The use of online methods to recruit and follow a hard-to-reach population in the Peer Alternatives for Addiction Study 2021 Cohort.

BACKGROUND: Although studies are increasingly adopting online protocols, few such studies in the addiction field have comprehensively described their data review procedures and successes in detecting low-quality/fraudulent data. The current study describes data collection protocols and outcomes of a large, longitudinal study (the PAL Study 2021) that implemented online design elements to study individuals seeking peer support for an alcohol use disorder. METHODS: In 2021, the PAL Study collaborated with mutual-help group (MHG) partners and recovery-related organizations to recruit individuals attending a 12-step group, Women for Sobriety (WFS), LifeRing Secular Recovery, and/or SMART Recovery for an alcohol problem in-person and/or online in the prior 30 days. Participation was solicited both online and in-person. Individuals accessed baseline surveys via an open web link; follow-ups occurred at 6 and 12 months. Analyses included calculating the proportion of surveys eliminated in data quality review; comparing MHG subsamples to internal survey (benchmark) data for Alcoholics Anonymous (AA), WFS, LifeRing, and SMART; and examining response rates and attrition. RESULTS: Although 93% of respondents who opened the baseline survey completed it, 87% of baseline surveys were eliminated in data quality review (final N = 531). Nonetheless, cleaned MHG subsamples were generally similar to benchmark samples on gender, age, race/ethnicity, and education. Follow-up rates for the cleaned sample were 88% (6 months) and 85% (12 months). Analyses revealed some differences in attrition by gender, primary MHG, and lifetime drug problems, but there was no evidence of greater attrition among those in earlier/less stable recovery. CONCLUSIONS: Study methods appear to have produced a valid, largely representative sample of the hard-to-reach target population that was successfully followed across 12 months. However, given the high survey elimination rate and need for extensive data review, we recommend that researchers avoid open-link designs and include comprehensive data review when incorporating online design elements.

Mode of mutual-help group attendance: Predictors and outcomes in a US national longitudinal survey of adults with lifetime alcohol use disorder.

INTRODUCTION: Although attending substance use-focused mutual-help meetings online may reduce attendance barriers, associations of attendance mode with group participation and outcomes are unknown. Using longitudinal data from mutual-help group attendees, this study, after identifying differences in baseline characteristics by attendance mode, examined associations of attendance mode with mutual-help participation (number of meetings attended, involvement) and outcomes (alcohol abstinence, heavy drinking, alcohol problems). METHODS: The Peer Alternatives for Addiction Study 2021 Cohort sampled attendees of 12-step groups (e.g., Alcoholics Anonymous), Women for Sobriety, LifeRing Secular Recovery, and/or SMART Recovery in-person and/or online within 30 days before baseline. The baseline sample, recruited in fall 2021, was 531 adults with lifetime alcohol use disorder, followed at 6 (88 %) and 12 months (85 %). Differences in baseline characteristics by attendance mode were tested using Chi-squares and ANOVAs. GEE models examined associations of attendance mode, time, and their interactions with mutual-help group participation and alcohol outcomes. The in-person only mode was compared to the online-only, and to the in-person plus online, modes. RESULTS: At baseline, 53.7 % of participants had attended only online meetings in the past 30 days, 33.7 % had attended both in-person and online meetings, and 12.6 % had attended only in-person meetings. Online meeting attendees were less likely to endorse lifetime abstinence as an alcohol recovery goal than in-person-only meeting attendees. In adjusted models (including for recovery goal), those attending online meetings only, or both online and in-person meetings, attended a greater number of meetings compared to those attending only in-person meetings. However, online-only attendance was associated with less involvement than in-person-only attendance. In adjusted models, compared to baseline, involvement increased and outcomes improved at follow-ups. Adjusted models examining alcohol outcomes found that no attendance at mutual-help groups at follow-ups was associated with more heavy drinking compared to in-person-only attendance. CONCLUSIONS: Findings inform efforts to ascertain benefits of mutual-help group participation by suggesting that online attendance is associated with attending more meetings, less involvement, and lower endorsement of abstinence as a recovery goal, and is comparable to in-person attendance on alcohol outcomes. In-person attendance may be more beneficial for less heavy drinking than terminating attendance.

