared to higher-income groups. Findings from this study suggest that little progress has been made toward reducing income-based differences in smoking and additional policy and tobacco control efforts may be required to meet national disparity reduction goals.

We examine whether county-level tobacco retailer density and adult smoking prevalence are positively associated in the United States and determine whether associations differ in metropolitan vs. nonmetropolitan counties. We merged a list of likely tobacco retailers from the 2012 National Establishment Time-Series with smoking prevalence data from the Behavioral Risk Factor Surveillance System for 2828 US counties, as well as state tobacco policy information and county-level demographic data for the same year. We modeled adult smoking prevalence as a function of tobacco retailer density, accounting for clustering of counties within states. Average density in US counties was 1.25 retailers per 1000 people (range = 0.3–4.5). Smoking prevalence was 0.86 percentage points higher in the most retailer-dense counties, compared to the least. This association, however, was only significant for metropolitan counties. Metropolitan counties in the highest tobacco retailer density quartile had smoking prevalence levels that were 1.9 percentage points higher than metropolitan counties in the lowest density quartile. Research should examine whether policies limiting the quantity, type and location of tobacco retailers could reduce smoking prevalence. Keywords: Tobacco retailer density, Smoking prevalence, Geographic disparities

There are associations between tobacco retailer density and smoking behaviors, but little is known about whether places with more tobacco retailers have more smoking-related health problems. Using cross-sectional data from 2014, we investigated the relationships between tobacco retailer density and chronic obstructive pulmonary disease (COPD) related outcomes in a sample of 1510 counties across the United States. Higher retailer density was associated with a 19% (IRR, 1.19; 95% CI, 1.12–1.27) higher COPD-related hospital discharge rate and 30% (IRR, 1.30; 95% CI 1.21–1.39) higher total COPD-related hospital costs per population. The tobacco retailer environment may be an important target for reducing smoking-related health burdens and costs.

Objectives. There is a shift toward a “health in all policies” approach in public health; however, most practitioners are not equipped with the necessary knowledge or skills to engage in and practice policy. This study explores how public health professionals can become policy practitioners and better engage in the policy process. This article also provides recommendations for training programs on how to increase students’ policy-related knowledge and skills. Method. We conducted in-depth interviews with 10 public health policy experts in the United States spanning academic, governmental, advocacy, and practice settings. Key informants provided perspectives regarding strengths and skill sets that practitioners need to better position themselves to do policy-relevant work and opportunities for public health programs to improve training. The research team conducted thematic analyses to determine commonality among expert responses. Results. Informants identified a number of strengths and skills that either support or impede practitioners’ ability to conduct policy work and proposed recommendations for public health curricula to integrate policy-related coursework or practical experiences to prepare practitioners for policy careers. Conclusion. Public health professionals need to become more politically astute to practice and advance public health policy. To facilitate the development of such skills, public health training and pedagogy must integrate policy practice into traditional public health coursework, include new policy-focused courses, and provide opportunities for real-world policy experience.

This study describes retail marketing for menthol cigarettes and its relationship with neighborhood demographics in a national sample of tobacco retailers in the United States. Mixed-effects models were used to examine three outcomes: menthol cigarette exterior advertising, menthol cigarette price promotions, and the pack price of menthol and non-menthol cigarettes. Thirty-eight percent of retailers displayed at least one menthol advertisement on the store exterior and 69% advertised price promotions. Retail advertising was more common in neighborhoods in the second (OR = 1.5 [1.1, 2.0]) and fourth (OR = 1.9 [1.3, 2.7]) quartiles of Black residents as compared to the lowest quartile. Menthol advertising was more prevalent in the third (OR = 1.4 [1.0, 1.9]) and lowest (OR = 1.6 [1.2, 2.2]) income quartiles as compared to the highest quartile. Price promotions for Newport were more common in neighborhoods with the highest quartile of Black residents (OR = 1.8 [1.2, 2.7]). Prices of Newport were cheaper in neighborhoods with the highest quartiles of youth, Black residents, and lower-income households. Policies that restrict the sales and marketing of menthol cigarettes are needed to address disparities.

BackgroundThere is evidence that the cheapest cigarettes cost even less in neighbourhoods with higher proportions of youth, racial/ethnic minorities and low-income residents. This study examined the relationship between the price of the cheapest cigarette pack and neighbourhood demographics in a representative sample of tobacco retailers in the USA.MethodsData collectors recorded the price of the cheapest cigarette pack (regardless of brand) in 2069 retailers in 2015. Multilevel linear modelling examined the relationship between price and store neighbourhood (census tract) characteristics, specifically median household income and percentage of youth, Black, Asian/Pacific Islander and Hispanic residents.ResultsAverage price for the cheapest pack was $5.17 (SD=1.73) and it was discounted in 19.7% of stores. The price was $0.04 less for each SD increase in the percentage of youth and $0.22 less in neighbourhoods with the lowest as compared with the highest median household incomes. Excluding excise taxes, the average price was $2.48 (SD=0.85), and associations with neighbourhood demographics were similar.ConclusionThe cheapest cigarettes cost significantly less in neighbourhoods with a greater percentage of youth and lower median household income. Non-tax mechanisms to increase price, such as minimum price laws and restrictions on discounts/coupons, may increase cheap cigarette prices.

