Perspectives of Sexual and Gender Minority Youth on Anti-Vaping Messages in Social Media.

INTRODUCTION: Sexual and gender minority (SGM) youth have higher rates of nicotine vaping than other youth in the United States. While social media can be effective in reaching youth and discouraging vaping, informed cultural tailoring is necessary to ensure effective messaging to SGM youth. This study aimed to understand SGM youth perspectives on anti-vaping social media messages and tailoring approaches. METHODS: In-depth, qualitative videoconference interviews were conducted from February to July 2022 with 34 SGM youth recruited in the United States via social media ads. The interview guide addressed participants' beliefs about vaping, the context of vaping, perspectives on tailoring messages, and responses to examples of social media anti-vaping messages. Coding and thematic analysis followed a team-based approach. RESULTS: SGM youth perspectives fell into four categories - representation and diversity, facts and evidence, empowering messages, and source credibility. Participants stressed the importance of accurate, genuine representation of SGM youth in messages, but also noted that more overt representation may be seen as tokenizing. Participants recommended partnering with known LGBTQ+ influencers who can promote or share anti-vaping messages on social media platforms. They also recommended using culturally tailored language, including statistics specific to SGM youth, and invoking themes of empowerment to improve the relevance, reach, and effectiveness of anti-vaping campaigns. CONCLUSIONS: Findings can inform future efforts to develop anti-vaping messages for SGM youth with effective reach through social media. Nuanced perspectives on SGM representation in messages suggest a careful approach to tailoring. Concerns around inauthenticity may be minimized by ensuring SGM youth are included in message development and dissemination. IMPLICATIONS: This study describes the importance of being attentive to the tailoring preferences among the current generation of sexual and gender minority youth. Findings will inform social media-based messaging strategies that discourage nicotine vaping tailored for SGM youth in health campaign material design and evaluation, ensuring that tailored messages are designed in ways that avoid unintended consequences. The study also describes methods for effectively engaging SGM youth in research to improve the relevance of health education materials for this population and increase reach, which in turn can lead to reduction in vaping practices among SGM youth.

Economic research in waterpipe tobacco smoking: reflections on data, demand, taxes, equity and health modelling.

Economic evaluation of tobacco control policies is common in high-income settings and mainly focuses on cigarette smoking. Evidence suggests that increasing the excise tax of tobacco products is a consistently effective tool for reducing tobacco use and is an efficient mechanism for increasing government revenues. However, less research has been conducted in low/middle-income countries where other tobacco forms are common. This paper presents insights from our work on the economics of waterpipe tobacco smoking conducted in the Eastern Mediterranean Region where waterpipe smoking originated and is highly prevalent. The specific areas related to economics of waterpipe smoking considered herein are: price elasticity, taxation, government revenue, expenditure and healthcare costs. This paper aims to provide practical guidance for researchers investigating the economics of waterpipe tobacco with potential implications for other novel tobacco products. We present lessons learnt across five thematic areas: data, demand, taxes, equity and health modelling. We also highlight knowledge gaps to be addressed in future research. Research implications include designing comprehensive assessment tools that investigate heterogeneity in waterpipe smoking patterns; accounting for cross-price elasticity of demand with other tobacco products; exploring the change in waterpipe tobacco smoking in response to a tax increase and analysing the equity impact of waterpipe tobacco control interventions.

Bullying Victimization and Use of Substances in High School: Does Religiosity Moderate the Association?

Alcohol, tobacco and other drug use continue to pose serious public health concerns among youth. Bullying victimization has been identified as a risk factor and religiosity a protective factor for adolescent substance use. No previous research has examined the potential moderating role of religiosity. We explore the association between bullying victimization and substance use in adolescents with low and high levels of religiosity. A cross-sectional survey was conducted with a representative sample of high school students in greater Beirut. Binary and multinomial logistic models were used, adjusting for demographics, and stratified by level of religiosity. Of the 986 students responding to the survey, 65% were females; 48% had experienced some form of bullying; and 52% self-rated as low in religiosity. Between 10 and 30% were current users of alcohol or tobacco. Students of lower religiosity levels who had been bullied were more likely to use substances than those who self-rated as high religiosity. Religiosity may be a potential moderator of the association between being bullied and substance use, but the exact mechanisms and underlying reasons need further investigation.

Validation of a simple tool to assess risk of waterpipe tobacco smoking among sixth and seventh graders in Lebanon.

