Automated generation of comparator patients in the electronic medical record.

Background: Well-designed randomized trials provide high-quality clinical evidence but are not always feasible or ethical. In their absence, the electronic medical record (EMR) presents a platform to conduct comparative effectiveness research, central to the emerging academic learning health system (aLHS) model. A barrier to realizing this vision is the lack of a process to efficiently generate a reference comparison group for each patient. Objective: To test a multi-step process for the selection of comparators in the EMR. Materials and Methods: We conducted a mixed-methods study within a large aLHS in North Carolina. We (1) created a list of 35 candidate variables; (2) surveyed 270 researchers to assess the importance of candidate variables; and (3) built consensus rankings around survey-identified variables (ie, importance scores >7) across two panels of 7-8 clinical research experts. Prioritized algorithm inputs were collected from the EMR and applied using a greedy matching technique. Feasibility was measured as the percentage of patients with 100 matched comparators and performance was measured via computational time and Euclidean distance. Results: Nine variables were selected: age, sex, race, ethnicity, body mass index, insurance status, smoking status, Charlson Comorbidity Index, and neighborhood percentage in poverty. The final process successfully generated 100 matched comparators for each of 1.8 million candidate patients, executed in less than 100 min for the majority of strata, and had average Euclidean distance 0.043. Conclusion: EMR-derived matching is feasible to implement across a diverse patient population and can provide a reproducible, efficient source of comparator data for observational studies, with additional testing in clinical research applications needed.

The Development and Testing of a Point-of-Sale E-Cigarette Health Communication Campaign.

Adolescents and young adults continue to use e-cigarettes, and communication campaigns are needed to decrease use among these populations. We developed and tested a point-of-sale communication campaign focused on e-cigarette chemical exposure. We developed messages based on formative research and tested them (versus text-only messages) in a nationally-representative online survey among adolescents and young adults (16-25) (Phase 1). Based on survey findings, we selected a message focused on nicotine and brain development for the point-of-sale trial (Phase 2). We then conducted a cluster-randomized trial at six gas stations with convenience stores, randomly assigned to the intervention (messages displayed) or no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 participants (ages 16-25) per store, at baseline and a four-week follow-up. Phase 1 included 1,636 participants in the online study. Intervention messages were rated as more attention grabbing than plain text messages (p < .05), though were rated similarly on other outcomes. Exposure to intervention messages resulted in larger changes from pre- to posttest for beliefs about addiction and relative harms versus cigarettes (p < .05). Phase 2 included 586 participants in the point-of-sale study. Real-world campaign exposure was low (31.8%), and no differences were found between conditions. E-cigarette prevention messages focused on nicotine's impact on brain development show promise. However, garnering attention for communication campaigns in saturated point-of-sale environments, often dominated by tobacco advertising, is challenging. Future efforts should utilize additional communication channels to directly target adolescents and young adults.

Knowing Is Not Doing: A Qualitative Study of Parental Views on Family Beverage Choice.

OBJECTIVE: Sugary drink consumption is associated with adverse health outcomes in children, highlighting the need for scalable family interventions that address barriers to water consumption. To inform development of a scalable, health-care-system-based intervention targeting family beverage choice, a formative qualitative study was conducted using semi-structured interviews with parents whose children were identified as over-consuming sugar-sweetened beverages (SSB) and/or fruit juice (FJ). The first goal of these interviews was to understand, in a diverse real-world patient population, what parents viewed as the primary drivers of their family's beverage choices, and explore how these drivers might need to be addressed in order to make changes to beverage consumption. A second goal was to explore parental preferences for planned intervention components. An exploratory goal of the interviews was to examine whether knowledge, attitudes, and beliefs around family beverage choice differed across racial and ethnic groups in this sample. DESIGN: Semi-structured phone interviews were conducted and interviews audio-recorded and transcribed. PARTICIPANTS: 39 parents/caregivers of children ages 1-8 who over-consumed sugary drinks as determined by screenings at pediatric visits. PHENOMENON OF INTEREST: Parents were interviewed about family beverage choices and preferences to inform development of a multi-component intervention. ANALYSIS: Thematic analysis was performed, including comparison of themes across racial/ethnic groups. RESULTS: Parents expressed that sugary drinks were unhealthy and water was a better alternative. Most were familiar with the health consequences of excess sugar consumption. They identified many reasons why sugary drinks are chosen over water despite this knowledge. One common reason was concern about tap water safety. Few differences were noted across racial and ethnic groups in our sample. Parents were enthusiastic about a technology-based intervention to be delivered through their child's doctor's office. CONCLUSIONS AND IMPLICATIONS: Knowledge is not enough to change behavior. Beverage interventions need to be easy to access, make water more appealing, and elevate beverage choice above the "white noise" of everyday life. Delivering an intervention in a clinical setting could provide an extra level of care, while technology would reduce the amount of live contact and decrease the burden for clinicians and parents.

