How should we define "rural" when investigating rural tobacco use in the United States?

Purpose: Investigations into rural tobacco-related disparities in the U.S. are hampered by the lack of a standardized approach for identifying the rurality-and, consequently, the urbanicity-of an area. Therefore, the purpose of this study was to compare the most common urban/rural definitions (Census Bureau, OMB, RUCA, and Isolation) and determine which is preferable for explaining the geographic distribution of several tobacco-related outcomes (behavior, receiving a doctor's advice to quit, and support for secondhand smoke policies). Methods: Data came from The Current Population Survey Tobacco Use Supplement. For each tobacco-related outcome, one logistic regression was conducted for each urban/rural measure. Models were then ranked according to their ability to explain the data using Akaike information criterion (AIC). Results: Each definition provided very different estimates for the prevalence of the U.S. population that is considered "rural" (e.g., 5.9% for the OMB, 17.0% for the Census Bureau). The OMB definition was most sensitive at detecting urban/rural differences, followed by the Isolation scale. Both these measures use strict, less-inclusive criteria for what constitutes "rural." Conclusions: Overall, results demonstrate the heterogeneity across urban/rural measures. Although findings do not provide a definitive answer for which urban/rural definition is the best for examining rural tobacco use, they do suggest that the OMB and Isolation measures may be most sensitive to detecting many types of urban/rural tobacco-related disparities. Caveats and implications of these findings for rural tobacco use disparities research are discussed. Efforts such as these to better understand which rural measure is appropriate for which situation can improve the precision of rural substance use research.

Community Engagement to Address Cancer Health Disparities: A Process EVALUATION using the Partnership Self-Assessment Tool.

BACKGROUND: African Americans suffer disproportionately from cancer health disparities, and population-level prevention is needed. OBJECTIVES: A community-academic partnership to address cancer health disparities in two predominately African American jurisdictions in Maryland was evaluated. METHODS: The Partnership Self-Assessment Tool (PSAT) was used in a process evaluation to assess the partnership in eight domains (partnership synergy, leadership, efficiency, management, resources, decision making, participation, and satisfaction). RESULTS: Mean scores in each domain were high, indicative of a functional and synergistic partnership. However, scores for decision making (Baltimore City's mean score = 9.3; Prince George's County's mean score = 10.8; p = .02) and participation (Baltimore City's mean score = 16.0; Prince George's County's mean score = 18.0; p = .04) were significantly lower in Baltimore City. CONCLUSIONS: Community-academic partnerships are promising approaches to help address cancer health disparities in African American communities. Factors that influence decision making and participation within partnerships require further research.

Regional Rural-Urban Differences in E-Cigarette Use and Reasons for Use in the United States.

PURPOSE: To determine whether there are rural/urban differences in e-cigarette use and reasons for use that vary across the 10 Health & Human Services (HHS) regions. METHODS: Age-adjusted bivariate and multivariable analyses were conducted for n = 225,413 respondents to the 2014-2015 Tobacco Use Supplement-Current Population Survey to estimate the prevalence of e-cigarette use. Reasons for e-cigarette use were collected from n = 16,023 self-respondents who reported ever using e-cigarettes. FINDINGS: While nationally rural residents appeared more likely to use e-cigarettes, adjusted results indicated that current e-cigarette use was significantly less likely across the northern and western regions (New England, East North Central, Heartland, North Central Mountain, Northwest, and Southwest Pacific regions). Reasons for e-cigarette use differed by urban/rural status and region; for example, the rationale to use e-cigarettes as a smoking cessation aid was significantly more common among rural compared to urban adults in the New England and New York/New Jersey regions, but less common in the Southeast. CONCLUSIONS: For several regions, there were no significant rural/urban differences in e-cigarette use and reasons for use. Yet those regions that present differences face the need to develop public health approaches to minimize urban/rural disparities in health education, services, and outcomes related to tobacco use, particularly where access to health care is limited. Public health campaigns and guidance for clinical care within HHS regions should be tailored to reflect regional differences in beliefs about e-cigarettes.

E-cigarettes in airports and on flights: Europe and the US. / Cigarrillos electrónicos en aeropuertos y en vuelos: Europa y EEUU.