BACKGROUND: Waterpipe tobacco smoking (WTS) is highly prevalent in the Eastern Mediterranean region. While studies have identified socio-demographic factors differentiating smokers from non-smokers, validated tools predicting WTS are lacking. METHODS: Over 1000 (n = 1164) sixth and seventh grade students in Lebanon were randomly assigned to a prediction model group and validation model group. In the prediction model group, backward stepwise logistic regression enabled the identification of socio-demographic and psychosocial factors associated with ever and current WTS. This formed risk scores which were tested on the validation model group. RESULTS: The risk score for current WTS was out of four and included reduced religiosity, cigarette use and the perception that WTS was associated with a good time. The risk score for ever WTS was out of seven and included an additional two variables: increased age and the belief that WTS did not cause oral cancer. In the validation model group, the model displayed moderate discrimination [area under the curve: 0.77 (current), 0.68 (ever)], excellent goodness-of-fit (P > 0.05 for both) and optimal sensitivity and specificity of 80.1 and 58.4% (current), and 39.5 and 94.4%, (ever), respectively. CONCLUSIONS: WTS use can be predicted using simple validated tools. These can direct health promotion and legislative interventions.

An effectiveness-implementation hybrid trial of phone-based tobacco cessation interventions in the Lebanese primary healthcare system: protocol for project PHOENICS.

BACKGROUND: Tobacco use remains the leading cause of preventable disease, disability, and death in the world. Lebanon has an exceptionally high tobacco use burden. The World Health Organization endorses smoking cessation advice integrated into primary care settings as well as easily accessible and free phone-based counseling and low-cost pharmacotherapy as standard of practice for population-level tobacco dependence treatment. Although these interventions can increase access to tobacco treatment and are highly cost-effective compared with other interventions, their evidence base comes primarily from high-income countries, and they have rarely been evaluated in low- and middle-income countries. Recommended interventions are not integrated as a routine part of primary care in Lebanon, as in other low-resource settings. Addressing this evidence-to-practice gap requires research on multi-level interventions and contextual factors for implementing integrated, scalable, and sustainable cessation treatment within low-resource settings. METHODS: The objective of this study is to evaluate the comparative effectiveness of promising multi-component interventions for implementing evidence-based tobacco treatment in primary healthcare centers within the Lebanese National Primary Healthcare Network. We will adapt and tailor an existing in-person smoking cessation program to deliver phone-based counseling to smokers in Lebanon. We will then conduct a three-arm group-randomized trial of 1500 patients across 24 clinics comparing (1) ask about tobacco use; advise to quit; assist with brief counseling (AAA) as standard care; (2) ask; advise; connect to phone-based counseling (AAC); and (3) AAC + nicotine replacement therapy (NRT). We will also evaluate the implementation process to measure factors that influence implementation. Our central hypothesis is that connecting patients to phone-based counseling with NRT is the most effective alternative. This study will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, supported by Proctor's framework for implementation outcomes. DISCUSSION: The project addresses the evidence-to-practice gap in the provision of tobacco dependence treatment within low-resource settings by developing and testing contextually tailored multi-level interventions while optimizing implementation success and sustainability. This research is significant for its potential to guide the large-scale adoption of cost-effective strategies for implementing tobacco dependence treatment in low-resource settings, thereby reducing tobacco-related morbidity and mortality. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05628389, Registered 16 November 2022.

Mixed methods evaluation of vaping and tobacco product use prevention interventions among youth in the Florida 4-H program.

INTRODUCTION: Novel prevention programs are developed to address the increase in e-cigarette use (vaping) among children. However, it remains paramount to test their feasibility in rural settings. This pilot study implemented and evaluated the feasibility and outcomes of two innovative programs, CATCH My Breath and smokeSCREEN, among youth in rural settings in Florida. METHODS: We conducted four focus groups with youth aged 11-17 recruited from 4-H rural clubs in Florida. In a subsequent randomized trial, we recruited 82 youth participants and assigned them to one of three arms: CATCH My Breath, smokeSCREEN, or control. CATCH My Breath and smokeSCREEN participants attended online group intervention sessions while the control group received educational material. Pre- and post-surveys were administered to all participants to assess knowledge, susceptibility, perceived positive outcomes and risk perceptions related to tobacco and e-cigarette use. Other feasibility parameters were also assessed. RESULTS: Focus group discussions provided insights about feasibility and informed the implementation of both interventions in terms of delivery format, scheduling of sessions and incentives. After the intervention, CATCH My Breath participants significantly improved their general tobacco-related knowledge (post-pre = 16.21-12.92 = 3.3, p <.01) and risk perceptions towards other flavored tobacco products (post-pre = 19.29-17.71 = 1.6, p <.05). smokeSCREEN participants significantly improved their general tobacco knowledge (post-pre = 18.77-13.77 = 5.0, p <.01), knowledge about e-cigarettes (post-pre = 9.08-6.31 = 2.8, p <.01) and risk perception towards e-cigarettes (post-pre = 24.69-21.92 = 2.8, p <.05). CONCLUSIONS: This study demonstrated feasibility of delivering the interventions via participant engagement, participants' willingness to be randomized, assessment of outcome measures, and exploration of different recruitment methods. Despite the potential positive influence of CATCH My Breath and smokeSCREEN on youth participants, further evaluation with larger samples is needed.