Reactions to using other nicotine and tobacco products instead of menthol cigarettes: A qualitative study of people who smoke menthol cigarettes in the United States.

The US Food and Drug Administration is considering banning menthol cigarettes, which could result in some people who smoke menthol cigarettes switching to other tobacco products (OTPs). This qualitative study explored reactions to using OTPs instead of menthol cigarettes. People who smoke menthol cigarettes (N=40) completed a behavioral economic assessment of the effects of menthol cigarette price increases on OTP purchasing. At the highest price, most participants could not afford menthol cigarettes. Instead, they could purchase non-menthol cigarettes, little cigars/cigarillos (LCCs), e-cigarettes, smokeless tobacco, or medicinal nicotine, or they could abstain from tobacco use. Participants used the OTPs they purchased for three days. During follow-up sessions, participants (n=35) completed semi-structured interviews discussing their purchasing-decisions and experiences using OTPs instead of menthol cigarettes. Interviews were analyzed using reflexive thematic analysis methods. Factors influencing purchasing decisions included flavor, price, prior use of OTPs, interest in trying new OTPs, and perceived ability to satisfy nicotine cravings. Participants described positive experiences using e-cigarettes including the "refreshing" menthol flavor, ability to use in places where cigarettes are prohibited, and convenience of use relative to smoking. Among those using non-menthol cigarettes, many reported they were acceptable but less satisfying products compared to menthol cigarettes while others reported negative reactions to them such as tasting like "cardboard". Reactions to smoking LCCs were mostly unfavorable but participants said it gave them "something to light". Multiple considerations may affect switching to OTPs in light of pending menthol cigarette regulation including the availability of menthol-flavored alternatives and (dis)satisfaction with OTPs.

Qualitative reactions to a low nicotine product standard for cigarettes from adolescents and young adults living in the United States who smoke.

The Biden Administration is considering a low nicotine product standard for cigarettes. This qualitative study examined reactions to a nicotine reduction policy among adolescents and young adults (AYA) who smoke cigarettes. After completing a lab study involving masked exposure either to low nicotine or normal nicotine research cigarettes and unmasked exposure to e-cigarettes varying in nicotine concentration and flavor, we conducted follow-up semi-structured interviews (N = 25) to explore participants' knowledge, attitudes, and perceptions of a low nicotine product standard and their anticipated tobacco use behavior after policy implementation. Interviews were audio-recorded, transcribed verbatim, double-coded, and analyzed using reflexive thematic analysis. Nearly half of participants supported the policy because they thought it would prevent young people from starting smoking and/or would help people quit. Reasons some participants opposed the policy included beliefs that adults should have the choice to smoke or that a nicotine reduction policy is counterintuitive because the government benefits from cigarette sales. Others believed the policy would be ineffective because youth could circumvent the policy (e.g., illicit market) or would increase their smoking to maintain the same nicotine level. Almost half of participants said they would quit smoking while the other half said they would continue smoking, although potentially reduce their smoking. Overall, our qualitative findings point to the need for pre-policy media campaigns targeting AYA who smoke to minimize negative reactions, dispel fears, and correct misperceptions as well as encourage quitting and provide information on accessing cessation resources.