OBJECTIVE Smoking poses significant health risks to cancer survivors. Cancer survivorship may heighten psychological distress and reduce social support and health-related quality of life (HRQOL) for years after diagnosis, which could inhibit long-term successful smoking cessation. Understanding longitudinal associations between these psychosocial characteristics and successful cessation could help clinicians tailor cessation interventions for their patients. METHODS Time-to-event analyses using data from the American Cancer Society Study of Cancer Survivors-I (SCS-I)-a longitudinal nationwide study-examined the relationship of psychosocial characteristics with cessation likelihood and amount of time from diagnosis to quitting in cancer survivors diagnosed 7 to 10 years prior. RESULTS Cancer survivors with high physical HRQOL were more likely to quit smoking within 10 years from cancer diagnosis than survivors with low physical HRQOL, controlling for cancer type and number of comorbid conditions at baseline (HR = 1.96; 95% CI: 1.10-2.70; P = .02). Survivors with high physical HRQOL also took less time to quit than survivors with low physical HRQOL. Survivors of tobacco-related cancers with low physical HRQOL were the least likely group to quit. No significant relationships between other psychosocial predictors and cessation outcomes were observed. CONCLUSIONS Smoking cessation programs are needed for all cancer survivors who smoke, but survivors with low physical HRQOL 1 year after diagnosis may need more intensive long-term smoking cessation interventions with multiple check-in points after smoking relapses. Cessation interventions that include strategies to mitigate physical symptoms in those with poor physical HRQOL deserve consideration in research and practice.

OBJECTIVES To address chronic disease risk holistically from a behavioral perspective, insights are needed to refine understanding of the covariance of key health behaviors. This study aims to identify distinct typologies of young adults based on 4 modifiable risk factors of chronic disease using a latent class analysis approach, and to describe patterns of class membership based on demographic characteristics, living arrangements, and weight. METHODS Overall, 441 young adults aged 18-35 attending community colleges in the Minnesota Twin Cities area completed a baseline questionnaire for the Choosing Healthy Options in College Environments and Settings study, a RCT. Behavioral items were used to create indicators for latent classes, and individuals were classified using maximum-probability assignment. RESULTS Three latent classes were identified: 'active, binge-drinkers with a healthy dietary intake' (13.1%); 'non-active, moderate-smokers and non-drinkers with poor dietary intake' (38.2%); 'moderately active, non-smokers and non-drinkers with moderately healthy dietary intake' (48.7%). Classes exhibited unique demographic and weight-related profiles. CONCLUSIONS This study may contribute to the literature on health behaviors among young adults and provides evidence that there are weight and age differences among subgroups. Understanding how behaviors cluster is important for identifying groups for targeted interventions in community colleges.

Citing potential economic harm to the state, the tobacco industry has a history of opposing tobacco control efforts in North Carolina. This commentary discusses the changing role of tobacco in North Carolina's economy, argues that tobacco control causes little economic harm to the state, and explores development of alternative industries.

BACKGROUND: Social interactions are a key mechanism through which health communication campaigns influence behavior. Little research has examined how conversations about pictorial warnings motivate behavior. PURPOSE: We sought to establish whether and how smokers’ conversations explain the effect of pictorial warnings on quit attempts. METHODS: US adult smokers (n=2,149) participated in a controlled trial that randomly assigned them to have their cigarette packs labeled with pictorial or text-only warnings for four weeks. Surveys assessed the number of conversations sparked by pictorial warnings and the theoretical mechanisms cognitive elaboration and social norms at each visit. Analyses used structural equation modeling to test our theorized mediation models. RESULTS: The number of conversations about the warnings mediated the relationship between exposure to pictorial warnings and quit attempts (p

We sought to understand the relative advantage of pharmacies compared to doctors' offices for delivering HPV vaccination to adolescents.Participants were a national sample of 1500 U.S. parents of adolescents ages 11-17 recruited in 2014-15. In an online survey, items informed by Diffusion of Innovation Theory assessed parents' perceptions of the relative advantages of HPV vaccine delivery in pharmacies and doctors' offices.Many parents believed doctor's offices offered a better health care environment than pharmacies, with more privacy (77%) and a safer place for vaccination (70%). However, many parents also believed pharmacies were more accessible than doctors' offices, requiring less time for vaccinations (71%) and offering more convenient hours (59%). Parents were more willing to get their children HPV vaccine from pharmacists if they indicated more relative advantages in vaccine delivery in pharmacies (β = .29; p .001) and believed patient accessibility more important than health care environment (β = .20; p .001).To be more appealing to parents as HPV vaccine providers, pharmacy providers within community and hospital settings should build on their relative advantage with respect to accessibility and enhance their appeal of their healthcare environment.

IntroductionActive duty military personnel have higher cigarette and smokeless tobacco use rates than civilian populations. Although US Airmen (called Airmen regardless of gender or rank) are required to be tobacco-free during initial training, many resume use once this period ends, perhaps as a result of easy access to cheap tobacco products.MethodsBetween July and September 2016, we collected tobacco product, price and promotion information by visiting on-base (n=28) and off-base (n=80) tobacco retailers near the eight technical training bases where approximately 99% of Airmen attend training. We conducted mixed linear effects models to examine on-base versus off-base differences.ResultsCigarette packs were 11%–12% cheaper at on-base retailers compared with off-base retailers. Newport Menthol and Marlboro Red cigarette packs were $0.87 and $0.80 lower on-base (pConclusionsRetail stores located on Air Force bases sell cigarettes and smokeless tobacco products at prices well below those in nearby off-base retailers: the vast majority of these retailers feature interior price promotions for these products. Federal policies regulating prices of on-base tobacco sales, if implemented more effectively, have the potential to protect the health of Airmen by helping them remain tobacco-free after technical training.