Intersectional disparities in outpatient alcohol treatment completion by gender and race and ethnicity.

BACKGROUND: Untreated alcohol use disorder (AUD) can have negative outcomes, including premature death. Completing specialty treatment for AUD can improve economic and educational outcomes. However, there are large racial and ethnic disparities in treatment completion, and how these disparities vary intersectionally (e.g., by gender and race and ethnicity) is unknown. Recent studies suggest that not using an intersectional approach can mask important disparities. We estimated disparities in AUD nonintensive outpatient treatment completion by gender alone, race and ethnicity alone, and intersectionally in a gender-by-race-and-ethnicity model. Accurately quantifying treatment completion disparities is critical not only for understanding healthcare disparities but reducing them to advance health equity. METHODS: Data are from SAMHSA's 2017 to 2019 Treatment Episode Dataset-Discharges for adults aged 18+ who entered nonintensive outpatient treatment primarily for alcohol (n = 559,447 episodes; 30.3% women; 63.7% White, 18.0% Black, 14.4% Hispanic/Latinx, 2.1% American Indian/Alaska Native [AIAN], 1.0% Asian/Pacific Islander). Using the rank-and-replace method, treatment completion disparities were estimated by gender, race and ethnicity, and gender-by-race-and-ethnicity due to any reason other than differences in need for treatment, consistent with the Institute of Medicine's definition of a healthcare disparity. RESULTS: The intersectional gender-by-race-and-ethnicity model identified the widest range of disparities among all models tested. Using this model, the largest disparities were identified for minoritized women's treatment episodes. Compared to White men whose completion rate was 60.79% (95% confidence interval [CI]: 60.06, 60.98), Black, Hispanic/Latina, AIAN, and Asian-American/Pacific Islander women had treatment episode completion rates that were 12.35 (CI: 12.33, 12.37), 9.08 (CI: 9.06, 9.11), 10.27 (CI: 10.22, 10.32), and 4.87 (CI: 4.78, 4.95) percentage points lower, respectively. CONCLUSIONS: In the United States, treatment completion rates for non-intensive outpatient alcohol treatment episodes are significantly lower for minoritized women than White men. The extent of the disparity is not apparent in univariate models, highlighting the importance of an intersectional approach to understanding disparities in the completion of non-intensive outpatient treatment for AUD.

Residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling by adults with lower incomes: Is increased access to primary care enough?

BACKGROUND: We investigate whether living in a state that expanded Medicaid eligibility is associated with receiving alcohol screening and brief counseling among nonelderly, low-income adults and a subgroup with chronic health conditions caused or exacerbated by alcohol use. METHOD: Data are from the 2017 and 2019 Behavioral Risk Factor Surveillance System (N = 15,743 low-income adults; n = 7062 with a chronic condition). We used propensity score-weighted, covariate-adjusted, modified Poisson regression to estimate associations between residence in a Medicaid-expansion state and receipt of alcohol screening and brief counseling. Models estimated associations in the overall sample and chronic conditions subsample, as well as differential associations across sex, race, and ethnicity using interaction terms. RESULTS: Living in a state that expanded Medicaid eligibility was associated with being asked whether one drank (prevalence ratio (PR) = 1.15, 95% confidence interval (CI) = 1.08, 1.22), but not with further alcohol screening, guidance about harmful drinking, or advice to reduce drinking. Among individuals with alcohol-related chronic conditions, expansion state residence was associated with being asked about drinking (PR = 1.13, 95% CI = 1.05, 1.20) and, among past 30-day drinkers with chronic conditions, being asked how much one drank (PR = 1.28, 95% CI = 1.04, 1.59) and about binge drinking (PR = 1.43, 95% CI = 1.03, 1.99). Interaction terms suggest that some associations differ by race and ethnicity. CONCLUSIONS: Living in a state that expanded Medicaid is associated with a higher prevalence of receiving some alcohol screening at a check-up in the past 2 years among low-income residents, particularly among individuals with alcohol-related chronic conditions, but not with the receipt of high-quality screening and brief counseling. Policies may have to address provider barriers to delivery of these services in addition to access to care.

