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BackgroundResearch on cigarettes and adult asthma offers mixed findings, perhaps due to overlap with chronic obstructive pulmonary disease (COPD) and inadequate adjustment for other smoke exposures. Associations between other tobacco products, including e-cigarettes, and asthma are also understudied.Research questionUsing Population Assessment of Tobacco and Health Study waves 2–4 (2014/2015–2016/2017) data, we assessed the relation between tobacco product use and asthma in persons unlikely to have COPD.Study design and methodsProspective study of 10 267 adults aged 18–39 years without COPD diagnoses. Past-month tobacco use at wave 2 was modelled first as combustible versus non-combustible use and second as specific product categories (former, cigarettes, e-cigarettes, cigars, hookah, smokeless tobacco). Outcomes included lifetime asthma prevalence at wave 2, incidence (waves 3 and 4) and Asthma Control Test score (lower=worse). Multivariable regressions adjusted for predictors of asthma, including other smoke exposures: cigarette pack-years, secondhand smoke and marijuana use. Sensitivity analyses examined findings when persons >39 years and those with both COPD and asthma were added, and when smoke exposure adjustments were removed.ResultsNo product, including cigarettes and e-cigarettes, was associated with prevalence or incidence of asthma. Among people with asthma at wave 2, combustible tobacco (beta=−0.86, 95% CI (−1.32 to –0.39)) and cigarettes (beta=−1.14, 95% CI (−1.66 to –0.62)) were associated with worse asthma control. No tobacco product was associated with asthma control over time. In sensitivity analyses, tobacco use became associated with incident asthma as adults >39 years and those with asthma+COPD were added, and as adjustments for other smoke exposures were omitted.InterpretationAlthough cigarette use was associated with worse asthma control, there were no longitudinal associations between combustible tobacco or e-cigarette use and new onset or worsening asthma in these preliminary analyses. Research on tobacco and asthma should exclude COPD and adjust for smoking history and other smoke exposures.

The purpose of this study is to validate the seven-item wheezing module from the International Study of Asthma and Allergies in Children (ISAAC) in the nationally representative Population Assessment of Tobacco and Health Study. Adult participants with complete Wave 2–3 data were selected, including those with asthma but excluding those with COPD and other respiratory diseases (n = 16,295). We created a nine-point respiratory symptom index from the ISAAC questions, assessed the reliability of the index, and examined associations with self-reported asthma diagnosis. Threshold values were assessed for association with functional outcomes. The weighted prevalence for one or more respiratory symptom was 18.0% (SE = 0.5) for adults without asthma, 70.1% (SE = 1.3) for those with lifetime asthma, 75.7% (SE = 3.7) for adults with past-year asthma not on medications, and 92.6% (SE = 1.6) for those on medications. Cronbach’s alpha for the respiratory symptom index was 0.86. Index scores of ≥2 or ≥3 yielded functionally important respiratory symptom prevalence of 7–10%, adequate sensitivity and specificity for identifying asthma, and consistent independent associations with all functional outcomes and tobacco use variables. Respiratory symptom index scores of ≥2 or ≥3 are indicative of functionally important respiratory symptoms and could be used to assess the relationship between tobacco use and respiratory health.

Objectives: Any potential harm-reduction benefit of electronic cigarettes (e-cigarettes) could be offset by nonsmokers who initiate e-cigarette use and then smoke combustible cigarettes. We examined correlates of e-cigarette use at baseline with combustible cigarette smoking at 1-year follow-up among adult distant former combustible cigarette smokers (ie, quit smoking ≥5 years ago) and never smokers. Methods: The Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal study, surveyed 26 446 US adults during 2 waves: 2013-2014 (baseline) and 2014-2015 (1-year follow-up). Participants completed an audio computer-assisted interview in English or Spanish. We compared combustible cigarette smoking at 1-year follow-up by e-cigarette use at baseline among distant former combustible cigarette smokers and never smokers. Results: Distant former combustible cigarette smokers who reported e-cigarette past 30-day use (9.3%) and ever use (6.7%) were significantly more likely than those who had never used e-cigarettes (1.3%) to have relapsed to current combustible cigarette smoking at follow-up ( P < .001). Never smokers who reported e-cigarette past 30-day use (25.6%) and ever use (13.9%) were significantly more likely than those who had never used e-cigarettes (2.1%) to have initiated combustible cigarette smoking ( P < .001). Adults who reported past 30-day e-cigarette use (7.0%) and ever e-cigarette use (1.7%) were more likely than those who had never used e-cigarettes (0.3%) to have transitioned from never smokers to current combustible cigarette smokers ( P < .001). E-cigarette use predicted combustible cigarette smoking in multivariable analyses controlling for covariates. Conclusions: Policies and counseling should consider the increased risk for nonsmokers of future combustible cigarette smoking use as a result of using e-cigarettes and any potential harm-reduction benefits e-cigarettes might bring to current combustible cigarette smokers.

The U.S. Department of Housing and Urban Development (HUD) recently issued rules requiring that federally funded authorities administering public housing must have smoke-free policies. Importantly, this requirement does not extend to Section 8 housing. Under the Section 8 program, public housing vouchers provide subsidies for private rental housing to low-income residents. This study examines support for smoke-free policy options in Section 8 housing. Using a nationally representative survey of adults, we asked 3,070 respondents to agree or disagree with two potential policies. The majority (71%) supported prohibiting indoor smoking everywhere inside buildings that have Section 8 housing units. Alternatively, respondents were less supportive (38%) of a policy to prohibit smoking only inside units with Section 8 subsidies, and allowing smoking in nonsubsidized units. Prohibiting smoking in all units in multiunit housing (MUH) buildings would help protect the health of both the 2.2 million households who receive Section 8 subsidies and their neighbors.

BackgroundEvidence is accumulating that youth who try Electronic Nicotine Delivery Systems (ENDS, e-cigarettes) may go on to try cigarettes. This analysis examines the bidirectional patterns of ENDS and cigarette use among US youth over one year and uses propensity score matching (PSM) to examine frequency of ENDS use on changes in cigarette smoking.MethodsOur analysis included 11 996 participants who had two waves of available data (Wave 1 [W1] 2013–2014; Wave 2 [W2] 2014–2015) drawn from the longitudinal Population Assessment of Tobacco and Health Study. Cross-sectional weighted prevalence estimates are reported for cigarettes and ENDS. We used PSM to estimate the likelihood of ENDS use at W1 and to draw matched analytic samples, then used regression (logistic or linear) models to examine the effect of W1 ENDS use on W2 cigarette smoking. All statistical tests were two-sided.ResultsIn weighted analyses, 69.3% of W1 past-30-day cigarette smokers exhibited past-30-day smoking at W2; 42.2% of W1 past-30-day ENDS users were using ENDS at W2. W1 ever use of either product was similarly associated with W2 new use of the other product. Unweighted PSM models indicated W1 cigarette-naïve ENDS use was associated with W2 ever-cigarette smoking (n = 676; adjusted odds ratio = 3.21, 95% confidence interval [CI] = 1.95 to 5.45, P ConclusionsEver-ENDS use predicts future cigarette smoking, and frequency of ENDS use has a differential impact on subsequent cigarette smoking uptake or reduction. These results suggest that both cigarettes and ENDS should be targeted in early tobacco prevention efforts with youth.

Adolescence and the transition to adulthood is an important developmental stage in the emergence of health risk behaviors, specifically underage alcohol use. Adolescents consume a tremendous amount of screened media (primarily streamed television), and media depictions of behaviors is prospectively linked to youth initiation of behaviors. With the arrival of streamed media technology, alcohol advertising can be nested within television content. This study describes alcohol brand depictions in television and evaluates impact of exposure to such depictions on adolescent drinking outcomes. A national sample of 2012 adolescents (M(age) = 17.07; SD = 1.60 years, range 15–20; 50.70% female) reported on television viewership, alcohol brand affiliation, and drinking behavior, with follow-up one year later. Ten series (that remain relevant to youth today) across television ratings from a single television season were content coded for presence/salience of alcohol brand appearances. Adjusting for covariates (e.g., peer/parent drinking, youth sensation seeking, movie alcohol brand exposure), higher exposure to brand appearances in the television shows was associated with youth drinking. Aspirational and usual brand to drink corresponded to television alcohol brand prominence, and television brand exposure was independently associated with drinking initiation and hazardous drinking.