The impact of the COVID-19 pandemic on a sample of US young adults who smoke cigarettes: A qualitative analysis.

INTRODUCTION: The ongoing COVID-19 pandemic has been associated with increased negative mood in youth, and a few reports of changes in tobacco use. We sought to increase the depth of knowledge on the effects of the pandemic on early young adult mood states, access to tobacco products and tobacco use behaviors, and knowledge of risks associated with tobacco use and COVID-19 by learning more about the lived experience of the pandemic among young adults early in their smoking trajectories. METHODS: Semi-structured qualitative interviews were conducted with 25 young adults ages 18-20 (M = 19) who smoked cigarettes daily or nearly every day and had used electronic cigarettes (ECs) on ≥ 2 occasions in their lifetime. RESULTS: Our results uncovered several themes: 1) The majority of teens experienced mental health disturbances as a result of the pandemic, which manifested as depression, anxiety, and/or acute loneliness due to social isolation; 2) tobacco purchasing behaviors sometimes changed, with both greater and less access reported among participants; 3) changes in tobacco use were also reported, with some reporting increases in use, others reporting decreases, and a few reporting quitting; and 4) while some youth reported that tobacco use could increase their risk related to COVID-19, the majority reported confusion and uncertainty about how tobacco use impacted their risk. CONCLUSIONS: The themes identified specific factors that may account for the heterogeneity of impacts of the pandemic on tobacco use, and highlight the value of qualitative work for centering the lived experience of youth for understanding larger trends in substance use.

Point-of-Sale Health Communication Campaigns for Cigarillos and Waterpipe Tobacco: Effects and Lessons Learned from Two Cluster Randomized Trials.

Many adolescents and young adults hold erroneous beliefs that cigarillos and waterpipe tobacco (WT) are safer than cigarettes, contributing to use. Communication campaigns can correct misperceptions and increase risk beliefs. We tested point-of-sale (POS) communication campaigns focused on chemical exposure for cigarillos and WT. We conducted two cluster randomized trials at 20 gas stations with convenience stores (10 stores for cigarillos, 10 for WT) in North Carolina between June and November 2017. Within each trial, stores were randomly assigned to either the intervention (campaign messages displayed) or a no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 adolescents and young adults (ages 16-25) per store, at baseline and follow-up. There were 978 participants (mean age = 20.9 years) in the cigarillo trial, and 998 participants (mean age = 21.0 years) in the WT trial. Rates of campaign exposure were low (26% for cigarillos; 24.3% for WT). The cigarillo campaign increased knowledge that ammonia is in cigarillo smoke (p < .01). There were also significant increases in knowledge about ammonia and cyanide in cigarillo smoke and arsenic in WT smoke (p < .05) in the sub-sample who reported exposure to the campaign. No differences were found in outcome expectancies, product attitudes, worry about chemical exposure, or behavioral intentions in either campaign. Garnering attention for communication campaigns in saturated POS environments, often dominated by tobacco advertising, is challenging. Our study demonstrates the feasibility of anti-tobacco campaigns at the POS and points to several lessons learned for future POS campaigns.

Facilitators and barriers to reducing chemotherapy for early-stage breast cancer: a qualitative analysis of interviews with patients and patient advocates.