Adolescent Tobacco Uptake and Other Substance Use: A Latent Class Analysis.

Objective: The purpose of this study was to identify patterns of tobacco uptake and other substance use, from early to late adolescence. Methods: We used weighted latent class analysis, conducted separately for 7th, 9th, and 11th graders, to assess patterns of susceptibility, ever and current use of combustible tobacco and e-cigarettes, and other substance use (ie, current alcohol, binge drinking, and marijuana). Data were from Wave 3 of the Texas Adolescent Tobacco and Marketing Surveillance System (n = 2733; N = 461,069), collected in fall 2015. Multinomial regression was used to examine differences in class membership by demographic factors. Results: Two latent classes were identified in 7th grade, 3 classes in 9th grade, and 4 classes in 11th grade models. In each grade, classes included both a "no risk" and a "tobacco susceptible" class. For 9th grade, there was an additional "tobacco ever use" class, and 11th grade had the same additional class as well as an "all products use" class. Conclusion: Distinct patterns of polysubstance use emerged as grade level increased, supporting a stage-sequential model of onset and progression across developmental age groups. Future research can examine other factors affecting transitions across these stages.

Positive Outcome Expectations and Tobacco Product Use Behaviors in Youth.

BACKGROUND: Outcome expectations are an important determinant of health behavior, according to Social Cognitive Theory; yet recent literature has not examined the relationship between outcome expectations and tobacco product use (e.g., use of cigarettes, cigars, hookah, e-cigarettes, or smokeless tobacco). OBJECTIVES: This study examines if outcome expectations at baseline, among an adolescent cohort of never users of tobacco products, predicts tobacco product use (i.e., cigarettes, hookah, e-cigarette, cigar, or smokeless tobacco) or susceptibility to use at 6-month follow-up. METHODS: Data are from the first two waves of a Texas cohort study of urban middle school and high school students, which were collected in 2014-2015. Logistic regression analyses were used; these adjusted for socio-demographic variables. Analyses were limited to never users of any tobacco product at baseline (n = 1999, N = 357,035). RESULTS: Outcome expectations related to stress relief predicted ever use of (AOR: 4.21, 95% CI 1.84-9.60) and susceptibility (AOR: 2.97, 95% CI 1.01-8.70) to tobacco products. Additional outcome expectations (e.g., relaxation, concentration, slimness, etc.) were not associated with ever use or susceptibility. Conclusions/Importance: This study extends the literature regarding outcome expectations among adolescents regarding tobacco products. It is important that interventions offer alternative solutions to stress relief that do not include tobacco products.

Weight Status and Cigarette and Electronic Cigarette Use in Adolescents.

INTRODUCTION: Research shows that adolescents who are overweight or obese may be at greater risk of cigarette smoking, and that this relationship may vary by gender. However, this relationship is understudied for electronic cigarettes (e-cigarettes). Given the high rate of adolescent obesity and the rise in e-cigarette use in adolescents, this relationship should be investigated. METHODS: Data are from the third wave (collected October 2015-January 2016) of the Texas Adolescent Tobacco and Marketing Surveillance system. Students were in the seventh, ninth, and 11th grades (n=2,733) from five counties surrounding four major Texas metropolitan areas (Houston, Austin, San Antonio, Dallas). Weighted logistic regression was used to determine if weight status (healthy weight, overweight, or obese) was correlated with ever and past 30-day cigarette or e-cigarette use, controlling for sociodemographics. Models were stratified by gender. Data analyses were conducted in March 2017. RESULTS: Compared with healthy-weight boys, obese boys had higher odds of past 30-day e-cigarette use (AOR=3.45, 95% CI=1.34, 8.33) and cigarette smoking (AOR=4.52, 95% CI=1.32, 15.51). There was no significant relationship between weight status and cigarette or e-cigarette use in girls. CONCLUSIONS: This study supports that there is a positive relationship between weight status and past 30-day cigarette and e-cigarette use for boys, but that there is no association for girls.

