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BackgroundThe standard approach for evaluating the effects of population-level substance use prevention efforts on youth and young adult perceptions and behaviors has been to compare outcomes across states using national surveillance data. Novel surveillance methods that follow individuals over shorter time intervals and capture awareness of substance use prevention policy and communication efforts may provide a stronger basis for their evaluation than annual cross-sectional studies. ObjectiveThis study aimed to identify a combination of strategies to recruit a sample of youth and young adults sufficiently representative of the Vermont population and determine how best to retain a web-based panel of youth and young adults over a 6-month period. MethodsEligible participants were Vermont residents aged 12 to 25 years who were willing to complete three 10 to 15-minute web-based surveys over a 6-month period. Recruitment was conducted via the following three main mechanisms: (1) web-based recruitment (paid and unpaid), (2) community-based recruitment through partners, and (3) participant referrals via a personalized link. Upon completion of the baseline survey, participants were randomly assigned to one of the following three retention incentive conditions: (1) guaranteed incentive (US $10), (2) lottery incentive (US $50 weekly lottery drawing), and (3) preferred method (guaranteed or lottery). Analyses examined cost per survey start by recruitment source, distribution of demographic characteristics across incentive conditions, and retention by study condition at 3-month and 6-month follow-ups. ResultsOver a 10-week period in 2019, we recruited 480 eligible youth (aged 12-17 years) and 1037 eligible young adults (aged 18-25 years) to the Policy and Communication Evaluation (PACE) Vermont Study. Facebook and Instagram advertising produced the greatest number of survey starts (n=2013), followed by posts to a state-wide web-based neighborhood forum (n=822) and Google advertisements (n=749). Retention was 78.11% (1185/1517) at 3 months and 72.18% (1095/1517) at 6 months. Retention was equivalent across all incentive study conditions at both waves, despite a strong stated preference among study participants for the guaranteed payment at baseline. Youth had greater retention than young adults at both waves (wave 2: 395/480, 82.3% vs 790/1037, 76.18%; wave 3: 366/480, 76.3% vs 729/1037, 70.30%). Substance use prevalence in this cohort was similar to national and state-level surveillance estimates for young adults, but was lower than state-level surveillance estimates for youth. Most participants retained at wave 3 provided positive qualitative feedback on their experience. ConclusionsOur study supports the feasibility of recruiting a web-based cohort of youth and young adults with representation across an entire state to evaluate substance use prevention efforts. Findings suggest that a guaranteed payment immediately upon survey completion coupled with a bonus for completing all survey waves and weekly survey reminders may facilitate retention in a cohort of youth and young adults.

OBJECTIVE: Plain packaging and graphic warning labels are two regulatory strategies that may impact cigarette risk beliefs and reduce consumption, but data are needed to better understand how smokers respond to such regulations. METHODS: Adult, daily, Marlboro non-menthol smokers (Red [n = 141] or Gold [n = 43]) completed a mixed factorial randomized trial. Participants smoked their usual cigarettes during baseline (5-days) and were randomized to receive cigarette packs with a warning label manipulation (graphic vs. text-only). Within each warning label condition, participants completed three within-subjects pack color manipulations (red, gold, plain), each lasting 15 days. Participants were blinded to the fact that all packs contained their usual cigarettes. Mixed-effects models examined between- and within-subject differences on risk beliefs, product perceptions, and smoking behavior. RESULTS: Warning type and package color did not impact cigarette consumption or subjective ratings. However, use increased in all conditions (2.59-3.59 cigarettes per day) relative to baseline. While smokers largely held correct risk beliefs at baseline (Mean = 6.02, SE = 0.17, Range:0-8), the cumulative number of incorrect or uncertain cigarette risk beliefs increased from baseline in all pack color manipulations in the text (IRR range = 1.70-2.16) and graphic (IRR range = 1.31-1.70) warning conditions. Across all pack color periods, those in the graphic (vs. text) warning condition had reduced odds of reporting their study cigarettes as safer than regular cigarettes (OR range = 0.22-0.32). CONCLUSIONS: Pack color modification may increase uncertainty about several key cigarette risk beliefs, though graphic warnings may attenuate these effects. Regulatory agencies could consider supporting policy changes with information campaigns to maximize public knowledge. TRIAL REGISTRATION: November 25, 2014; Registration number: NCT02301351.