BACKGROUND: As the combination of systemic and targeted chemotherapies is associated with severe adverse side effects and long-term health complications, there is interest in reducing treatment intensity for patients with early-stage breast cancer (EBC). Clinical trials are needed to determine the feasibility of reducing treatment intensity while maintaining 3-year recurrence-free survival of greater than 92%. To recruit participants for these trials, it is important to understand patient perspectives on reducing chemotherapy. METHODS: We collected qualitative interview data from twenty-four patients with Stage II-III breast cancer and sixteen patient advocates. Interviews explored potential barriers and facilitators to participation in trials testing reduced amounts of chemotherapy. As the COVID-19 pandemic struck during data collection, seventeen participants were asked about the potential impact of COVID-19 on their interest in these trials. Interviews were audio-recorded and transcribed, and researchers used qualitative content analysis to code for dominant themes. RESULTS: Seventeen participants (42.5%) expressed interest in participating in a trial of reduced chemotherapy. Barriers to reducing chemotherapy included (1) fear of recurrence and inefficacy, (2) preference for aggressive treatment, (3) disinterest in clinical trials, (4) lack of information about expected outcomes, (5) fear of regret, and (6) having young children. Facilitators included (1) avoiding physical toxicity, (2) understanding the scientific rationale of reducing chemotherapy, (3) confidence in providers, (4) consistent monitoring and the option to increase dosage, (5) fewer financial and logistical challenges, and (6) contributing to scientific knowledge. Of those asked, nearly all participants said they would be more motivated to reduce treatment intensity in the context of COVID-19, primarily to avoid exposure to the virus while receiving treatment. CONCLUSIONS: Among individuals with EBC, there is significant interest in alleviating treatment-related toxicity by reducing chemotherapeutic intensity. Patients will be more apt to participate in trials testing reduced amounts of chemotherapy if these are framed in terms of customizing treatment to the individual patient and added benefit-reduced toxicities, higher quality of life during treatment and lower risk of long-term complications-rather than in terms of taking treatments away or doing less than the standard of care. Doctor-patient rapport and provider support will be crucial in this process.

Patient perspectives on chemotherapy de-escalation in breast cancer.

BACKGROUND: Given excellent survival outcomes in breast cancer, there is interest in de-escalating the amount of chemotherapy delivered to patients. This approach may be of even greater importance in the setting of the COVID-19 pandemic. METHODS: This concurrent mixed methods study included (1) interviews with patients and patient advocates and (2) a cross-sectional survey of women with breast cancer served by a charitable nonprofit organization. Questions evaluated interest in de-escalation trial participation, perceived barriers/facilitators to participation, and language describing de-escalation. RESULTS: Sixteen patient advocates and 24 patients were interviewed. Key barriers to de-escalation included fear of recurrence, worry about decision regret, lack of clinical trial interest, and dislike for focus on less treatment. Facilitators included trust in physician recommendation, toxicity avoidance, monitoring for progression, perception of good prognosis, and impact on daily life. Participants reported that the COVID-19 pandemic made them more likely to avoid chemotherapy if possible. Of 91 survey respondents, many (43%) patients would have been unwilling to participation in a de-escalation clinical trial. The most commonly reported barrier to participation was fear of recurrence (85%). Few patients (19%) considered clinical trials themselves as a barrier to de-escalation trial participation. The most popular terminology describing chemotherapy de-escalation was "lowest effective chemotherapy dose" (53%); no patients preferred the term "de-escalation." CONCLUSIONS: Fear of recurrence is a common concern among breast cancer survivors and patient advocates, contributing to resistance to de-escalation clinical trial participation. Additional research is needed to understand how to engage patients in de-escalation trials.

What Do Adolescents and Young Adults Think a Cigarillo Is? Implications for Health Communication.

Cigarillo use has increased among adolescents and young adults and has remained high. Public education efforts are needed to communicate with these populations about cigarillo use risks, but little is known about the implications of using the term "cigarillo" in such efforts. The study goal was to assess adolescent and young adult perceptions of the term "cigarillo". We conducted a nationally representative online survey of 3517 adolescents and young adults (ages 13-25). We asked participants "what is a cigarillo?" with several response options. Participants were 49.6% female, 69.8% white, 5.2% reported past 30-day cigarillo use, and 11.6% reported lifetime cigarillo use. The most common response to the question "what is a cigarillo" was "I don't know" (51% of participants), followed by "a thinner and smaller version of a traditional cigar" (30.1% of participants), which was chosen by 19.4% of adolescents and 36.8% of young adults. Among past 30-day cigarillo users, the most common response was "I don't know" (54.9%) followed by "a thinner and smaller version of a traditional cigar" (45.1%). Cigarillo users were more likely to select the "a thinner and smaller version of a traditional cigar" response than nonusers. Findings suggest that many adolescents and young adults have varied understandings of the term "cigarillo". Researchers and practitioners need to ensure that terminology used in health communication campaigns is clearly understood by the target audience to maximize effectiveness.