Texas Adolescent Tobacco and Marketing Surveillance System's Design.

OBJECTIVES: To provide a full methodological description of the design of the wave I and II (6-month follow-up) surveys of the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS), a longitudinal surveillance study of 6th, 8th, and 10th grade students who attended schools in Bexar, Dallas, Tarrant, Harris, or Travis counties, where the 4 largest cities in Texas (San Antonio, Dallas, Fort Worth, Houston, and Austin, respectively) are located. METHODS: TATAMS used a complex probability design, yielding representative estimates of these students in these counties during the 2014-2015 academic year. Weighted prevalence of the use of tobacco products, drugs and alcohol in wave I, and the percent of: (i) bias, (ii) relative bias, and (iii) relative bias ratio, between waves I and II are estimated. RESULTS: The wave I sample included 79 schools and 3,907 students. The prevalence of current cigarette, e-cigarette and hookah use at wave I was 3.5%, 7.4%, and 2.5%, respectively. Small biases, mostly less than 3.5%, were observed for nonrespondents in wave II. CONCLUSIONS: Even with adaptions to the sampling methodology, the resulting sample adequately represents the target population. Results from TATAMS will have important implications for future tobacco policy in Texas and federal regulation.

Exposure and Engagement With Tobacco- and E-Cigarette-Related Social Media.

PURPOSE: Little is known about the nature and extent of adolescents' exposure to tobacco- and e-cigarette-related communications on social media. In this study, we describe the prevalence and correlates of youth exposure and engagement with tobacco- and e-cigarette-related social media. METHODS: Data are from the baseline survey of the Texas Adolescent Tobacco and Marketing Surveillance system, a cross-sectional sample of sixth, eighth, and 10th graders (n = 3907, N = 461,097). Weighted logistic regression models were used to examine associations between demographic characteristics, sensation seeking, tobacco use, and exposure and engagement with tobacco-related social media. RESULTS: Overall, 52.5% of students reported exposure to tobacco-related social media in the past month, whereas < 6% reported engagement. Exposure and some forms of engagement were more common among high school students, girls, those with friends who use tobacco, and high sensation seekers (p < .05). The odds of exposure were significantly higher among students susceptible to combustible tobacco (adjusted odds ratio [AOR] = 1.71, p < .05), e-cigarettes (AOR = 2.10, p < .01), and both combustible tobacco and e-cigarettes (AOR = 2.24, p < .001). The odds of engaging with social media was higher among those who were susceptible to, had ever, or currently use both combustible tobacco and e-cigarettes (AOR = 2.10-3.46, p < .05). CONCLUSIONS: About 1 in every 2 adolescents in Texas are exposed to tobacco-related social media. Adolescents who are susceptible to or use e-cigarettes and/or combustible tobacco are exposed to and engage with tobacco-related social media more than their peers. Social media appears to be an important venue when targeting vulnerable youth in prevention campaigns.

Implementation of a Computerized Tablet-Survey in an Adolescent Large-Scale, School-Based Study.

BACKGROUND: Computerized surveys present many advantages over paper surveys. However, school-based adolescent research questionnaires still mainly rely on paper-and-pencil surveys as access to computers in schools is often not practical. Tablet-assisted self-interviews (TASI) present a possible solution, but their use is largely untested. This paper presents a method for and our experiences with implementing a TASI in a school setting. METHODS: A TASI was administered to 3907 middle and high school students from 79 schools. The survey assessed use of tobacco products and exposure to tobacco marketing. To assess in-depth tobacco use behaviors, the TASI employed extensive skip patterns to reduce the number of not-applicable questions that nontobacco users received. Pictures were added to help respondents identify the tobacco products they were being queried about. RESULTS: Students were receptive to the tablets and required no instructions in their use. None were lost, stolen, or broken. Item nonresponse, unanswered questions, was a pre-administration concern; however, 92% of participants answered 96% or more of the questions. CONCLUSIONS: This method was feasible and successful among a diverse population of students and schools. It generated a unique dataset of in-depth tobacco use behaviors that would not have been possible through a paper-and-pencil survey.