Vaping and e-cigarette use have been driven by highly effective marketing and advertising tactics, recruiting new users with innovative vaping products that have disrupted the tobacco industry. Prevention of e-cigarette and vaping initiation requires a multipronged approach including policy approaches to restrict youth access to tobacco, policies to reduce the impact of marketing including advertising bans, mass media campaigns, and statewide, community-wide, and school-based programs that educate and change social norms around tobacco use. Tobacco prevention is possible, and our first tobacco-free generation within reach if the trend can be reversed on the current epidemic of vaping among youth.

Recently, there has been a significant increase in the use of noncombustible nicotine–containing products, including electronic cigarettes (e-cigarettes). Of increasing popularity are e-cigarettes that can deliver high doses of nicotine over short periods of time. These devices have led to a rise in nicotine addiction in adolescent users who were nonsmokers. Use of noncombustible nicotine products by pregnant mothers is also increasing and can expose the developing fetus to nicotine, a known teratogen. In addition, young children are frequently exposed to secondhand and thirdhand nicotine aerosols generated by e-cigarettes, with little understanding of the effects these exposures can have on health. With the advent of these new nicotine-delivery systems, many concerns have arisen regarding the short- and long-term health effects of nicotine on childhood health during all stages of development. Although health studies on nicotine exposure alone are limited, educating policy makers and health care providers on the potential health effects of noncombustible nicotine is needed because public acceptance of these products has become so widespread. Most studies evaluating the effects of nicotine on health have been undertaken in the context of smoke exposure. Nevertheless, in vitro and in vivo preclinical studies strongly indicate that nicotine exposure alone can adversely affect the nervous, respiratory, immune, and cardiovascular systems, particularly when exposure occurs during critical developmental periods. In this review, we have included both preclinical and clinical studies to identify age-related health effects of nicotine exposure alone, examining the mechanisms underlying these effects.

Objectives Tobacco products in the US market are growing in diversity. Little is known about how youth access tobacco products given this current landscape. Methods Data were drawn from 15- to 17-year-olds from the Wave 1 youth sample of the US nationally representative Population Assessment of Tobacco and Health (PATH) Study. Past 30-day tobacco users were asked about usual sources of access to 12 different tobacco products, and if they had been refused sale because of their age. Results Among 15- to 17-year-olds, social sources (“someone offered” or “asked someone”) were the predominant usual source of access for each tobacco product. “Bought by self” was the usual source of access for users of smokeless (excluding snus, 23.2%), cigarillos (21.0%), cigarettes (13.8%), hookah (12.0%), and electronic cigarettes (10.5%). Convenience stores and/or gas stations were the most often selected retail source for all products except hookah. Among youth who attempted purchase, 24.3% were refused sale of cigarettes, 23.9% cigarillos, and 13.8% smokeless tobacco. Conclusions Most 15- to 17-year-old tobacco users obtain tobacco products through social sources; however, among those who purchased tobacco, the majority report not being refused sale because of age. At the time of survey, cigarette and cigar sales to under 18 years were prohibited in all 50 states, and electronic cigarettes sales in 47 states and two territories. 2014 Annual Synar Reports signaled increasing trends in retail violations of state and/or district laws prohibiting tobacco product sales to under 18 years. Monitoring illicit youth sales, conducting compliance check inspections, and penalizing violations remain important to reduce youth tobacco access at retail venues. Implications Access to the spectrum of tobacco products by youth in the United States remains predominantly through social sources. However, of the minority of youth tobacco users in 2014 who purchased tobacco themselves, a few reported being refused sale: Convenience stores and/or gas stations were the most common retail source for tobacco products. The strategies of monitoring illicit youth sales, conducting compliance checks, and penalizing violations remain important to reduce youth tobacco access at retail venues. Limiting sources of youth tobacco access remains an important focus to reduce the burden of tobacco on the public health.

The purpose of this study was to examine the relationships between screening questions for secondhand smoke (SHS) exposure and biomarker results using hair nicotine levels. Our ultimate goal was to develop sensitive and valid screening tools in pediatric clinical settings for SHS exposure. Investigators developed a core set of questions regarding exposure. Data from two separate ongoing studies of well children and those with bronchopulmonary dysplasia (BPD) were used to assess the concordance between responses and hair nicotine levels. Sensitivity, a positive predictive value, and accuracy were examined. There was no single question with similar sensitivity in both populations. The question with the highest positive predictive value (90.8% well-cohort and 84.6% BPD cohort) for both the groups was whether the child had been exposed to in-home smoking in the last 7 days. The question with the highest accuracy for both groups was the number of smokers at home (0 vs ≥ 1), with an accuracy of 72.4% for well children and 79.0% for the BPD cohort. There was a wide variability in the performance of specific questions. These data demonstrate that a “one-size-fits-all” approach to screening for secondhand tobacco smoke exposure may not be appropriate for all pediatric populations.

BACKGROUND AND OBJECTIVES: Since 2000, tobacco control efforts have greatly increased state and local protections from childhood tobacco smoke exposure. The objective of this study is to examine changes in attitudes and practices regarding smoking bans in multiple public and private settings from 2000 to 2015, as well as to examine the changes in pediatrician and family practitioner screening and counseling for tobacco smoke exposure. METHODS: Cross-sectional data from the annual Social Climate Survey of Tobacco Control were analyzed. RESULTS: The majority of adults, 69.3%, reported household smoking restrictions in 2000, and these restrictions increased to 79.5% through 2015 (P < .05). Car smoking prohibitions increased from 68.3% to 81.8% (P < .05). A growing majority of adults supports smoke-free policies in public settings, and tobacco counseling by child health care providers also increased. However, members of 1 in 5 households still permit smoking inside the home and family vehicle, and half of the US population is not protected by state or local laws prohibiting smoking inside of hospitality venues. CONCLUSIONS: Despite dramatic progress since 2000, these trend data reveal potential areas where child health care clinicians might focus effort at the family and community level to accelerate the protection of children from tobacco smoke exposure.

OBJECTIVE: Adolescents are exposed to alcohol marketing through traditional advertising and through newer digital media channels. Cumulative marketing exposure across channels is of concern but has been insufficiently studied. This study explores the measurement of alcohol marketing exposure across channels and whether cumulative recalled exposure is independently associated with underage drinking. METHOD: Two hundred two New England adolescents (ages 12–17 years) were recruited from a general pediatrics clinic and completed an online survey. Recall of alcohol marketing across channels (e.g., Internet, magazines) was assessed, along with drinking behavior and relevant covariates (i.e., demographics, parental/peer drinking, smoking status, sensation seeking, Internet use, social media use, television use, and parental Internet monitoring). Confirmatory factor analysis was used to establish a latent construct of alcohol marketing exposure recall. Logistic regression tested associations between alcohol marketing recall and adolescent drinking, with covariates controlled for. RESULTS: Adolescents reported recall of alcohol marketing across all marketing channels. Alcohol marketing recall items were significantly correlated, with α = .83. The latent measurement model of alcohol marketing recall provided excellent fit to the data, χ(2)(17, n = 202) = 27.402, p = .052; root mean square error of approximation (.000–.092) = .055; Tucker–Lewis Index = .960; comparative fit index = .976; standardized root mean square residual = .037). Adjusted cross-sectional logistic regression analyses demonstrated that the latent alcohol marketing recall construct was significantly associated with underage drinking (adjusted odds ratio = 4.08, 95% CI [1.15, 14.46]) when relevant covariates were accounted for. CONCLUSIONS: The final measurement model provided support for construct validity of a novel alcohol marketing recall construct assessing cumulative cross-channel marketing exposure. Adolescent recall of alcohol marketing across channels was significantly associated with underage drinking, while associated factors such as peer/parental drinking were accounted for.