BACKGROUND: While progress has been made to create smoke-free airports, sales of e-cigarettes at airports and airplanes and the presence of advertisements might detract from these smoke-free policies. The objective of this study is to describe the presence of policies, advertising, sales and use of e-cigarettes in airports and on flights in Europe and the US. METHODS: A cross-sectional study was conducted between March-May, 2014. The study included 21 large and mid-sized airports of Europe and the US as well as 19 flights. A standardised protocol was used to observe points of sales and advertisements and to collect information on the implementation of policies on e-cigarette use. In addition, a series of questions were developed to obtain policy details from airport personnel and flight attendants. RESULTS: Retail outlets selling e-cigarettes in airports were present in approximately 20% and 40% of the observed pre and post-security areas, respectively. In post-security, 27.8% of the airport staff reported that the use of e-cigarettes indoors was not allowed, 22.2% reported that they did not know, 27.8% reported that it was only allowed in the smoking room, and 22.2% reported that it was allowed anywhere. Smoking ban announcements were made on all flights. However, only 15.8% of the flights made a specific announcement regarding the ban of using e-cigarettes. Conclusions. In light of our results, it seems necessary to reinforce in-flight e-cigarette smoking ban announcements and to instruct airport employees about the existence of e-cigarette smoking policies. Furthermore, airports themselves should also be encouraged to adopt smoke-free policies.

Antecedentes. Pese a los avances en las políticas libres de humo en los aeropuertos, las ventas de cigarrillos electrónicos en aeropuertos y aviones y la presencia de publicidad pueden suponer un paso atrás en la implementación de dichas políticas. El objetivo de este estudio es describir la presencia de políticas, publicidad, ventas y el uso de cigarrillos electrónicos en aeropuertos y en vuelos de Europa y los EE.UU.Métodos. Estudio transversal realizado entre marzo y mayo del año 2014. El estudio incluyó 21 aeropuertos grandes y medianos de Europa y los EE.UU., así como 19 vuelos. Se utilizó un protocolo estandarizado para observar puntos de venta y publicidad y se recogió información sobre la implementación de políticas sobre el uso de cigarrillos electrónicos. Además, obtuvo información más detallada del personal del aeropuerto y de los asistentes de vuelo sobre las políticas de uso de cigarrillo electrónicos.Resultados. Los puntos de venta de cigarrillos electrónicos en los aeropuertos estaban presentes en aproximadamente el 20% y el 40% de las áreas observadas antes y después del control de seguridad, respectivamente. Después del control, el 27,8% del personal del aeropuerto declaró que no estaba permitido el uso los cigarrillos electrónicos en el interior, el 22,2% declaró que no sabía si se podían usar, el 27,8% declaró que sólo estaba permitido en el área de fumadores y el 22,2% declaró que se podía fumar en cualquier parte. Todos los vuelos anunciaron la prohibición de fumar. Sin embargo, sólo el 15,8% de los vuelos específicamente anunció la prohibición de usar cigarrillos electrónicos.Conclusiones. Nuestros resultados muestran que sería necesario reforzar los avisos de prohibición del uso de cigarrillos electrónicos durante los vuelos y de instruir a los empleados del aeropuerto sobre la existencia de políticas sobre el uso de cigarrillos electrónicos. Además, también se debería promover políticas libres de humo sin excepciones en todos los aeropuertos.

Validation of a new continuous geographic isolation scale: A tool for rural health disparities research.

The purpose of this study was to develop and test a new continuous measure for rural health disparities research that characterizes geographic areas according to a perspective of access to resources. We call the measure Isolation and anticipate it will be useful as an alternative to commonly used rural classification schemes (e.g., the Census Bureau's measure). Following the best known standards for measuring rurality, it captures the trade-off between access to resource-rich, high-population-density areas and the cost of travel to those areas; thus even intrinsically low-resource areas may have high access to nearby resources. Validity was tested with proxies such as distance to hospitals, physician availability, and access to high quality food. The Isolation scale demonstrated good construct validity (i.e., both convergent and criterion validity). Fit statistics indicated that, compared to other commonly-used urban/rural definitions, the Isolation scale was the best overall measure when predicting several proxies for rurality, even when categorized. We also show that the measure does a substantially better job at explaining national health outcome data at the state level. This new continuous Isolation scale shows considerable promise for improving our conceptualization, theorization, and measurement of the features of rurality that are pertinent to rural health disparities research, and can also be useful to policy makers who may find value in using isolation thresholds that are most relevant to their policy planning needs.