BackgroundFew studies have addressed enrollment and retention methods in online smoking cessation interventions. Fully automated Web-based trials can yield large numbers of participants rapidly but suffer from high rates of attrition. Personal contact with participants can increase recruitment of smokers into cessation trials and improve participant retention. ObjectiveTo compare the impact of Web-based (WEB) and phone (PH) baseline assessments on enrollment and retention metrics in the context of a Facebook smoking cessation study. MethodsParticipants were recruited via Facebook and Google ads which were randomly displayed to adult smokers in the United States over 27 days from August to September 2013. On each platform, two identical ads were randomly displayed to users who fit the advertising parameters. Clicking on one of the ads resulted in randomization to WEB, and clicking on the other ad resulted in randomization to PH. Following online eligibility screening and informed consent, participants in the WEB arm completed the baseline survey online whereas PH participants completed the baseline survey by phone with a research assistant. All participants were contacted at 30 days to complete a follow-up survey that assessed use of the cessation intervention and smoking outcomes. Participants were paid $15 for follow-up survey completion. ResultsA total of 4445 people clicked on the WEB ad and 4001 clicked on the PH ad: 12.04% (n=535) of WEB participants and 8.30% (n=332) of PH participants accepted the online study invitation (P

BackgroundScreening for diabetic retinopathy is both effective and cost-effective, but rates of screening compliance remain suboptimal. As screening improves, new methods to deal with screening data may help reduce the human resource needs. Crowdsourcing has been used in many contexts to harness distributed human intelligence for the completion of small tasks including image categorization. ObjectiveOur goal was to develop and validate a novel method for fundus photograph grading. MethodsAn interface for fundus photo classification was developed for the Amazon Mechanical Turk crowdsourcing platform. We posted 19 expert-graded images for grading by Turkers, with 10 repetitions per photo for an initial proof-of-concept (Phase I). Turkers were paid US $0.10 per image. In Phase II, one prototypical image from each of the four grading categories received 500 unique Turker interpretations. Fifty draws of 1-50 Turkers were then used to estimate the variance in accuracy derived from randomly drawn samples of increasing crowd size to determine the minimum number of Turkers needed to produce valid results. In Phase III, the interface was modified to attempt to improve Turker grading. ResultsAcross 230 grading instances in the normal versus abnormal arm of Phase I, 187 images (81.3%) were correctly classified by Turkers. Average time to grade each image was 25 seconds, including time to review training images. With the addition of grading categories, time to grade each image increased and percentage of images graded correctly decreased. In Phase II, area under the curve (AUC) of the receiver-operator characteristic (ROC) indicated that sensitivity and specificity were maximized after 7 graders for ratings of normal versus abnormal (AUC=0.98) but was significantly reduced (AUC=0.63) when Turkers were asked to specify the level of severity. With improvements to the interface in Phase III, correctly classified images by the mean Turker grade in four-category grading increased to a maximum of 52.6% (10/19 images) from 26.3% (5/19 images). Throughout all trials, 100% sensitivity for normal versus abnormal was maintained. ConclusionsWith minimal training, the Amazon Mechanical Turk workforce can rapidly and correctly categorize fundus photos of diabetic patients as normal or abnormal, though further refinement of the methodology is needed to improve Turker ratings of the degree of retinopathy. Images were interpreted for a total cost of US $1.10 per eye. Crowdsourcing may offer a novel and inexpensive means to reduce the skilled grader burden and increase screening for diabetic retinopathy.

IntroductionWhile risk factors for cigarette smoking among youth and young adults are well-documented, less is known about the correlates of initiation of other tobacco products. This study aims to provide estimates and correlates of initiation among U.S. youth and young adults.MethodsData on youth aged 12-17 (n = 10,072) and young adults aged 18-24 (N = 5,727) who provided information on cigarettes, electronic nicotine delivery systems (ENDS), cigars, pipe, hookah and smokeless tobacco use in Wave 1 (W1: 2013-2014)-Wave 4 (W4: 2016-2018) of the nationally-representative PATH Study were used to calculate ever use initiation and correlates of initiation by W4.ResultsNearly 6 million youth and 2.5 million young adults used tobacco for the first time between W1-W4. Approximately one quarter of youth and young adult ENDS never users initiated ENDS between W1-W4 of the PATH Study. Among youth, use of other tobacco products, ever substance use, and high externalizing problems were associated with initiation of most products. Among young adults, use of other tobacco products and ever substance use were associated with initiation of most products. In both youth and young adults, Hispanics were more likely to initiate hookah use than their non-Hispanic White counterparts. While male sex was a risk factor for most tobacco product initiation across both age groups, it was not associated with hookah initiation.ConclusionsCigarette and non-cigarette products shared many correlates of initiation, although there are noteworthy demographic differences. Findings can help tailor product specific interventions to reach populations at risk during preliminary stages of use.