Importance The prevalence of electronic nicotine delivery systems (ENDS) use, including e-cigarettes, among US young adults (YAs) has raised questions about how these products may affect future tobacco and nicotine use among YAs. Given this prevalence and that young adulthood is a critical period for the establishment of tobacco and nicotine use, it is important to consider the association between ENDS use and cigarette smoking specifically in this age group. Objective To examine whether ENDS use frequency or intensity is associated with changes in cigarette smoking among US YA ever smokers during 1 year. Design, Setting, and Participants This cohort study used 3 waves of data (2013-2014, 2014-2015, and 2015-2016) from the Population Assessment of Tobacco and Health (PATH) Study, an ongoing longitudinal cohort study of adults and youth. Unweighted 1:6 propensity score matching was used to match participants on wave 1 risk factors for ENDS use at wave 2. The changes in smoking between wave 2 and wave 3 were assessed using the matched sample. In total, 1096 ENDS-naive, ever cigarette–smoking YAs (18-24 years of age) at wave 1 who participated in wave 2 and wave 3 and who had complete data in the PATH Study were included in the analyses, which were conducted from August 2018 to October 2019. Exposures Never ENDS use (n = 987), any previous 30-day ENDS use (n = 109), 1 to 5 days of ENDS use in the previous 30 days (n = 75), and 6 or more days ENDS use in the previous 30 days at wave 2 (n = 34). Main Outcomes and Measures The analytic sample was selected using multiple variables based on peer-reviewed literature supporting associations with ENDS use. The main outcomes—changes in cigarette smoking behavior between wave 2 and wave 3—were defined using 2 measures: (1) change in smoking frequency, defined as the number of smoking days in the previous 30 days at wave 3 vs wave 2, and (2) change in smoking intensity, defined as the number smoking days in the previous 30 days multiplied by the mean number of cigarettes consumed on smoking days at wave 3 vs wave 2. Results The present cohort analyses included 1096 YA ever smokers who were ENDS naive at wave 1. The majority of the sample were women (609 [55.6%]) and White individuals (698 [63.7%]), and the mean (SD) age was 21.4 (1.9) years. In wave 1, 161 YAs (14.7%) were daily smokers in the previous 30 days. After propensity score matching, no statistically significant associations were observed between any definition of wave 2 ENDS use and changes in either the frequency or intensity of smoking at wave 3. Conclusions and Relevance In this cohort study of US YA ever smokers, ENDS use was not associated with either decreased or increased cigarette smoking during a 1-year period. However, it is possible that the rapidly evolving marketplace of vaping products may lead to different trajectories of YA cigarette and ENDS use in the future.

Objective Evidence suggests that adolescents are exposed to alcohol marketing in digital media. We aimed to assess recall of Internet alcohol marketing and its association with underage drinking. Methods New England adolescents age 12-17 years (N=202) were recruited from a pediatric clinic. Subjects completed an online survey assessing: 1) general simple recall of Internet alcohol marketing and 2) image-prompted recall of specific Internet alcohol marketing channels (display ads, commercials, brand websites, brand social media pages). Cross-sectional associations between recall (simple and image-prompted) and ever-drinking were each assessed in regression analysis adjusting for age, gender, race, parent education, ever-smoking, media use, sensation-seeking, peer/parent drinking, parent monitoring/responsiveness, and parent Internet monitoring. Results In this sample (Mage=14.5 years; 55% female; 89% white; high parent education), 20% reported ever-drinking and 87% recalled Internet alcohol marketing. Of the latter, 67% recalled display ads, 67% Internet commercials, 5% websites, 5% social media pages. In logistic regression, higher Internet alcohol advertising recall was independently associated with higher odds of ever-drinking for simple (AOR: 2.66 [1.04,6.83]) but not for image-prompted recall. Conclusions Despite controlling for potential confounders, simple recall of Internet alcohol marketing was significantly associated with underage drinking whereas image-prompted recall was significant only in bivariate analysis, likely due to small sample and a more limited range of specific channels assessed than those accessed by adolescents. Further longitudinal studies using image-prompted recall and capturing a broader range of internet platforms could be used to better understand adolescent engagement with alcohol marketing and guide policy and prevention efforts.

Objective To examine whether mental health problems predict incident use of 12 different tobacco products in a nationally representative sample of youth and young adults. Method This study analyzed Wave (W) 1 and W2 data from 10,533 12- to 24-year-old W1 never tobacco users in the Population Assessment of Tobacco and Health (PATH) Study. Self-reported lifetime internalizing and externalizing symptoms were assessed at W1. Past 12-month use of cigarettes, electronic nicotine delivery systems (ENDS), traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, other smokeless tobacco, bidis and kreteks (youth only), and dissolvable tobacco was assessed at W2. Results In multivariable regression analyses, high-severity W1 internalizing (adjusted odds ratio [AOR] = 1.5, 95% CI = 1.3−1.8) and externalizing (AOR = 1.3, 95% CI = 1.1−1.5) problems predicted W2 onset of any tobacco use compared to no/low/moderate severity. High-severity W1 internalizing problems predicted W2 use onset across most tobacco products. High-severity W1 externalizing problems predicted onset of any tobacco (AOR = 1.6, 95% CI = 1.3−1.8), cigarettes (AOR = 1.4, 95% CI = 1.0−2.0), ENDS (AOR = 1.8, 95% CI = 1.5−2.1), and cigarillos (AOR = 1.5, 95% CI = 1.0−2.1) among youth only. Conclusion Internalizing and externalizing problems predicted onset of any tobacco use. However, findings differed for internalizing and externalizing problems across tobacco products, and by age, gender, and race/ethnicity. In addition to screening for tobacco product use, health care providers should screen for a range of mental health problems as a predictor of tobacco use. Interventions addressing mental health problems may prevent youth from initiating tobacco use.

BACKGROUND: Little is known about the characteristics of electronic cigarettes (e-cigarettes) used by adolescents. Understanding the product landscape of adolescent e-cigarette use may inform counseling and policy strategies. METHODS: Results are from 13 651 adolescents in wave 1 and 12 172 adolescents in wave 2 of the Population Assessment of Tobacco and Health Study, a nationally representative longitudinal study. Past 30-day regular e-cigarettes users were asked about the characteristics of the e-cigarette they used most of the time. RESULTS: In waves 1 and 2, 2.1% and 2.8% of adolescents were regular users in the past 30 days, respectively. These adolescents more often used rechargeable rather than disposable devices (wave 1: 76.0%; wave 2: 82.9%) and refillable rather than nonrefillable devices (wave 1: 66.6%; wave 2: 84.4%) and tended not to use cartridge systems (wave 1: 33.7%; wave 2: 30.5%). Most adolescent past 30-day users (wave 1: 87.5%; wave 2: 89.4%) reported using flavored e-cigarettes. An increased frequency of use was associated with the use of rechargeable (wave 1 adjusted odds ratio [aOR]: 2.7; wave 2 aOR: 2.7) and refillable e-cigarettes (wave 1 aOR: 2.0; wave 2 aOR: 2.7; P < .05). Most users in wave 1 did not continue regular use in wave 2 (70.2%). Among those who continued to use and had reported using closed systems (nonrechargeable and/or nonrefillable) in wave 1, most had progressed to open systems (rechargeable and refillable) in wave 2. CONCLUSIONS: Most adolescents use open-system e-cigarettes, and frequent users are even more likely to use open-system e-cigarettes. The majority of regular users use rechargeable devices that are refillable. A change in product preferences across waves suggests a starter product phenomenon, with a graduation to products that have weaker quality controls and may increase health risks.