Variations in support for secondhand smoke restrictions across diverse rural regions of the United States.

Significant disparities exist between rural-urban U.S. POPULATIONS: Besides higher smoking rates, rural Americans are less likely to be protected from SHS. Few studies focus across all regions, obscuring regional-level differences. This study compares support for SHS restrictions across all HHS regions. DATA: 2014/15 TUS-CPS; respondents (n = 228,967): 47,805 were rural residents and 181,162 urban. We examined bi-variates across regions and urban-rural adjusted odds ratios within each. Smoking inside the home was assessed along with attitudes toward smoking in bars, casinos, playgrounds, cars, and cars with kids. Urban respondents were significantly more supportive of all SHS policies: (e.g. smoking in bars [57.9% vs. 51.4%]; support for kids in cars [94.8% vs. 92.5%]. Greatest difference between urban-rural residents was in Mid-Atlantic (bar restrictions) and Southeast (home bans): almost 10% less supportive. Logistic regression confirmed rural residents least likely, overall, to support SHS in homes (OR = 0.78, 95% CI 0.74, 0.81); in cars (OR = 0.87, 95% CI 0.79, 0.95), on playgrounds (OR = 0.88, 95% CI.83, 0.94) and in bars OR = 0.88, 95% CI 0.85, 0.92), when controlling for demographics and smoking status. South Central rural residents were significantly less likely to support SHS policies-home bans, smoking in cars with kids, on playgrounds, in bars and casinos; while Heartland rural residents were significantly more supportive of policies restricting smoking in cars, cars with kids and on playgrounds. Southeast and South Central had lowest policy score with no comprehensive state-level SHS policies. Understanding differences is important to target interventions to reduce exposure to SHS and related health disparities.

Application of the Consolidated Framework for Implementation Research to assess factors that may influence implementation of tobacco use treatment guidelines in the Viet Nam public health care delivery system.

BACKGROUND: Services to treat tobacco dependence are not readily available to smokers in low-middle income countries (LMICs) where smoking prevalence remains high. We are conducting a cluster randomized controlled trial comparing the effectiveness of two strategies for implementing tobacco use treatment guidelines in 26 community health centers (CHCs) in Viet Nam. Guided by the Consolidated Framework for Implementation Research (CFIR), prior to implementing the trial, we conducted formative research to (1) identify factors that may influence guideline implementation and (2) inform further modifications to the intervention that may be necessary to translate a model of care delivery from a high-income country (HIC) to the local context of a LMIC. METHODS: We conducted semi-structured qualitative interviews with CHC medical directors, health care providers, and village health workers (VHWs) in eight CHCs (n = 40). Interviews were transcribed verbatim and translated into English. Two qualitative researchers used both deductive (CFIR theory driven) and inductive (open coding) approaches to analysis developed codes and themes relevant to the aims of this study. RESULTS: The interviews explored four out of five CFIR domains (i.e., intervention characteristics, outer setting, inner setting, and individual characteristics) that were relevant to the analysis. Potential facilitators of the intervention included the relative advantage of the intervention compared with current practice (intervention characteristics), awareness of the burden of tobacco use in the population (outer setting), tension for change due to a lack of training and need for skill building and leadership engagement (inner setting), and a strong sense of collective efficacy to provide tobacco cessation services (individual characteristics). Potential barriers included the perception that the intervention was more complex (intervention characteristic) and not necessarily compatible (inner setting) with current workflows and staffing historically designed to address infectious disease prevention and control rather than chronic disease prevention and competing priorities that are determined by the MOH (outer setting). CONCLUSIONS: In this study, CFIR provided a valuable framework for evaluating factors that may influence implementation of a systems-level intervention for tobacco control in a LMIC and understand what adaptations may be needed to translate a model of care delivery from a HIC to a LMIC. TRIAL REGISTRATION: NCT02564653 . Registered September 2015.

Tobacco policies and on-premise smoking in bars and clubs that cater to young African Americans following the Maryland Clean Indoor Air Act of 2007.