IntroductionThis study examined in youth (12-17 years), young adults (18-24 years), and adults (25+ years): (1) the prevalence of the first menthol cigarette and menthol/mint cigar use among new tobacco users; (2) association between the first menthol/mint use, subsequent tobacco use, and nicotine dependence ~1 year later compared with the first non-menthol/mint use.Aims and methodsLongitudinal analysis of data from Waves 1 to 4 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2017; 10 086 youth and 21 281 adults). Main outcome measures were past 12-month and past 30-day cigarette and cigar use, and nicotine dependence.ResultsYouth and young adult new cigarette users are more likely to smoke a menthol cigarette or indicate that they do not know the flavor compared with adults aged 25+. A greater proportion of adults aged 25+ first used menthol/mint-flavored cigars (13.4%) compared with youth (8.5%) and young adults (7.4%). Among young adults, first use of a menthol cigarette is associated with past 12-month use of cigarettes at the subsequent wave and first use of any menthol/mint-flavored cigars is associated with past 30-day use of these products at the subsequent wave in both youth and young adults. In youth and adults, there were no significant relationships between first use of a menthol/mint cigarette or cigar and nicotine dependence scores at a subsequent wave in multivariable analyses.ConclusionsThe first use of menthol/mint cigarettes and cigars is associated with subsequent cigarette and cigar use in young people aged 12-24.ImplicationsThis study examined the relationship between initiation with menthol cigarettes and menthol/mint cigars, subsequent tobacco use, and nicotine dependence in US youth, young adults, and adults who participated in Waves 1-4 of the Population Assessment of Tobacco and Health study. New use of menthol cigarettes was associated with greater past 12-month cigarette use in young adults and new use of menthol/mint-flavored cigars was associated with greater past 30-day cigar use in youth and young adults compared with non-menthol use. Initiation with menthol/mint cigarette and cigar products may lead to subsequent use of those products.

Background: E-cigarette advertising, which often includes various features, may prompt e-cigarette use and product switching. This study examined the associations between noticing e-cigarette ad features and perceived product appeal and interest in completely switching from cigarettes to advertised e-cigarettes among young adult dual users of both products. Methods: We analyzed data from an online heatmap experiment among young adult dual users defined as established cigarette smokers who currently used e-cigarettes (ages 18-34 years; n = 1,821). Participants viewed 12 e-cigarette ads, clicked on ad features (e.g., fruit flavors, nicotine warnings, price promotions, smoker-targeted claims) that attracted their attention (defined as "noticing"), and answered questions about e-cigarette product appeal and interest in completely switching from cigarettes to the e-cigarettes shown. We examined within-person associations between noticing specific ad features and outcomes, controlling for demographic and tobacco use-related characteristics. Results: Noticing fruit flavors (AOR = 1.67 and 1.28) and fruit images (AOR = 1.53 and 1.21) was positively associated with having any e-cigarette product appeal and switching interest. Noticing price promotions (AOR = 1.23) was positively associated with product appeal. In contrast, noticing nicotine warnings (AOR = 0.74 and 0.86), smoker-targeted claims (AOR = 0.78 and 0.89), and tobacco flavors (AOR = 0.92 and 0.90) was negatively associated with product appeal and switching interest. Conclusions: Noticing certain e-cigarette ad features (e.g., fruit flavors and nicotine warnings) may be associated with product appeal and/or switching interest among young adult dual users. More research is needed to assess the influence of e-cigarette ad features that promote product switching interests among cigarette smokers while discourage interests among tobacco-naïve individuals. [ABSTRACT FROM AUTHOR]

Introduction Considering recent and proposed bans on menthol cigarettes, methods are needed to understand the substitutability of potential menthol cigarette alternatives (MCAs) for menthol cigarettes. This study examined the prospective relationship between behavioral economic demand indices and subjective effects of usual brand menthol cigarettes (UBMC) and preferred MCAs with subsequent performance on a laboratory-based concurrent-choice task comparing UBMC and MCAs. Methods Eighty participants who typically smoked menthol cigarettes completed this clinical laboratory study. After sampling each product, participants completed the cigarette purchase task (CPT) and modified cigarette evaluation questionnaire (mCEQ). Following 1 week of substituting their preferred MCA for their UBMC, participants completed a 90-minute concurrent-choice self-administration (SA) task comparing their UBMC and preferred MCA. Linear regression models explored associations between CPT demand indices and mCEQ subjective effects in the laboratory with subsequent response effort for UBMCs on the concurrent-choice task. Results Three demand indices for UBMC were positively associated with UBMC response effort: essential value (EV; p  = .02), O max (p  = .02), and breakpoint (p  = .04). Four CPT demand indices for the preferred MCA significantly corresponded with UBMC response effort: EV (p  = .03), price associated with maximal expenditure (P max) (p  = .04), maximal expenditure (O max) (p  = .03), and breakpoint (p  = .03). Subjective effects captured by the mCEQ were not associated with response effort. Conclusions Demand indices reflecting Persistence (ie, sensitivity to escalating price) predicted effort to obtain UBMC puffs on the concurrent-choice task. Among this sample, the CPT captured information on the relative reinforcing value (ie, addiction potential) of combustible tobacco products similar to the longer SA task. Implications In an ever-changing product market, assessing the reinforcing efficacy of menthol cigarettes and putative substitutes quickly and with validity is an important methodological tool for understanding abuse liability. Results suggest that behavioral economic demand indices of CPT efficiently capture information on the relative reinforcing value of UBMC and plausible alternative tobacco products, similar to a 90-minute in-laboratory SA task. [ABSTRACT FROM AUTHOR]