Background While evidence suggests bidirectional associations between cigarette use and substance (alcohol or drug) use, how these associations are reflected across the range of currently available tobacco products is unknown. This study examined whether ever tobacco use predicted subsequent substance use, and ever substance use predicted subsequent tobacco use among 11,996 U.S. youth (12–17 years) from Waves 1 (2013–2014) and 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Methods Ever use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, smokeless tobacco excluding snus pouches, dissolvable tobacco, bidis, kreteks, alcohol, marijuana, prescription drugs, and other drugs (cocaine and other stimulants, heroin, inhalants, solvents, and hallucinogens) was assessed at Wave 1 followed by past 12-month use assessments at Wave 2. The analyses included covariates (demographics, mental health, sensation seeking, prior use) to mitigate confounding. Results Ever tobacco use predicted subsequent substance use. The magnitude of the associations was lowest for alcohol, higher for marijuana, and highest for other drugs. Ever substance use also predicted subsequent tobacco use. Specifically, ever alcohol, marijuana, and non-prescribed Ritalin/Adderall use predicted tobacco-product use. Ever e-cigarette and cigarette use exclusively and concurrently predicted subsequent any drug (including and excluding alcohol) use. E-cigarette and cigarette use associations in the opposite direction were also significant; the strongest associations were observed for exclusive cigarette use. Conclusion Tobacco and substance use prevention efforts may benefit from comprehensive screening and interventions across tobacco products, alcohol, and drugs, and targeting risk factors shared across substances.

* Abbreviations: AAP — : American Academy of Pediatrics HRB — : health risk behavior TECH — : talk, educate, co-view, and house rules As media and technology proliferate in the lives of US children, parents are confronted with the ever-growing task of home media management. Accumulating evidence reveals that youth media exposure to health risk behaviors (HRBs) (eg, risky sexual behavior, substance use) during the preteen years is associated with increased risk for subsequent engagement in HRBs,1,2 and greater intensity of exposure leads to greater youth risk. Whereas parents remain a strong influence on youth behavior and guidelines advocate for parental media restriction and monitoring, the definition of specific media parenting behaviors that impact child outcomes is needed. The American Academy of Pediatrics (AAP) has offered an evidence-informed summary of recommended parenting practices within the media environment.3 However, parents generally express a desire for more information about effective youth media management and are relatively unaware of the AAP’s media recommendations.4 To support AAP guidelines, a review of the literature and evidence from behavioral observation and focus group studies reveal 4 behavioral domains encapsulated by our proposed talk, educate, co-view, and house rules (TECH) parenting.5 We propose TECH parenting as a useful framework to address important behavioral targets for parental media management of preadolescent youth (Table 1 and Supplemental Fig 1). View this table: TABLE 1 Behavioral Strategies and Example Wording to Promote Effective TECH Parenting Parental monitoring is associated with reduced youth risk for HRBs, and talking with youth about media use allows parents to learn what their child is viewing or using.5 Some … Address correspondence to Joy Gabrielli, PhD, Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth, 46 Centerra Parkway, Suite 301, Lebanon, NH 03766. E-mail: joy.l.gabrielli{at}dartmouth.edu

OBJECTIVE: Marketing aims to foster brand allegiance, and alcohol is a heavily marketed commodity. We hypothesize that exposed youth who are able to identify an aspirational alcohol brand will be at higher risk for underage drinking. METHOD: U.S. youth ages 15–20 (N = 2,012; 51% female) were surveyed twice in 2011–2013. Aspirational brand was assessed by asking, “If you could drink any brand you want, what is the name of the brand of alcohol you would choose?” Multivariable logistic regression tested associations between having an aspirational brand at baseline and onset of ever, binge (≥6 drinks/occasion), and hazardous drinking (Alcohol Use Disorders Identification Test–Consumption ≥ 4). RESULTS: Baseline ever, binge, and hazardous drinking prevalence was 55%, 26%, and 19%, respectively; 47% reported having an aspirational brand, of whom 20% were nondrinkers. Top five reported brands were Budweiser, Smirnoff, Corona, Jack Daniels, and Bacardi, all heavily advertised brands. Older age, male gender, sensation seeking, and peer/parent drinking were associated with having an aspirational brand. After we controlled for these confounders, having an aspirational brand was independently associated cross-sectionally with greater risk of ever, binge, and hazardous drinking (adjusted odds ratio = 4.47, 95% CI [3.33, 6.00], 4.84 [3.41, 6.86], and 5.46 [3.63, 8.23], respectively) and longitudinally with initiation of binge and hazardous drinking (1.80 [1.19, 2.73] and 2.02 [1.33, 3.06], respectively). CONCLUSIONS: Having an aspirational alcohol brand is both common and independently associated with subsequent underage alcohol use and misuse. Further studies examining how youth interact with and are affected by branded advertising are critical to guide development of effective education and policy interventions.

© 2018 American Medical Association. All rights reserved. IMPORTANCE Cigarette marketing contributes to initiation of cigarette smoking among young people, which has led to restrictions on use of cigarette advertising. However, little is known about other tobacco advertising and progression to tobacco use in youth and young adults. OBJECTIVE To investigate whether receptivity to tobacco advertising among youth and young adults is associated with progression (being a susceptible never user or ever user) to use of the product advertised, as well as conventional cigarette smoking. DESIGN, SETTING, AND PARTICIPANTS The Population Assessment of Tobacco and Health (PATH) Study at wave 1 (2013-2014) and 1-year follow-up at wave 2 (2014-2015) was conducted in a US population-based sample of never tobacco users aged 12 to 24 years from wave 1 of the PATH Study (N = 10 989). Household interviews using audio computer-assisted self-interviews were conducted. EXPOSURES Advertising for conventional cigarettes, electronic cigarettes (e-cigarettes), cigars, and smokeless tobacco products at wave 1. MAIN OUTCOMES AND MEASURES Progression to susceptibility or ever tobacco use at 1-year follow-up in wave 2. RESULTS Of the 10 989 participants (5410 male [weighted percentage, 48.3%]; 5579 female [weighted percentage, 51.7%]), receptivity to any tobacco advertising at wave 1 was high for those aged 12 to 14 years (44.0%; 95%confidence limit [CL], 42.6%-45.4%) but highest for those aged 18 to 21 years (68.7%; 95%CL, 64.9%-72.2%). e-Cigarette advertising had the highest receptivity among all age groups. For those aged 12 to 17 years, susceptibility to use a product at wave 1 was significantly associated with product use at wave 2 for conventional cigarettes, e-cigarettes, cigars, and smokeless tobacco products. Among committed never users aged 12 to 17 years at wave 1, any receptivity was associated with progression toward use of the product at wave 2 (conventional cigarettes: adjusted odds ratio [AOR], 1.43; 95% CL, 1.23-1.65; e-cigarettes: AOR, 1.62; 95%CL, 1.41-1.85; cigars: AOR, 2.01; 95%CL, 1.62-2.49; and smokeless [males only]: AOR, 1.42; 95%CL, 1.07-1.89) and with use of the product (conventional cigarettes: AOR, 1.54; 95%CL, 1.03-2.32; e-cigarettes: AOR, 1.45; 95%CL, 1.19-1.75; cigars: AOR, 2.07; 95%CL, 1.26-3.40). Compared with those not receptive to any product advertising, receptivity to e-cigarette advertising, but not to cigarette advertising, was independently associated with those aged 12 to 21 years having used a cigarette at wave 2 (AOR, 1.60; 95%CL, 1.08-2.38). CONCLUSIONS AND RELEVANCE Receptivity to tobacco advertisingwas significantly associated with progression toward use in adolescents. Receptivity was highest for e-cigarette advertising and was associated with trying a cigarette.

Purpose: The aerosol from e-cigarettes contains nicotine and carcinogens that deposit, on indoor surfaces. This study examines adults’ household rules about e-cigarette use and beliefs about the harms of these products to children. Methods: The Social Climate Survey of Tobacco Control was administered in 2015 to respondents recruited from a nationally representative dual-frame sample. Adults were asked about household rules and beliefs about e-cigarette harms to children. Results: Of 3,070 respondents, 67.9% …

Although non-cigarette tobacco product use is increasing among U.S. adults, their associations with substance use and mental health problems are unclear. This study examined co-occurrence of tobacco use, substance use, and mental health problems, and its moderation by gender, among 32,202U.S. adults from Wave 1 (2013-2014) of the nationally representative longitudinal Population Assessment of Tobacco and Health (PATH) Study.Participants self-reported current cigarette, e-cigarette, traditional cigar, cigarillo, filtered cigar, hookah, smokeless tobacco and other tobacco product use; past year alcohol, marijuana, and other drug use; and past year substance use, internalizing and externalizing problems.Compared to non-current tobacco users, current users were more likely to report alcohol or drug use (adjusted odds ratio (AOR)=2.6; 95% confidence interval (CI): 2.3, 2.9), with the strongest associations observed for cigarillo and hookah users. Across all tobacco product groups, users were more likely to report internalizing (AOR=1.9; 95% CI: 1.7, 2.1), externalizing (AOR=1.6; 95% CI: 1.5, 1.8), and substance use (AOR=3.4; 95% CI: 2.9, 4.1) problems than non-users. Gender moderated many of these associations and, of these, all non-cigarette tobacco product associations were stronger among females.This nationally representative study of U.S. adults is the first to comprehensively document tobacco use, substance use, and mental health comorbidities across the range of currently available tobacco products, while also demonstrating that female tobacco users are at increased risk for substance use and mental health problems. These findings may point to gender differences in vulnerability and suggest that interventions incorporate gender-specific approaches.