African American young adults ages 18-25 smoke less than their Caucasian peers, yet the burden of tobacco-related illness is significantly higher in African Americans than in Caucasians across the lifespan. Little is known about how clean indoor air laws affect tobacco smoking among African American young adults. We conducted a systematic observation of bars and clubs with events targeted to African American adults 18-25 in Baltimore City at two timepoints (October and November of 2008 and 2010) after enforcement of the Maryland Clean Indoor Air Act (CIAA). Twenty venues-selected on the basis of youth reports of popular venues-were rated during peak hours. All surveillance checklist items were restricted to what was observable in the public domain. There was a significant decrease in observed indoor smoking after CIAA enforcement. Observed outdoor smoking also decreased, but this change was not significant. Facilities for smoking outdoors increased significantly. The statewide smoking ban became effective February 1, 2008, yet measurable changes in smoking behavior in bars were not evident until the City engaged in stringent enforcement of the ban several months later.

Tobacco Smoke Exposure in Indoor and Outdoor Locations in Airports Across Europe and the United States: A Cross-Sectional Study.

OBJECTIVE: Conduct a systematic evaluation of indoor and outdoor areas of selected airports, assess compliance and identify areas of improvement with smoke-free policies in airports. METHODS: Cross-sectional observational study conducted at 21 airports in Europe (11) and the United States (10). Using a standardized protocol, we assessed compliance (smoking, cigarette butts, smoke smell), and the physical environment (signage, ashtrays, designated smoking rooms [DSRs], tobacco sales). RESULTS: Cigarette butts (45% vs. 0%), smoke smell (67% vs. 0%), ashtrays (18% vs. 10%), and DSRs (63% vs. 30%) were observed more commonly indoors in Europe than in the United States. Poor compliance indoors was related to the presence of DSRs (OR 4.8, 95% CI 0.69, 33.8) and to cigarettes sales in pre-security areas (OR 6.0, 95% CI 0.57, 64.7), although not significantly different. Smoking was common in outdoor areas of airports in Europe and the United States (mean (SD) number of smokers 27.7 (23.6) and 6.3 (7.7), respectively, p value < .001). Around half (55%) of airports in Europe and all airports in the United States had some/partial outdoor smoking restrictions. CONCLUSIONS: Exposure to secondhand smoke (SHS) remains a public health problem in major airports across Europe and in some airports in the United States, specifically related to the presence of DSRs and SHS exposure in outdoor areas. Airports must remove DSRs. Research is needed in low- and middle-income countries and on the effectiveness of outdoor smoking-restricted areas around entryways. Eliminating smoking at airports will protect millions of people from SHS exposure and promote social norms that discourage smoking. IMPLICATIONS: Airports are known to allow exceptions to smoke-free policy by providing DSRs. We found that smoking still occurs in indoor areas in airports, particularly in the context of DSRs. Smoking, moreover, is widespread in outdoor areas and compliance with smoking restrictions is limited. Advancing smoke-free policy requires improvements to the physical environment of airports, including removal of DSRs and implementation of stricter outdoor smoking restrictions.

A Cross-Sectional Study of Tobacco Advertising, Promotion, and Sponsorship in Airports across Europe and the United States.

Tobacco advertising, promotion, and sponsorship (TAPS) bans are effective and are increasingly being implemented in a number of venues and countries, yet the state of TAPS in airports and their effect on airport smoking behavior is unknown. The objective of this study was to evaluate the presence of TAPS in airports across Europe and the US, and to begin to examine the relationship between TAPS and smoking behaviors in airports. We used a cross-sectional study design to observe 21 airports in Europe (11) and the US (10). Data collectors observed points of sale for tobacco products, types of products sold, advertisements and promotions, and branding or logos that appeared in the airport. Tobacco products were sold in 95% of all airports, with significantly more sales in Europe than the US. Advertisements appeared mostly in post-security areas; however, airports with advertisements in pre-security areas had significantly more smokers observed outdoors than airports without advertisements in pre-security areas. Tobacco branding appeared in designated smoking rooms as well as on non-tobacco products in duty free shops. TAPS are widespread in airports in Europe and the US and might be associated with outdoor smoking, though further research is needed to better understand any relationship between the two. This study adds to a growing body of research on tobacco control in air transit and related issues. As smoke-free policies advance, they should include comprehensive TAPS bans that extend to airport facilities.