Purpose: Few studies have addressed beliefs about treatment for opioid use disorder (OUD) among family members of people with OUD, particularly in rural communities. This study examined the beliefs of rural family members of people with OUD regarding treatment, including medication for OUD (MOUD), and recovery. Methods: Semi‐structured qualitative interviews were conducted with rural Vermont family members of people with OUD. Twenty family members completed interviews, and data were analyzed using thematic analysis. Results: Four primary themes related to beliefs about OUD treatment emerged: (1) MOUD is another form of addiction or dependency and should be used short‐term; (2) essential OUD treatment components include residential and mental health services and a strong support network involving family; (3) readiness as a precursor to OUD treatment initiation; and (4) stigma as an impediment to OUD treatment and other health care services. Conclusions: Rural family members valued mental health services and residential OUD treatment programs while raising concerns about MOUD and stigma in health care and the community. Several themes (e.g., MOUD as another form of addiction, residential treatment, and treatment readiness) were consistent with prior research. The belief that MOUD use should be short‐term was inconsistent with the belief that OUD is a disease. Findings suggest a need for improved education on the effectiveness of MOUD for family members and on stigma for health care providers and community members. [ABSTRACT FROM AUTHOR]

Introduction: Many people who smoke cigarettes report believing that nicotine causes cancer, a misperception that may reduce interest in switching to noncombustible nicotine products. Quantitative survey questions do not capture how this population thinks about nicotine and switching to noncombustible products. Methods: This study used an online convenience sample of 193 US adults who smoke cigarettes and reported that nicotine causes cancer. Respondents were asked if they thought nicotine was harmful (and why or why not) and if they would consider switching to a noncombustible product (and why or why not). Inductive and deductive coding were used, and descriptive statistics are reported. Results: Descriptions of nicotine directly causing disease (61%) were more common than descriptions of nicotine causing addiction to a harmful product (8%). One-third expressly stated that nicotine causes cancer, and 21% that nicotine causes lung disease. Interest in switching was moderate (mean 47.4 out of 100). When asked about switching, 34% described enjoying their current smoking experience, 23% described a perceived health benefit, 16% described a health concern, and 11% worried that switching would not address nicotine addiction. Discussion: Adults who smoke commonly perceived nicotine as a direct cause of cigarette-related disease, and harm and addictiveness perceptions were often mentioned as reasons for interest or disinterest in switching to a noncombustible. Future studies could explore strategies for correcting nicotine misperception, stigma related to addiction, and common concerns related to health as well as user experience. [ABSTRACT FROM AUTHOR]

Introduction: Many US young adults are susceptible to waterpipe (i.e., hookah) tobacco smoking (WTS) initiation, but research on factors associated with WTS susceptibility is limited. We examined sociodemographic, other tobacco and substance use, and attitudes and perceptions correlates of WTS susceptibility among young adults. Methods: Baseline data from a randomized trial testing WTS risk messages was collected in US young adults aged 18 to 30 years who never used waterpipe tobacco but were susceptible to WTS (n = 294). Extent of susceptibility to WTS was defined using the average score of a valid scale with higher scores indicating higher susceptibility. Correlates were sociodemographics, other tobacco and substance use, and attitudes and perceptions. Multiple linear regression models identified correlates of greater WTS susceptibility. Results: Participants averaged 25 (SD 3.2) years of age, 60% were male, 22% were Black non-Hispanic, 47% completed some college education, and 66% were employed. Our models consistently showed that more positive attitudes toward WTS (β = -0.08, p<0.01), lower perceived addictiveness relative to cigarettes (β = -0.09, p = 0.04), and greater perceived social acceptability of WTS (β = 0.05, p<0.01) were positively correlated with WTS susceptibility. Additionally, young adults who smoked cigarillos (β = 0.53, p<0.01), used cannabis (β = 0.14, p = 0.02), and Black non-Hispanic versus White non-Hispanic young adults (β = 0.18, p = 0.03) also had higher WTS susceptibility. Conclusions: Findings suggest that WTS prevention efforts require multicomponent interventions including targeting subpopulations at greater risk based on race/ethnicity and other tobacco and substance use. These interventions should consider attitudes and social acceptability of WTS as modifiable targets to maximize public health benefits. [ABSTRACT FROM AUTHOR]