Negative health symptoms reported by youth e-cigarette users: Results from a national survey of US youth.

BACKGROUND: E-cigarettes are the most prevalent tobacco product among US youth, but little is known about the health symptoms users experience. METHODS: Between August 2016 and May 2017, we conducted a nationally representative cross-sectional telephone survey of 975 US youth ages 13-17. Respondents who reported ever trying e-cigarettes were asked whether they ever experienced six physical health symptoms they thought were caused by e-cigarette use. We examined whether symptoms varied by demographics and tobacco use. RESULTS: Approximately 12.4% of respondents (n = 141) reported ever trying e-cigarettes. Of lifetime e-cigarette users, 37.0% reported past 30-day e-cigarette use, 17.2% reported past 30-day cigarette use, and 23.7% reported past 30-day use of another tobacco product. Most (63.3%) reported a symptom, most often cough (42.3%), followed by dizziness or lightheadedness (31.5%), headache or migraine (25.4%), dry or irritated mouth or throat (14.9%), shortness of breath (13.7%), change in or loss of taste (3.5%), and other (5.7%; nausea, dry eyes, earache, and tight chest). Headaches were more common among past 30-day e-cigarette users than non-users (43.8% vs. 14.6%). Shortness of breath was more common among past 30-day cigarette (33.8% vs. 9.5%) and other tobacco users (31.6% vs. 8.2%). Past 30-day cigarette users were also more likely to report any symptom (86.0% vs. 58.6%). CONCLUSIONS: Most youth e-cigarette users attribute health symptoms to their e-cigarette use. Past 30-day users were more likely to report certain symptoms than non-users. Findings can educate health practitioners and school nurses about common symptoms youth may experience and inform prevention messages.

Measuring waterpipe tobacco smoking in survey research.

Waterpipe tobacco (WT) smoking remains a significant public health problem. However, few validated measures exist, presenting challenges for obtaining accurate prevalence estimates and making comparisons across studies. We identified items used to measure several WT smoking behaviours in eight US national surveys of youth and adults and two international studies, including the National Youth Tobacco Survey, National Adult Tobacco Survey, Population Assessment of Tobacco and Health Adult and Youth Surveys, Monitoring the Future, National Health Interview Survey, Health Styles, Tobacco Use Supplement: Current Population Survey, Global Adult Tobacco Survey and Global Youth Tobacco Survey. We also identified WT survey items across the first 14 Food and Drug Administration-funded Tobacco Centers of Regulatory Science. Constructs included product description and terminology, ever and current use, quantity and frequency, use of flavours and reasons for use. There was little consistency in WT measurement, highlighting the need for validated measures.

Adverse symptoms users attribute to e-cigarettes: Results from a national survey of US adults.