The association between airline flight and sinonasal symptoms.

BACKGROUND: Airplane cabin supply air has been shown to contain multiple possible respiratory irritants. In addition, changes in barometric pressure in flight may contribute to specific respiratory conditions. Therefore, there may be an association between commercial airline flight and sinus disease. METHODS: Participants of the Secondhand-Smoke, Air Quality and Respiratory Health Among Flight Attendants Study were administered an online questionnaire pertaining to their flight experience and respiratory health. Working years, working days per month, and number of trips per month were quantified, as well as smoking exposure and self-reported physician diagnoses of sinusitis, asthma, and rhinitis. The sinonasal outcomes were quantified using a Respiratory Questionnaire Survey (RQS) score. Multivariable analyses were performed to evaluate the associations between flight time and sinus disease. RESULTS: A total of 579 participants met the inclusion criteria for this study, with cohort prevalence of sinusitis, asthma, and rhinitis of 25.3%, 14.4%, and 20.5%, respectively. Tertiles 2 and 3 of working days per month were associated with higher RQS scores compared to tertile 1 (p for trend <0.01). Individual symptoms significantly associated with increasing number of working days per month included "need to blow nose," "sneezing," and "thick nasal discharge," and the number of international trips per month was significantly associated with "coughing" and "facial pain and pressure," among other symptoms. CONCLUSION: This is the largest study to analyze the relations between airline flight time and sinonasal disease. The results suggest a possible association between sinusitis diagnosis, symptom scores, and specific sinonasal symptoms, and airline flight time.

Parental receptivity to child biomarker testing for tobacco smoke exposure: A qualitative study.

OBJECTIVE: Widespread tobacco smoke exposure (TSE) of children suggests that parents may be unaware of their children's exposure. Biomarkers demonstrate exposure and may motivate behavior change, but their acceptability is not well understood. METHODS: Sixty-five in-depth interviews were conducted with parents of young children, in smoking families in central Israel. Data were analyzed using thematic analysis. RESULTS: Consent to testing was associated with desire for information, for reassurance or to motivate change, and with concerns for long-term health, taking responsibility for one's child, and trust in research. Opposition to testing was associated with preference to avoid knowledge, reluctance to cause short-term discomfort, perceived powerlessness, and mistrust of research. Most parents expressed willingness to allow measurement by urine (83%), hair (88%), or saliva (93%), but not blood samples (43%); and believed that test results could motivate behavior change. CONCLUSIONS: Parents were receptive to non-invasive child biomarker testing. Biomarker information could help persuade parents who smoke that their children need protection. PRACTICE IMPLICATIONS: Biomarker testing of children in smoking families is an acceptable and promising tool for education, counseling, and motivation of parents to protect their children from TSE. Additionally, biomarker testing allows objective assessment of population-level child TSE.

Clear Skies and Grey Areas: Flight Attendants' Secondhand Smoke Exposure and Attitudes toward Smoke-Free Policy 25 Years since Smoking was Banned on Airplanes.

Our objective was to provide descriptive data on flight attendant secondhand smoke (SHS) exposure in the work environment, and to examine attitudes toward SHS exposure, personal health, and smoke-free policy in the workplace and public places. Flight attendants completed a web-based survey of self-reported SHS exposure and air quality in the work environment. We assessed the frequency and duration of SHS exposure in distinct areas of the workplace, attitudes toward SHS exposure and its health effects, and attitudes toward smoke-free policy in the workplace as well as general public places. A total of 723 flight attendants participated in the survey, and 591 responded to all survey questions. The mean level of exposure per flight attendant over the past month was 249 min. The majority of participants reported being exposed to SHS always/often in outdoor areas of an airport (57.7%). Participants who worked before the in-flight smoking ban (n=240) were more likely to support further smoking policies in airports compared to participants who were employed after the ban (n=346) (76.7% versus 60.4%, p-value<0.01). Flight attendants are still being exposed to SHS in the workplace, sometimes at concerning levels during the non-flight portions of their travel. Flight attendants favor smoke-free policies and want to see further restrictions in airports and public places.

Establishing smoke-free hospitals in Vietnam: a pilot project.