Flavorings and Perceived Harm and Addictiveness of E-cigarettes among Youth.

OBJECTIVES: Given the increasing trend in use of electronic cigarettes ("e-cigarettes") among youth, it is crucial to understand how these products are perceived and how these perceptions are associated with their decision whether or not to use them. METHODS: This is a cross-sectional analysis of data from a rapid response surveillance system of 6th, 8th and 10th grade students' tobacco use behaviors (sample [n] = 3704 from a population of students [N] = 434,601). We used weighted logistic regression models to investigate the relationship between perceptions of harm and addictiveness and e-cigarette use, including the use of flavored and non-flavored e-cigarettes. RESULTS: Compared to youth who did not use e-cigarettes, ever and current e-cigarette users had higher odds of reporting that e-cigarettes were "not at all harmful" to health and "not at all addictive." Ever and current e-cigarette users had higher odds of reporting that flavored e-cigarettes were "less harmful" than non-flavored e-cigarettes, compared to youth who did not use e-cigarettes. CONCLUSIONS: These findings warrant attention given that nicotine is an addictive substance whose effects on the adolescent brain are potentially negative. Youth e-cigarette users perceived lower harm from flavored e-cigarettes, which is worrisome given emerging research documenting harmful constituents in certain e-cigarette flavorings.

School-level economic disadvantage and obesity in middle school children in central Texas, USA: a cross-sectional study.

BACKGROUND: Although children of lower socio-economic status (SES) in the United States have generally been found to be at greater risk for obesity, the SES-obesity association varies when stratified by racial/ethnic groups-with no consistent association found for African American and Hispanic children. Research on contextual and setting-related factors may provide further insights into ethnic and SES disparities in obesity. We examined whether obesity levels among central Texas 8th grade students (n=2682) vary by school-level economic disadvantage across individual-level family SES and racial/ethnicity groups. As a secondary aim, we compared the association of school-level economic disadvantage and obesity by language spoken with parents (English or Spanish) among Hispanic students. METHODS: Multilevel regression models stratified by family SES and ethnicity were run using cross-sectional baseline data from five school districts participating in the Central Texas CATCH Middle School project. For family SES, independent multi-level logistic regression models were run for total sample and by gender for each family SES stratum (poor/near poor/just getting by, living comfortably, and very well off), adjusting for age, ethnicity, and gender. Similarly, multi-level regression models were run by race/ethnic group (African American, Hispanic, and White), adjusting for age, family SES, and gender. RESULTS: Students attending highly economically disadvantaged (ED) schools were between 1.7 (95% CI: 1.1-2.6) and 2.4 (95% CI: 1.2-4.8) times more likely to be obese as students attending low ED schools across family SES groups (p<.05). African American (OR(Adj) =3.4, 95% CI: 1.1-11.4), Hispanic (OR(Adj)=1.8, 95% CI 1.1-3.0) and White (OR(Adj)=3.8, 95% CI: 1.6-8.9) students attending high ED schools were more likely to be obese as counterparts at low ED schools (p<.05). Gender-stratified findings were similar to findings for total sample, although fewer results reached significance. While no obesity differences across school ED categories were found for Hispanic Spanish-speaking students, Hispanic English-speaking students (HES) attending high ED schools were 2.4 times more likely to be obese as HES students at low ED schools (p=.003). CONCLUSION: Findings support the need to prioritize economically disadvantaged schools for obesity prevention efforts and support further exploration of school SES context in shaping children's physical activity and dietary behaviors.

Promoting teacher adoption of physical activity breaks in the classroom: findings of the Central Texas CATCH Middle School Project.