BACKGROUND: Little is known about the prevalence of adverse symptoms electronic cigarette (e-cigarette) users report experiencing. METHODS: Between August 2016 and May 2017, we conducted a nationally representative cross-sectional telephone survey of 4964 US adults age 18 and over. Respondents who reported ever trying e-cigarettes were asked whether they ever experienced six symptoms they thought were caused by e-cigarette use. In weighted analyses, we assessed whether symptoms varied by demographics, e-cigarette use frequency, and cigarette smoking status. RESULTS: Approximately one-fourth of respondents (n = 1,624, 26.8%) reported ever trying e-cigarettes. Most were current (40.3%) or former (30.7%) cigarette smokers, with 29.0% never smokers. Just over half (58.2%) reported at least one symptom and on average 1.6 (SE = 0.1) symptoms. Symptoms included cough (40.0%), dry or irritated mouth or throat (31.0%), dizziness or lightheadedness (27.1%), headache or migraine (21.9%), shortness of breath (18.1%), change in or loss of taste (12.9%), or other (6.2%; most commonly nausea, tight chest, congestion). Among past 30-day e-cigarette users, current and never cigarette smokers were more likely than former smokers to report any symptoms (AOR = 5.25, CI = 2.05-13.46 and AOR = 2.58, CI = 0.85-7.81, respectively). CONCLUSIONS: A majority of e-cigarette users reported at least one symptom, most commonly cough or dry or irritated mouth or throat. Former cigarette smokers who used e-cigarettes in the past 30 days were less likely than current or never smokers to report adverse symptoms of e-cigarette use. Future research should examine frequency of symptoms among different user groups to understand how e-cigarettes may influence public health.

Developing a Point-of-Sale Health Communication Campaign for Cigarillos and Waterpipe Tobacco.

Adolescents and young adults smoke waterpipe tobacco (WT) and cigarillos, at least in part, based on erroneous beliefs that these products are safer than cigarettes. To address this challenge, we used a systematic, three-phase process to develop a health communication campaign to discourage WT and cigarillo smoking among at-risk (tobacco users and susceptible non-users) 16- to 25-year-olds. In Phase 1, we used a national phone survey (N = 896) to determine salient message beliefs. Participants reported constituents (i.e., harmful chemicals) emitted by the products were worrisome. In Phase 2, we developed and evaluated four message executions, with varying imagery, tone, and unappealing products with the same constituents, using focus groups (N = 38). Participants rated one execution highly, resulting in our development of a campaign where each message: (1) identified a tobacco product and constituent in the smoke; (2) included an image of an unappealing product containing the constituent (e.g., pesticides, gasoline) to grab attention; and (3) used a humorous sarcastic tone. In Phase 3, we tested the campaign messages (17 intervention and six control) with a nationally representative online survey (N = 1,636). Participants rated intervention and control messages highly with few differences between them. Exposure to messages resulted in significant increases in all risk beliefs from pre to post (p < 0.05). For WT, intervention messages increased beliefs about addiction more than control messages (p < 0.05). This systematic, iterative approach resulted in messages that show promise for discouraging WT and cigarillo use.

Polytobacco Use Among a Nationally Representative Sample of Adolescent and Young Adult E-Cigarette Users.

PURPOSE: Electronic nicotine delivery systems (ENDS) are adolescents' most commonly used tobacco product and young adults' second most used. Little is known about ENDS use alongside other tobacco products (polytobacco use) and whether exclusive ENDS users differ from polytobacco ENDS users. METHODS: In spring 2016, we surveyed a nationally representative sample of 3,517 13-25-year olds (36.9% 13-17-year olds), and examined sociodemographic and relative risk perceptions between two groups of past 30-day ENDS users: exclusive (only ENDS) and polytobacco (ENDS and at least one other tobacco product). RESULTS: 4.5% of adolescents and 10% of young adults reported past 30-day ENDS use (n = 281; analytic sample). ENDS users were 38.8% female and 70.6% white. Over half (55.9%) were polytobacco ENDS users. The most common patterns of polytobacco ENDS use were ENDS and cigarettes (11.5%), ENDS and cigars (7.7%), and ENDS, cigars, and waterpipe (5.2%). Those who perceived ENDS to be less harmful than cigarettes were more likely to be exclusive ENDS users than those who perceived ENDS to be as or more harmful than cigarettes (adjusted odds ratio = 2.6, confidence interval = 1.2, 5.7). There were no differences between ENDS groups on age, race, sex, parental education, sexual orientation, or ENDS use frequency. CONCLUSIONS: Just over half of ENDS users also used other tobacco products, increasing their risk for nicotine addiction and other health harms. The Food and Drug Administration is responsible for communicating product risk to consumers and should consider common patterns of use and relative risk perceptions in its ENDS public education efforts.