In Vietnam, a pilot 'smoke-free hospital' model was implemented in nine hospitals in 2009-2010 to supply lessons learned that would facilitate a replication of this model elsewhere. This study aimed to assess smoking patterns among health professionals and to detect levels of second-hand smoke (SHS) exposure within hospital premises before and after the 'smoke-free hospital' model implementation. A pre- and post-intervention cross-sectional study was conducted in nine purposively selected hospitals. Air nicotine levels were measured using passive nicotine monitors; smoking evidence was collected through on-site observations; and smoking patterns were assessed through interviews with health workers. Despite the 'smoke-free hospital' intervention, smoking continued among health-care workers who were former smokers. Specifically, self-reported smoking prevalence significantly decreased post-intervention, but the number of daily cigarettes smoked at workplaces among male health workers remained unchanged. Post-intervention, smoking was more likely to take place outside buildings and cafeterias. However, air nicotine levels in the doctors' lounges and in emergency departments did not change post-intervention. Air nicotine levels at other sites decreased minimally. Tailored tobacco cessation programmes, targeting current smokers and mechanisms to enforce non-smoking, should be established to meet requirements of Vietnam's comprehensive National Tobacco Control Law effective in May 2013.

A review of smoking policies in airports around the world.

OBJECTIVE: To review smoking policies of major international airports, to compare these policies with corresponding incountry tobacco control legislation and to identify areas of improvement for advancing smoke-free policy in airports. METHODS: We reviewed smoking policies of 34 major international airports in five world regions, and collected data on current national and subnational legislation on smoke-free indoor places in the corresponding airport locations. We then compared airport smoking policies with local legislation. Additionally, we collected anecdotal information concerning smoking rules and practices in specific airports from an online traveller website. RESULTS: We found that 52.9% of the airports reviewed had indoor smoking rooms or smoking areas; smoking policy was unknown or unstated for two airports. 55.9% of the airports were located in countries where national legislation allowed designated smoking rooms and areas, while 35.3% were in smoke-free countries. Subnational legislation restricted smoking in 60% of the airport locations, while 40% were smoke-free. 71.4% of the airport locations had subnational legislation that allowed smoke-free laws to be more stringent than at the national level, but only half of these places had enacted such laws. CONCLUSIONS: Despite the increasing presence of smoke-free places and legal capacity to enact stricter legislation at the local level, airports represent a public and occupational space that is often overlooked in national or subnational smoke-free policies. Secondhand smoke exposure in airports can be reduced among travellers and workers by implementing and enforcing smoke-free policies in airports. Additionally, existing information on smoke-free legislation lacks consistent terminology and definitions, which are needed to inform future tobacco control policy within airports and in the law.

Clearing the air: improving smoke-free policy compliance at the national oncology hospital in Armenia.

BACKGROUND: Smoke-free policies shown to reduce population exposure to secondhand smoke (SHS) are the norm in hospitals in many countries around the world. Armenia, a transition economy in the South Caucasus, has one of the highest male smoking rates in the European region. Although smoking in healthcare facilities has been banned since 2005, compliance with this ban has been poor due to lack of implementation and enforcement mechanisms and social acceptability of smoking. The study aimed to develop and test a model intervention to address the lack of compliance with the de jure smoking ban. The national oncology hospital was chosen as the intervention site. METHODS: This study used employee surveys and objective measurements of respirable particles (PM2.5) and air nicotine as markers of indoor air pollution before and after the intervention. The intervention developed in partnership with the hospital staff included an awareness campaign on SHS hazards, creation of no-smoking environment and building institutional capacity through training of nursing personnel on basics of tobacco control. The survey analysis included paired t-test and McNemar's test. The log-transformed air nicotine and PM2.5 data were analyzed using paired t-test. RESULTS: The survey showed significant improvement in the perceived quality of indoor air, reduced worksite exposure to SHS and increased employees' awareness of the smoke-free policy. The number of employees reporting compliance with the hospital smoke-free policy increased from 36.0% to 71.9% (p < 0.001). The overall indoor PM2.5 concentration decreased from 222 µg/m3 GM (95% CI = 216-229) to 112 µg/m3 GM (95% CI = 99-127). The overall air nicotine level reduced from 0.59 µg/ m3 GM (95% CI = 0.38-0.91) to 0.48 µg/ m3 GM (95% CI = 0.25-0.93). CONCLUSIONS: The three-faceted intervention developed and implemented in partnership with the hospital administration and staff was effective in reducing worksite SHS exposure in the hospital. This model can facilitate a tangible improvement in compliance with smoke-free policies as the first step toward a smoke-free hospital and serve as a model for similar settings in transition countries such Armenia that have failed to implement the adopted smoke-free policies.