Design and Implementation of the Amenah Early Marriage Pilot Intervention Among Syrian Refugees in Lebanon.

Implementing and evaluating interventions in humanitarian settings in low- and middle-income countries presents unique challenges that are little addressed in the implementation literature. We document the process of developing, implementing, and evaluating the Amenah pilot intervention that aimed to mitigate the drivers of early marriage in a Syrian refugee community in Lebanon. Adolescent girls' vulnerability to early marriage increases following displacement due to poverty, insecurity, and school disruptions. We delineate how, as a local research team, we triangulated evidence from the international literature and formative community research to make informed decisions during the intervention's design and implementation phases. The pilot was delivered to 203 Syrian refugee schoolgirls aged 11-14 years during the 2017-2018 academic year. It consisted of 16 structured, interactive sessions with girls and a set of facilitated meetings with the girls' mothers, both of which were implemented by trained female community workers from the Syrian refugee community. Process evaluation results showed that sociodemographic factors predicted attendance among mothers, but relationships with peers in the intervention were the only significant predictor of attendance among girls. The primary outcomes of the pilot were attitudinal measures related to education and marriage. Attitudes toward education were highly positive at baseline and did not change over the course of the intervention. There were no significant changes in girls' ideal age at marriage. Among girls aged 13 and older at endline, the mean self-reported expected age at marriage increased slightly from 20.2 to 20.8 years (P<.05). Our results also suggest that girls may adjust their expected age at marriage downward as they become older and if they drop out of school. We reflect in the discussion on some of the challenges encountered and lessons learned for the benefit of researchers intending to conduct community-based interventions in displacement settings.

A Randomized Controlled Trial of a Theory-Informed School-Based Intervention to Prevent Waterpipe Tobacco Smoking: Changes in Knowledge, Attitude, and Behaviors in 6th and 7th Graders in Lebanon.

Waterpipe tobacco smoking (WTS) is spreading worldwide. Research has indicated health consequences of WTS similar to cigarettes. Prevalence of WTS is high among young people. In Lebanon, current use rates of 35% have been documented among 13⁻15 year olds. We evaluated a school-based intervention. Method: We conducted a randomized-controlled-trial of a theory-informed WTS intervention. The intervention consisted of ten sessions based on social cognitive theory and the social influences approach. Thirty-one schools participated: 14 intervention and 17 control; a total of 1279 students completed pre and post assessments. We measured knowledge, attitudes and self-reported behaviors related to WTS using Chi-square tests and regression analyses to compare results between the two study arms. Results: The intervention increased knowledge of intervention group compared to control group participants-about WTS constituents and health consequences; and shifted attitudes of intervention group participants to be even more unfavorable towards WTS. We found no impact of the intervention on WTS behaviors. Discussion: The effectiveness of the intervention on knowledge and attitudes supports previous research. The lack of intervention effect on behavior is not surprising given the timing of the post assessment immediately after the intervention, and the social context that was supportive of waterpipe use.

Process evaluation and challenges of implementation of a school-based waterpipe tobacco smoking prevention program for teens in Lebanon.

INTRODUCTION: Waterpipe tobacco smoking is increasing globally particularly among youth. In Lebanon, the high prevalence of waterpipe tobacco smoking among younger age groups calls for immediate intervention particularly given its negative health effects. To date, such interventions have rarely been implemented or evaluated. METHODS: This manuscript describes the process evaluation of a school-based intervention to prevent/delay waterpipe tobacco smoking among 6th and 7th graders (n=844) in Lebanon. Process evaluation documents whether an intervention is implemented as planned, and guides understanding of the relationship between the intervention activities and outcomes. The intervention was carried out over 5 months during 2011-2012 on school premises and during school hours, using a participatory approach. The ten intervention sessions included knowledge, skills and a social promise. The process evaluation assessed fidelity, dose delivered, dose received, reach, satisfaction, and the influence of context. Tools included observation and satisfaction forms, attendance log sheets, focus group discussions, and daily journal entries. RESULTS: The majority of participants (87.2%) attended at least 75% of the sessions. Results indicate high fidelity of implementation; 72.3% of the activities were rated by facilitators to be fully implemented - with high participant satisfaction; 89.5% of children chose a happy face to express their rating of the session. Facilitators rated children's participation as 'positive and active' in 77.9% of the sessions. CONCLUSIONS: Main challenges to implementation were contextual at the country and school level, and related to local pro social norms around waterpipe tobacco smoking. The experience of this intervention confirms the critical importance of context in program implementation.