Adolescents' First Tobacco Product: Results from a Nationally Representative Survey.

OBJECTIVES: To inform targeted prevention efforts, it is important to understand which tobacco products are used first and associations by demographic characteristics. METHODS: We conducted a nationally-representative random digit-dial telephone survey of 1125 adolescents ages 13-17. Adolescents reported the first tobacco product they tried, and we analyzed associations with demographic variables. RESULTS: Two-hundred nineteen (18.6%) adolescents reported ever using a tobacco product. The most common first product tried was cigarettes (35.4%), followed by electronic nicotine delivery systems (24.3%), smokeless tobacco (17.7%), cigars (11.4%), and waterpipe (11.2%). Weighted multivariable logistic regression analyses showed girls were 2.7 times more likely than boys to report cigarettes as their first product, Hispanic/Latinos were 5.0 times more likely than non-Hispanic/Latinos to report cigarettes, and those whose mothers had at least a 4-year college degree were 6.1 times more likely to report waterpipe compared to those whose mothers had less than a 4-year college degree. CONCLUSIONS: Nearly one in 5 adolescents had tried a tobacco product. Although cigarettes were the most frequently reported product, most youth initiated with a non-cigarette tobacco product, and demographic differences were found. These findings point towards potential regulatory policies, including targeted campaigns, which might deter adolescents from initiating tobacco use.

Adolescent and Young Adult Perceptions of Hookah and Little Cigars/Cigarillos: Implications for Risk Messages.

Use of hookah and little cigars/cigarillos (LCCs) is high among adolescents and young adults. Although these products have health effects similar to cigarettes, adolescents and young adults believe them to be safer. This study examined adolescent and young adult perceptions of hookah and LCCs to develop risk messages aimed at discouraging use among users and at-risk nonusers. Ten focus groups with 77 adolescents and young adults were conducted to explore their perceptions about the perceived risks and benefits of hookah and LCC use. Participants were users of other (non-cigarette) tobacco products (n = 47) and susceptible nonusers (n = 30). Transcripts were coded for emergent themes on participants' perceptions of hookah and LCCs. Participants did not perceive health effects associated with hookah and LCC use to be serious or likely to happen given their infrequency of use and perceptions that they are less harmful than cigarettes. Participants generally had positive associations with smoking hookah and LCCs for several reasons, including that they are used in social gatherings, come in various flavors, and can be used to perform smoke tricks. Because adolescents and young adults underestimate and discount the long-term risks associated with hookah and LCC use, effective messages may be those that focus on the acute/immediate health and cosmetic effects.

E-cigarettes, Hookah Pens and Vapes: Adolescent and Young Adult Perceptions of Electronic Nicotine Delivery Systems.

INTRODUCTION: Most studies have assessed use of "e-cigarettes" or "electronic cigarettes," potentially excluding new electronic nicotine delivery systems (ENDS), such as e-hookahs and vape pens. Little is known about how adolescents and young adults perceive ENDS and if their perceptions vary by sub-type. We explored ENDS perceptions among these populations. METHODS: Ten focus groups with 77 adolescents and young adults, ages 13-25, were conducted in spring 2014. Participants were users or susceptible nonusers of novel tobacco products. Focus group transcripts were coded for emergent themes. RESULTS: Participants reported positive ENDS attributes, including flavor variety; user control of nicotine content; and smoke trick facilitation. Negative attributes included different feel compared to combustible cigarettes, nicotine addiction potential, and no cue to stop use. Participants perceived less harm from ENDS compared to combustible cigarettes, perhaps due to marketing and lack of product regulation, but noted the uncertainty of ingredients in ENDS. Numerous terms were used to describe ENDS, including "e-cigarette," "e-hookah," "hookah pens," "tanks," and "vapes." Although no clear classification system emerged, participants used product characteristics like nicotine content and chargeability to attempt classification. Perceptions differed by product used. E-hookah users were perceived as young and trendy while e-cigarette users were perceived as old and addicted to nicotine. CONCLUSIONS: Young adults and adolescents report distinct ENDS sub-types with varying characteristics and social perceptions of users. Although they had more positive than negative perceptions of ENDS, prevention efforts should consider highlighting negative attributes as they may discourage use and product trial among young nonusers. IMPLICATIONS: Our study underscores the need for a standardized measurement system for ENDS sub-types and additional research on how ENDS sub-types are perceived among adolescents and young adults. In addition, our findings highlight negative product attributes reported by participants that may be useful in prevention and regulatory efforts to offset favorable marketing messages.