Out of view but in plain sight: the illegal sale of single cigarettes.

The practice of selling single cigarettes (loosies) through an informal economy is prevalent in urban, low socioeconomic (low SES) communities. Although US state and federal laws make this practice illegal, it may be occurring more frequently with the recent increase in taxes on cigarettes. This investigation provides information concerning the illegal practice of selling single cigarettes to better understand this behavior and to inform intervention programs and policymakers. A total of 488 African American young adults were recruited and surveyed at two education and employment training programs in Baltimore City from 2005 to 2008. Fifty-one percent of the sample reported smoking cigarettes in the past month; only 3.7% of the sample were former smokers. Approximately 65% of respondents reported seeing single cigarettes sold daily on the street. Multivariate logistic regression modeling found that respondents who reported seeing single cigarettes sold on the street several times a week were more than two times as likely to be current smokers compared to participants who reported that they never or infrequently saw single cigarettes being sold, after controlling for demographics (OR = 2.16; p = 0.034). Tax increases have led to an overall reduction in cigarette smoking. However, smoking rates in urban, low SES communities and among young adults remain high. Attention and resources are needed to address the environmental, normative, and behavioral conditions influencing tobacco use and the disparities it causes. Addressing these factors would help reduce future health care costs and save lives.

Factors influencing tobacco use treatment patterns among Vietnamese health care providers working in community health centers.

BACKGROUND: Almost half of adult men in Viet Nam are current smokers, a smoking prevalence that is the second highest among South East Asian countries (SEAC). Although Viet Nam has a strong public health delivery system, according to the 2010 Global Adult Tobacco Survey, services to treat tobacco dependence are not readily available to smokers. The purpose of this study was to characterize current tobacco use treatment patterns among Vietnamese health care providers and factors influencing adherence to guideline recommended tobacco use screening and cessation interventions. METHODS: A cross sectional survey of 134 health care providers including physicians, nurses, midwives, physician assistants and pharmacists working in 23 community health centers in Viet Nam. RESULTS: 23% of providers reported screening patients for tobacco use, 33% offered advice to quit and less than 10% offered assistance to half or more of their patients in the past three months. Older age, attitudes, self-efficacy and normative beliefs were associated with screening for tobacco use. Normative beliefs were associated with offering advice to quit. However in the logistic regression analysis only normative beliefs remained significant for both screening and offering advice to quit. Over 90% of providers reported having never received training related to tobacco use treatment. Major barriers to treating tobacco use included lack of training, lack of referral resources and staff to support counseling, and lack of patient interest. CONCLUSIONS: Despite ratifying the FCTC, Viet Nam has not made progress in implementing policies and systems to ensure that smokers are receiving evidence-based treatment. This study suggests a need to change organizational norms through changes in national policies, training and local system-level changes that facilitate treatment.

Building capacity for implementation of the framework convention for tobacco control in Vietnam: lessons for developing countries.

Effective implementation of the WHO international Framework Convention on Tobacco Control (FCTC) is the key to controlling the tobacco epidemic. Within countries, strong national tobacco control capacity is the primary determinant for successful implementation of the FCTC. This case study of tobacco control policy describes the experience of building national tobacco control capacity in Vietnam under the Reduce Smoking in Vietnam Partnership project within a national capacity-building framework. In the Vietnam experience, four components of tobacco control capacity emerged as especially important to achieve 'quality' outputs and measurable outcomes at the implementation level: (i) organizational structure/infrastructure; (ii) leadership and expertise; (iii) partnerships and networks and (iv) data and evidence from research. The experience gained in this project helps in adapting our tobacco control capacity-building model, and the lessons that emerged from this country case study can provide guidance to global funders, tobacco control technical assistance providers and nations as governments endeavor to meet their commitment to the FCTC.