BACKGROUND: Research suggests that physical activity breaks (ABs) during class increase students' physical activity levels and provide an academic benefit. This study evaluates a 3-year intervention aimed at encouraging teacher AB use. METHODS: Thirty central Texas middle schools were assigned to 1 of 3 conditions: training-only (Basic), training plus facilitator support (Basic Plus), and training/facilitator support and a social marketing campaign (Basic Plus SM). Teachers completed surveys at end of years 2 (N = 1039) and 3 (N = 831) to assess exposure to program, self-efficacy, and frequency of AB use. RESULTS: At end of year 3, teachers in facilitator-supported conditions reported increased exposure, self-efficacy, and use compared to Basic condition. Only 43.2% of teachers in the Basic condition reported receiving training in ABs compared to 84.2% and 90.6% in the Basic Plus and Basic Plus SM conditions, respectively. Additionally, a greater percentage of teachers in the facilitator-support conditions reported conducting ABs weekly (Basic = 23.3%, Basic Plus = 34.4%, Basic Plus SM = 38.7%, at year 3; p < .001). CONCLUSIONS: Despite perceived barriers, including fear that ABs will detract from instructional time, the intervention was successful in having a core group of teachers implement them weekly. More research is needed to increase the percentage of teachers implementing ABs regularly.

Promoting energy-balance behaviors among ethnically diverse adolescents: overview and baseline findings of The Central Texas CATCH Middle School Project.

The Central Texas Coordinated Approach To Child Health (CATCH) Middle School Project is a 3.5-year school-based project aimed at promoting physical activity (PA), healthy eating, and obesity prevention among public middle school students in Texas. This article describes the CATCH intervention model and presents baseline findings from spring 2009. CATCH comprises six core components: CATCH Team, CATCH PE, CATCH Classroom, CATCH Eat Smart Cafeteria, CATCH Family, and CATCH Social Marketing. A group randomized serial cross-sectional design is being employed to test the effect of three program support conditions (n = 10 schools each) on energy-balance behaviors: Basic (training and curriculum only), Basic Plus (training and curriculum plus CATCH facilitator support), and Basic Plus Social Marketing (all inputs plus social marketing component). The study sample is composed of a cross-sectional sample of eighth-grade students (primary outcome evaluation sample) and sixth- and seventh-grade students (PE process evaluation sample) who are selected and measured each year. At baseline, 37.9% of eight-grade students (n = 2,841; 13.9 years) were overweight/obese and 19.2% were obese. Eighth-grade students reported, on average, consuming sugar-sweetened beverages more than two times on the previous day and fruits and vegetables roughly three times on the previous day; only two of five school districts surpassed the recommended 50% cut-point for class time spent in moderate-and-vigorous PA as measured in classes of sixth- and seventh-grade students. Additional behavioral findings are reported. Body mass index and behaviors were comparable across conditions. Baseline findings underscore the need to promote student energy-balance behaviors.

Promoting physical activity and fruit and vegetable consumption through a community-school partnership: the effects of Marathon Kids® on low-income elementary school children in Texas.

BACKGROUND: Marathon Kids® (MK) is a community and school-based program that promotes running, walking, and healthy eating in elementary school children. This study assessed the impact of MK on self-reported physical activity (PA), fruit and vegetable consumption (FVC), and related psycho-social factors in a sample of low-income, 4th- and 5th-grade students in Texas (n = 511). Intervention strategies included structured school running time, behavioral tracking, celebratory events, and rewards. METHODS: A quasi-experimental design with 5 intervention (MK) and 3 comparison schools was employed. Students were assessed at baseline in the fall and at 3 time points during 2008 to 09. Mixed-effect regression methods were used to model pooled means, adjusting for baseline and sociodemographic variables. RESULTS: MK students reported a higher mean time of running in past 7 days compared with non-MK students (mean = 4.38 vs. 3.83, respectively. P = .002), with a standardized effect size of 0.16. Mean times of FVC (P = .008), athletic identity self-concept (P < .001), PA outcome expectations (P = .007), and PA and FVC self-efficacy (P < .001 and P = .02, respectively) were also higher in MK students. Fewer differences in social support were observed. CONCLUSION: Findings provide further evidence on the importance of community and school partnerships for promoting PA and healthy eating in children.