Objective To assess the extent to which multiple tobacco product use among adolescents and young adults falls outside current Food and Drug Administration (FDA) regulatory authority. Methods We conducted a web-based survey of 1596 16–26-year-olds to assess use of 11 types of tobacco products. We ascertained current (past 30 days) tobacco product use among 927 respondents who ever used tobacco. Combustible tobacco products included cigarettes, cigars (little filtered, cigarillos, premium) and hookah; non-combustible tobacco products included chew, dip, dissolvables, e-cigarettes, snuff and snus. We then fitted an ordinal logistic regression model to assess demographic and behavioural associations with higher levels of current tobacco product use (single, dual and multiple product use). Results Among 448 current tobacco users, 54% were single product users, 25% dual users and 21% multiple users. The largest single use category was cigarettes (49%), followed by hookah (23%), little filtered cigars (17%) and e-cigarettes (5%). Most dual and multiple product users smoked cigarettes, along with little filtered cigars, hookah and e-cigarettes. Forty-six per cent of current single, 84% of dual and 85% of multiple tobacco product users consumed a tobacco product outside FDA regulatory authority. In multivariable analysis, the adjusted risk of multiple tobacco use was higher for males, first use of a non-combustible tobacco product, high sensation seeking respondents and declined for each additional year of age that tobacco initiation was delayed. Conclusions Nearly half of current adolescent and young adult tobacco users in this study engaged in dual and multiple tobacco product use; the majority of them used products that fall outside current FDA regulatory authority. This study supports FDA deeming of these products and their incorporation into the national media campaign to address youth tobacco use.

Objectives We assessed the comparability of self-reported smoking prevalence estimates from a dual-frame survey with those from two large-scale, national surveys. Methods The Social Climate Survey of Tobacco Control (SCS-TC) obtained self-reported current smoking status via a dual-frame methodology in the fall of 2010. One frame used random digit dialling procedures and consisted of households with a landline telephone; the other frame consisted of a population-based probability-based online panel. Current smoking prevalence was compared with national estimates from the 2010 National Health Interview Survey (NHIS) and the 2009–2010 National Health and Nutrition Examination Survey (NHANES). Results 18.3% (95% CI 17.0% to 19.6%) of SCS-TC respondents reported current smoking. NHIS and NHANES estimates found 19.4% (95% CI 18.8% to 20.1%) and 20.3% (95% CI 18.7% to 22.1%), respectively, reporting current smoking. Conclusions Prevalence estimates for cigarette smoking obtained from the dual-frame SCS-TC are comparable to those from other national surveys. A mixed-mode approach may be a useful strategy to transition cross-sectional surveys with established trend data to newer dual-frame designs to maintain compatibility with surveys from previous years and to include the growing number of households that do not have landline telephones.

Introduction The 2006 U.S. Surgeon General's Report found that there is no safe level of exposure to secondhand smoke (SHS). Many smokers attempt to protect others from exposure to SHS; however, it is difficult to assess effectiveness of these behavior changes. There is a need for personal monitoring devices that provide real-time SHS exposure data; at present, there is no device that measures ambient nicotine levels in real time. The development of such a sensor is the objective of this research. Methods A nicotine sensing film comprising the conductive polymer polyaniline was linked with a reporting layer, recording changes in chemiresistance due to adsorption of nicotine. Experiments were carried out in a microprocessor-controlled smoking chamber using sidestream smoke from standard reference cigarettes; up to 10 cigarettes were smoked simultaneously. The exposure chamber was calibrated for total suspended particle, carbon monoxide, and nicotine concentrations. Results We found significant real-time increases in the resistance of films upon exposure to SHS. The sensors were shown to be sensitive to the number of cigarettes consumed and ambient nicotine and demonstrated reasonable recovery between measurements. The sensors have sufficient sensitivity to detect off-gassing of nicotine or "thirdhand smoke." Conclusions A sensing element has been developed that can reliably detect secondhand and thirdhand tobacco smoke in real time through the adsorption of ambient nicotine vapor. The device was calibrated to the number of smoked cigarettes and to nicotine concentration. Development of integrated personal sensors to record exposure to SHS using this technology is currently underway.

Introduction The American Academy of Pediatrics (AAP) advises pediatricians to counsel parents and patients who use tobacco to quit. This study assesses changes in counseling between 2004 and 2010, and factors associated with counseling in 2010. Methods In 2004 and 2010, the Periodic Survey, a national survey of AAP members, inquired about tobacco counseling. Chi-square tests were performed to compare responses by survey year. Bivariate and multivariable analyses examined factors associated with counseling. Results Similar proportions of pediatricians in both years (N 2004 = 535 and N 2010 = 549) advised adolescents who smoke to quit (85% vs 81%), discussed quitting techniques (34% vs 32%), and recommended nicotine replacement medications (17% vs 18%). More pediatricians in 2010 reported helping patients assess reasons for and against continuing to smoke (56% vs 48%), providing quitting materials (20% vs 15%), and referring patients to cessation programs (18% vs 13%). More pediatricians in 2010 reported providing quitting materials to parents who smoke (14% vs 10%) and referring to smoking cessation programs (16% vs 11%) (all P Conclusions Most pediatricians advised patients and parents who smoke to quit, and these percentages did not change from 2004 to 2010. Although percentages for assisting with cessation did increase for several activities, most pediatricians still do not do so. Opportunities exist to improve clinicians' protection of children from tobacco and tobacco smoke through quit-line referrals, motivational interviewing, and offering medications.

This clinical case presentation discusses a family in which 3 generations are affected by tobacco. The discussants discuss approaches to be taken to minimize the exposure of an infant to tobacco smoke from older relatives, behavioral and pharmacological approaches to assist smoking cessation, and concerns regarding electronic cigarettes.

BACKGROUND AND OBJECTIVE: Internet alcohol marketing is not well studied despite its prevalence and potential accessibility and attractiveness to youth. The objective was to examine longitudinal associations between self-reported engagement with Internet alcohol marketing and alcohol use transitions in youth. METHODS: A US sample of 2012 youths aged 15 to 20 was surveyed in 2011. An Internet alcohol marketing receptivity score was developed, based on number of positive responses to seeing alcohol advertising on the Internet, visiting alcohol brand Web sites, being an online alcohol brand fan, and cued recall of alcohol brand home page images. We assessed the association between baseline marketing receptivity and both ever drinking and binge drinking (≥6 drinks per occasion) at 1-year follow-up with multiple logistic regression, controlling for baseline drinking status, Internet use, sociodemographics, personality characteristics, and peer or parent drinking. RESULTS: At baseline, ever-drinking and binge-drinking prevalence was 55% and 27%, respectively. Many (59%) reported seeing Internet alcohol advertising, but few reported going to an alcohol Web site (6%) or being an online fan (3%). Higher Internet use, sensation seeking, having family or peers who drank, and past alcohol use were associated with Internet alcohol marketing receptivity, and a score of 1 or 2 was independently associated with greater adjusted odds of initiating binge drinking (odds ratio 1.77; 95% confidence interval, 1.13–2.78 and odds ratio 2.15; 95% confidence interval, 1.06–4.37 respectively) but not with initiation of ever drinking. CONCLUSIONS: Although high levels of engagement with Internet alcohol marketing were uncommon, most underage youths reported seeing it, and we found a prospective association between receptivity to this type of alcohol marketing and future problem drinking, making additional research and ongoing surveillance important.