Adolescents' and Young Adults' Knowledge and Beliefs About Constituents in Novel Tobacco Products.

INTRODUCTION: Novel tobacco products, such as little cigars, cigarillos, hookah, and e-cigarettes, and their smoke or aerosol contain chemicals which the FDA has determined to be Harmful or Potentially Harmful Constituents. We explored adolescents' and young adults' knowledge and beliefs about constituents in novel tobacco products and their smoke or aerosol, in order to inform risk communication messages. METHODS: Seventy-seven adolescents and young adults (ages 13-25) participated in 10 focus groups, including 47 novel tobacco product users and 30 susceptible nonusers. Participants were asked to discuss 10 pre-selected constituents found in novel tobacco products and their smoke or aerosol. The first author analyzed the discussion for emergent themes. RESULTS: Participants were generally familiar with arsenic, carbon monoxide, formaldehyde, and nicotine, but unfamiliar with acetaldehyde, acrolein, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanon (NNK), and N-nitrosonornicotine (NNN). All participants had negative beliefs about most constituents, although users had positive beliefs about nicotine. "Unfamiliar" constituents were associated with similarly-sounding words (eg, acetaldehyde sounds like acetaminophen), and some participants recognized words in the chemical names of NNK/NNN (eg, "nitro"). "Familiar" constituents were associated with negative health effects and other common products the constituents are found in. All participants wanted more information about the constituents' health effects, toxicity, and other common products. Most participants were unaware the constituents discussed are in novel tobacco products and their smoke or aerosol. CONCLUSIONS: Risk communication messages could capitalize on negative associations with familiar constituents, or attempt to educate about unfamiliar constituents, to discourage novel tobacco product use among adolescents and young adults. IMPLICATIONS: The results of this study have implications for how the FDA and other agencies can communicate about the risks of novel tobacco products to the general public, which will be particularly important once the Deeming Rule is finalized. Our findings suggest it may be effective to capitalize on the public's negative beliefs about and associations with familiar constituents, or to educate about unfamiliar constituents and their health effects, their concentration and toxicity in novel tobacco products and their smoke or aerosol, and other products they are found in.

Improving Physical Activity in Hispanics with Diabetes and their Families.

OBJECTIVE: This study examined changes in physical activity among Hispanics with diabetes and their families who received an 8-week diabetes self-management intervention. DESIGN: A quasi-experimental design was used to conduct a secondary analysis of physical activity data from two intervention studies that used the same protocols and measures. SAMPLE: A total of 65 patients and 66 family members participated in the studies. MEASURES: Physical activity was measured with the International Physical Activity Questionnaire (IPAQ) and pedometers. Self-report of physical activity was collected pre- and postintervention, and pedometer data for the 8 weeks of the intervention period. INTERVENTION: The interventions consisted of 8 weeks of educational sessions. RESULTS: IPAQ walking Metabolic Equivalent of Task (MET)-minutes per week significantly increased for patients (p < .001) and family members (p < .001) from pre- to postintervention as did moderate activity MET-minutes/week for family members (p = .004). Based on pedometer steps, the percentage of sedentary patients declined from 38% to 17% over the intervention record; differences in pedometer steps over time were not significant for patients (p = .803) or family members (p = .144). CONCLUSIONS: Pedometers are a cost effective and user-friendly method of measuring physical activity. Pedometers can also serve as a motivator to help increase physical activity among Hispanics with diabetes and their family members.