Aims This study assesses how race/ethnicity and socio-economic status modify the relationship between exposure to movie smoking and having tried smoking in adolescents. Design Data come from a cross-sectional telephone survey and were analyzed using logistic regression models. A respondent reporting ever having tried smoking was regressed on exposure to movie smoking, race, socio-economic status, the interactions of these variables and family and background characteristics. Setting National sample of US adolescents. Participants A total of 3653 respondents aged 13–18 years. Measurements Outcome was if subjects reported ever having tried smoking. Movie smoking exposure was assessed through respondents’ reporting having watched a set of movie titles, which were coded for smoking instances. Findings The proportion having tried smoking was lower for blacks (32%) compared to Hispanics (41%) and whites (38%). The relationship between movie smoking and having tried smoking varied by race/ethnicity. Among whites and Hispanics exposure to movie smoking positively predicted smoking behavior, but movie smoking had no impact on blacks. Socio-economic status further modified the relation among whites; high socio-economic status white adolescents were more susceptible to movie smoking than low socio-economic status white adolescents. Conclusions Exposure to movie smoking is not experienced uniformly as a risk factor for having ever tried smoking among US adolescents. Whites and Hispanics are more likely to try smoking as a function of increased exposure to movie smoking. In addition, higher socio-economic status increases susceptibility to movie smoking among whites. Youth with fewer risk factors may be more influenced by media messages on smoking.

OBJECTIVE:To examine the association between movie smoking exposure (MSE) and adolescent smoking according to rating category.METHODS:A total of 6522 US adolescents were enrolled in a longitudinal survey conducted at 8-month intervals; 5503 subjects were followed up at 8 months, 5019 subjects at 16 months, and 4575 subjects at 24 months. MSE was estimated from 532 recent box-office hits, blocked into 3 Motion Picture Association of America rating categories: G/PG, PG-13, and R. A survival model evaluated time to smoking onset.RESULTS:Median MSE in PG-13–rated movies was ∼3 times higher than median MSE from R-rated movies, but their relation with smoking was essentially the same, with adjusted hazard ratios of 1.49 (95% confidence interval [CI]: 1.23–1.81) and 1.33 (95% CI: 1.23–1.81) for each additional 500 occurrences of MSE respectively. MSE from G/PG-rated movies was small and had no significant relationship with adolescent smoking. Attributable risk estimates showed that adolescent smoking would be reduced by 18% (95% CI: 14–21) if smoking in PG-13–rated movies was reduced to the fifth percentile. In comparison, making all parents maximally authoritative in their parenting would reduce adolescent smoking by 16% (95% CI: 12–19).CONCLUSIONS:The equivalent effect of PG-13-rated and R-rated MSE suggests it is the movie smoking that prompts adolescents to smoke, not other characteristics of R-rated movies or adolescents drawn to them. An R rating for movie smoking could substantially reduce adolescent smoking by eliminating smoking from PG-13 movies.

This study of youth smoking onset aims to replicate previously published media moderation effects for race/ethnicity in a national longitudinal multiethnic sample of U.S. adolescents. Previous research has demonstrated that associations between media and smoking during adolescence are greater for Whites than Hispanics or Blacks, and for youth living in non-smoking families. In this study, changes in smoking status over 24 months were assessed among 4,511 baseline never-smokers. The incidence of smoking onset was 14.3% by 24 months with no differences by race/ethnicity. Blacks had higher exposure to movie smoking and overall television viewing compared with Whites and Hispanics. Whites responded to movie smoking regardless of parent smoking but more strongly if their parents were non-smokers. In contrast, Black adolescents showed little behavioral response to any media, regardless of parent smoking. Hispanic adolescents responded only to TV viewing and only when their parents did not smoke. In an analysis assessing the influence of the race of smoking characters on smoking behavior of White and Black adolescents, Whites responded to both White and Black movie character smoking, whereas Blacks responded only to smoking by Black movie characters. Taken as a whole, the findings replicate and extend previous findings, suggesting media factors are more influential among adolescents at low to moderate overall risk for smoking. We draw analogies between these low-moderate risk adolescents and “swing voters” in national elections, suggesting that media effects are more apt to influence an adolescent in the middle of the risk spectrum, compared with his peers at either end of it. Electronic supplementary material The online version of this article (doi:10.1007/s11121-011-0244-3) contains supplementary material, which is available to authorized users.

BACKGROUND: Tests are available to measure children's exposure to tobacco smoke. One potential barrier to testing children for tobacco-smoke exposure is the belief that parents who smoke would not want their child tested. No previous surveys have assessed whether testing children for exposure to tobacco smoke in the context of their child's primary care visit is acceptable to parents. OBJECTIVE: To assess whether testing children for tobacco-smoke exposure is acceptable to parents. DESIGN AND METHODS: We conducted a national random-digit-dial telephone survey of households from September to November 2006. The sample was weighted by race and gender, based on the 2005 US Census, to be representative of the US population. RESULTS: Of 2070 eligible respondents contacted, 1803 (87.1%) completed the surveys. Among 477 parents in the sample, 60.1% thought that children should be tested for tobacco-smoke exposure at their child's doctor visit. Among the parental smokers sampled, 62.0% thought that children should be tested for tobacco-smoke exposure at the child's doctor visit. In bivariate analysis, lower parental education level, allowing smoking in the home, nonwhite race, and female gender were each associated (P < .05) with wanting the child tested for tobacco-smoke exposure. CONCLUSIONS: The majority of nonsmoking and smoking parents want their children tested for tobacco-smoke exposure during the child's health care visit.

OBJECTIVES: In this study, we examined how often US youths reported having complete parental restrictions on watching R-rated movies. In addition, we assessed the relationship between parental R-rated movie restrictions and adolescents' sensation seeking and how this interplay is related to smoking onset. METHODS: Data from a 4-wave longitudinal study of 6522 adolescents (10–14 years of age) who were recruited through a random-digit-dial telephone survey were used. At baseline, subjects were nationally representative of the US population. Subjects were monitored for 2 years and queried about their smoking status, their sensation-seeking propensity, and how often they were allowed to watch R-rated movies. A cross-lagged model combined with survival analysis was used to assess the relationships between parental R-rated movie restrictions, sensation-seeking propensity, and risk for smoking onset. RESULTS: Findings demonstrated that 32% of the US adolescents reported being completely restricted from watching R-rated movies by their parents. Model findings revealed that adolescents' sensation seeking was related to greater risk for smoking onset not only directly but also indirectly through their parents becoming more permissive of R-rated movie viewing. Parental R-rated movie restrictions were found to decrease the risk of smoking onset directly and indirectly by changing children's sensation seeking. CONCLUSIONS: These findings imply that, beyond direct influences, the relationship between adolescents' sensation seeking and parental R-rated movie restrictions in explaining smoking onset is bidirectional in nature. Finally, these findings highlight the relevance of motivating and supporting parents in limiting access to R-rated movies.

Objectives. We examined whether the geographic density of alcohol retailers was greater in geographic areas with higher levels of demographic characteristics that predict health disparities. Methods. We obtained the locations of all alcohol retailers in the continental United States and created a map depicting alcohol retail outlet density at the US Census tract level. US Census data provided tract-level measures of poverty, education, crowding, and race/ethnicity. We used multiple linear regression to assess relationships between these variables and retail alcohol density. Results. In urban areas, retail alcohol density had significant nonlinear relationships with Black race, Latino ethnicity, poverty, and education, with slopes increasing substantially throughout the highest quartile for each predictor. In high-proportion Latino communities, retail alcohol density was twice as high as the median density. Retail alcohol density had little or no relationship with the demographic factors of interest in suburban, large town, or rural census tracts. Conclusions. Greater density of alcohol retailers was associated with higher levels of poverty and with higher proportions of Blacks and Latinos in urban census tracts. These disparities could contribute to higher morbidity in these geographic areas.

Impoverished children suffer disproportionately from asthma and are more likely than other children to be exposed to secondhand smoke (SHS). We conducted a case-control study to describe and compare knowledge, attitudes, and household practices regarding SHS exposure among parents of young urban children with and without asthma (response rate, 76%). Overall, 39% of children lived with ≥1 smoker (cases, 36%; controls, 43%). The majority of parents (78%) felt that cigarette smoking is very dangerous and agreed that smoke harms the health of children (97%). Cases were more likely than controls to report that smoking in a car affects children’s health (54% vs 42%) and that smoking in front of children is never allowed in their home (88% vs 79%). Additionally, more cases reported a home smoking ban (81% vs 70%). Our findings suggest that parents of children with asthma have somewhat better knowledge, attitudes, and practices regarding SHS; however, gaps remain, and many urban children continue to be exposed.

The aim of this study was to determine if parental restriction regarding Restricted-rated movies (R movies) predicts lower rates of early-onset alcohol use.Students from 15 northern New England middle schools were surveyed in 1999, and never-drinkers were resurveyed 13-26 months later to determine alcohol use. Drinking was determined by the question, "Have you ever had beer, wine, or other drink with alcohol that your parents didn't know about?" R-movie restriction was assessed by the question, "How often do your parents allow you to watch movies that are rated R?"The sample included 2,406 baseline never-drinkers who were surveyed at follow-up, of whom 14.8% had initiated alcohol use. At baseline, 20% reported never being allowed to watch R movies, and 21% reported being allowed all the time. Adolescents allowed to watch R-rated movies had higher rates of alcohol initiation (2.9% initiation among never allowed, 12.5% once in a while, 18.8% sometimes, and 24.4% all the time). Controlling for sociodemographics, personality characteristics, and authoritative parenting style, the adjusted odds ratios for initiating alcohol use were 3.0 (95% CI [1.7, 5.1]) for those once in a while allowed, 3.3 [1.9, 5.6] for those sometimes allowed, and 3.5 [2.0, 6.0] for those always allowed to watch R-rated movies. Alcohol initiation was more likely if R-rated movie restriction relaxed over time; tightening of restriction had a protective effect (p.001). A structural model was developed that modeled two latent parenting constructs: (a) authoritative parenting and (b) media parenting. Both constructs had direct inverse paths to trying alcohol and indirect paths through lower exposure to R-rated movies.After accounting for differences in authoritative parenting style, adolescents reporting lesser restrictions for R movies have higher odds of future alcohol use. The structural model suggests that media parenting operates independently from authoritative parenting and should be incorporated explicitly into parenting prevention programs.

OBJECTIVE: To assess the association between smoking onset and exposure to movie smoking according to character type.METHODS: A longitudinal, random-digit-dial telephone survey of 6522 US adolescents was performed with movie exposure assessed at 4 time points over 24 months. Adolescents were asked whether they had seen a random subsample of recently released movies, for which we identified smoking by major characters and type of portrayal (divided into negative, positive, and mixed/neutral categories). Multivariate hazard regression analysis was used to assess the independent effects of these exposures on the odds of trying smoking.RESULTS: By the 24-month follow-up survey, 15.9% of baseline never-smokers had tried smoking. Within the sample of movies, 3848 major characters were identified, of whom 69% were male. Smokers represented 22.8% of 518 negative characters, 13.7% of 2486 positive characters, and 21.1% of 844 mixed/neutral characters. Analysis of the crude relationship showed that episodes of negative character smoking exposure had the strongest influence on smoking initiation. However, because most characters were portrayed as positive, exposure to this category was greatest. When the full population effect of each exposure was modeled, each type of character smoking independently affected smoking onset. There was an interaction between negative character smoking and sensation-seeking with stronger response for adolescents lower in sensation-seeking.CONCLUSIONS: Character smoking predicts adolescent smoking initiation regardless of character type, which demonstrates the importance of limiting exposure to all movie smoking. Negative character portrayals of smoking have stronger impact on low risk-taking adolescents, undercutting the argument that greater exposure is a marker for adolescent risk-taking behavior.

OBJECTIVE. There is no safe level of exposure to tobacco smoke. Thirdhand smoke is residual tobacco smoke contamination that remains after the cigarette is extinguished. Children are uniquely susceptible to thirdhand smoke exposure. The objective of this study was to assess health beliefs of adults regarding thirdhand smoke exposure of children and whether smokers and nonsmokers differ in those beliefs. We hypothesized that beliefs about thirdhand smoke would be associated with household smoking bans. METHODS. Data were collected by a national random-digit-dial telephone survey from September to November 2005. The sample was weighted by race and gender within Census region on the basis of US Census data. The study questions assessed the level of agreement with statements that breathing air in a room today where people smoked yesterday can harm the health of children. RESULTS. Of 2000 eligible respondents contacted, 1510 (87%) completed surveys, 1478 (97.9%) answered all questions pertinent to this analysis, and 273 (18.9%) were smokers. Overall, 95.4% of nonsmokers versus 84.1% of smokers agreed that secondhand smoke harms the health of children, and 65.2% of nonsmokers versus 43.3% of smokers agreed that thirdhand smoke harms children. Strict rules prohibiting smoking in the home were more prevalent among nonsmokers: 88.4% vs 26.7%. In multivariate logistic regression, after controlling for certain variables, belief that thirdhand smoke harms the health of children remained independently associated with rules prohibiting smoking in the home. Belief that secondhand smoke harms the health of children was not independently associated with rules prohibiting smoking in the home and car. CONCLUSIONS. This study demonstrates that beliefs about the health effects of thirdhand smoke are independently associated with home smoking bans. Emphasizing that thirdhand smoke harms the health of children may be an important element in encouraging home smoking bans.

Alcohol is the most common drug among youth and a major contributor to morbidity and mortality worldwide. Billions of dollars are spent annually marketing alcohol.To examine the reach of television alcohol advertising and its effect on drinking among underage youth.Longitudinal telephone- and web-based surveys conducted in 2011 and 2013 involving 2541 US adolescents 15 to 23 years of age at baseline, with 1596 of these adolescents completing the follow-up survey. Cued recall of television advertising images for top beer and distilled spirits brands that aired nationally in 2010-2011 (n = 351). Images were digitally edited to remove branding, and the respondents were queried about 20 randomly selected images. An alcohol advertising receptivity score was derived (1 point each for having seen the ad and for liking it, and 2 points for correct brand identification). Fast-food ads that aired nationally in 2010-2011 (n = 535) were similarly queried to evaluate message specificity.Among the underage youth at baseline, we determined (1) the onset of drinking among those who never drank, (2) the onset of binge drinking among those who were never binge drinkers, and (3) the onset of hazardous drinking among those with an Alcohol Use Disorders Identification Test consumption subscore of less than 4. Multivariate regressions were used to predict each outcome, controlling for covariates (demographics, drinking among friends and parents, and sensation seeking), weighting to the US population, and using multiple imputation to address loss to follow-up.Underage participants were only slightly less likely than participants of legal drinking age to have seen alcohol ads (the mean percentage of ads seen were 23.4%, 22.7%, and 25.6%, respectively, for youth 15-17, 18-20, and 21-23 years of age; P .005). The transition to binge and hazardous drinking occurred for 29% and 18% of youth 15 to 17 years of age and for 29% and 19% of youth 18 to 20 years years of age, respectively. Among underage participants, the alcohol advertising receptivity score independently predicted the onset of drinking (adjusted odds ratio [AOR], 1.69 [95% CI, 1.17-2.44]), the onset of binge drinking (AOR, 1.38 [95% CI, 1.08-1.77]), and the onset of hazardous drinking (AOR, 1.49 [95% CI, 1.19-1.86]). Fast-food advertising receptivity was not associated with any drinking outcome.Receptivity to television alcohol advertising predicted the transition to multiple drinking outcomes. The findings are consistent with the idea that marketing self-regulation has failed to keep television alcohol advertising from reaching large numbers of underage persons and affecting their drinking patterns.

Importance Many adolescents and young adults use alternative tobacco products, such as water pipes and snus, instead of cigarettes. Objective To assess whether prior water pipe tobacco smoking and snus use among never smokers are risk factors for subsequent cigarette smoking. Design, Setting, and Participants We conducted a 2-wave national longitudinal study in the United States among 2541 individuals aged 15 to 23 years old. At baseline (October 25, 2010, through June 11, 2011), we ascertained whether respondents had smoked cigarettes, smoked water pipe tobacco, or used snus. At the 2-year follow-up (October 27, 2012, through March 31, 2013), we determined whether baseline non–cigarette smokers had subsequently tried cigarette smoking, were current (past 30 days) cigarette smokers, or were high-intensity cigarette smokers. We fit multivariable logistic regression models among baseline non–cigarette smokers to assess whether baseline water pipe tobacco smoking and baseline snus use were associated with subsequent cigarette smoking initiation and current cigarette smoking, accounting for established sociodemographic and behavioral risk factors. We fit similarly specified multivariable ordinal logistic regression models to assess whether baseline water pipe tobacco smoking and baseline snus use were associated with high-intensity cigarette smoking at follow-up. Exposures Water pipe tobacco smoking and the use of snus at baseline. Main Outcomes and Measures Among baseline non–cigarette smokers, cigarette smoking initiation, current (past 30 days) cigarette smoking at follow-up, and the intensity of cigarette smoking at follow-up. Results Among 1596 respondents, 1048 had never smoked cigarettes at baseline, of whom 71 had smoked water pipe tobacco and 20 had used snus at baseline. At follow-up, accounting for behavioral and sociodemographic risk factors, baseline water pipe tobacco smoking and snus use were independently associated with cigarette smoking initiation (adjusted odds ratios: 2.56; 95% CI, 1.46-4.47 and 3.73; 95% CI, 1.43-9.76, respectively), current cigarette smoking (adjusted odds ratios: 2.48; 95% CI, 1.01-6.06 and 6.19; 95% CI, 1.86-20.56, respectively), and higher intensity of cigarette smoking (adjusted proportional odds ratios: 2.55; 95% CI, 1.48-4.38 and 4.45; 95% CI, 1.75-11.27, respectively). Conclusions and Relevance Water pipe tobacco smoking and the use of snus independently predicted the onset of cigarette smoking and current cigarette smoking at follow-up. Comprehensive Food and Drug Administration regulation of these tobacco products may limit their appeal to youth and curb the onset of cigarette smoking.

Tobacco use and tobacco smoke exposure are among the most important preventable causes of premature disease, disability, and death and therefore constitute a major pediatric health concern. The pediatric primary care setting offers excellent opportunities to prevent tobacco use in youth and to deliver cessation-related treatment to youth and parents who use tobacco. This report updates a “state-of-the-art” article published a decade ago on office-based interventions to address these issues. Since then there has been marked progress in understanding the nature, onset, and trajectories of tobacco use and nicotine addiction in youth with implications for clinical practice. In addition, clinicians need to remain abreast of emerging nicotine delivery systems, such as electronic cigarettes, that may influence uptake or continuation of smoking. Although evidence-based practice guidelines for treating nicotine addiction in youth are not yet available, research continues to build the evidence base toward that goal. In the interim, practical guidelines are available to assist clinicians in addressing nicotine addiction in the pediatric clinical setting. This article reports current practices in addressing tobacco in pediatric primary care settings. It reviews our increasing understanding of youth nicotine addiction, summarizes research efforts on intervention in the past decade and additional research needed going forward, and provides practical guidelines for pediatric health care providers to integrate tobacco use prevention and treatment into their clinical practice. Pediatric providers can and should play an important role in addressing tobacco use and dependence, both in the youth they care for and in parents who use tobacco.

OBJECTIVE. Provision of telephone smoking cessation counseling can increase the rate of quitting smoking. The US Public Health Service recently helped to establish a free national quitline enrollment service. No previous surveys have assessed the acceptability to parents of enrollment in quitline counseling in the context of their child's health care visits. Therefore, the objective of this study was to assess acceptability to parents of enrollment in quitline counseling and to compare that with the reported rate of actually being enrolled in any smoking cessation counseling outside the office in the context of the child's health care visit.METHODS. Data were collected by a national random-digit-dial telephone survey of households from September to November 2004. The sample is weighted by race and gender on the basis of the current US Census to be representative of the US population.RESULTS. Of 3615 eligible respondents contacted, 3011 (83.3%) completed surveys; 958 (31.8%) who completed the survey were parents with children under the age of 18 years. Of these parents, 187 (19.7%) were self-identified smokers. Of the parents who smoked, 113 (64.2%) said that they would accept enrollment in a telephone cessation program if the child's doctor offered it to them. In contrast, of the 122 smoking parents who accompanied their child to the doctor in the past year, only 11 (9%) had any counseling recommended to them, and only 1 (0.8%) was actually enrolled. These results did not vary by parent age, gender, race, or child age.CONCLUSIONS. When interacting with parents who smoke, child health care providers have low rates of referring and enrolling parents in any services related to smoking. Enrollment in quitlines would be acceptable to the majority of parents in the context of their child's health care visit. Tobacco control efforts in the child health care setting should include implementation of office systems that can facilitate enrollment of parental smokers in telephone quitlines.

Background. Smokers who use cessation medications when they attempt to quit double their like- lihood of success. No prior survey has assessed the ac- ceptability to parents of receiving smoking cessation medication prescriptions in the context of their child's primary care visits. Objective. To assess acceptability to parents of receiv- ing smoking cessation medication prescriptions and to compare that with the reported rate of actually receiving smoking cessation medication prescriptions in the con- text of the child's health care visit. Methods. Data were collected through a national ran- dom-digit dial telephone survey of households from July to September 2003. The sample was weighted according to race and gender, on the basis of the 2002 US Census, to be representative of the US population. Results. Of 3990 eligible respondents contacted, 3010 (75%) completed surveys; 1027 (34%) of those were par- ents. Of those parents, 211 (21%) were self-identified smokers. One half would consider using a smoking ces- sation medication and, of those, 85% said that it would be acceptable if the child's doctor prescribed or recom- mended it to them. In contrast, of the 143 smoking par- ents who accompanied their child to the doctor, only 15% had pharmacotherapy recommended and only 8% re- ceived a prescription for a smoking cessation medication. These results did not vary according to parent age, gen- der, race, or child age. Conclusions. Child health care clinicians have low rates of recommending and prescribing cessation thera- pies that have proved effective in other settings. The recommendation or provision of cessation medications would be acceptable to the majority of parents in the context of their child's health care visit. Pediatrics 2005; 115:1013-1017; smoking, tobacco, pediatrics, family prac

There is realistic concern about the impact of environmental influences on the health of human populations. First, exposure to environmental agents continues despite successes in reducing exposures to known toxicants such as lead, polychlorinated biphenyls (PCBs) and tobacco smoke. Second, there has been increasing concern about the cause of autism and other neurodevelopmental problems and hypotheses that environmental influences may play a role in the prevalence of these and other such childhood and adult conditions as asthma and obesity. Third, many other conditions are directly or indirectly related to environmental influences and are preventable, such as injuries, untoward consequences of alcohol, suicide, drug addiction, and gun-related deaths. There have been numerous publications since the 1970s of symposia, proceedings, monographs, and articles dealing with the increased susceptibility of the embryo, infant, and child to environmental toxicants,1–17 reflecting a greater level of concern about embryonic and childhood exposures. Indeed, great deal of attention has been paid to the vulnerability of the embryo and the fetus to environmental chemicals, drugs, and physical agents. In fact, the publication edited by Miller1 was primarily devoted to exposures to the embryo and the fetus. Because the embryo and the child are growing and their tissues and organs are differentiating, deleterious effects may occur at lower exposures to some chemicals, drugs, and physical agents and produce more severe effects than those seen in adults. In fact, some effects may not occur in adults. Thus, maximal permissible exposures (MPEs) for some environmental chemicals should be lower for the embryo and the child. It is important to note that children and adolescents have better recuperative capacities than adults for many toxic agents, and, similarly, appropriate drug dosages may be lower or higher on a mg/kg or surface area basis in children than in adults to … Reprint requests to (R.L.B.) Rm 308, R/A, Alfred I. duPont Hospital for Children, Box 269, Wilmington, DE 19899. E-mail: rbrent{at}nemours.org