Claims of Reduced Odor on Tobacco Packs in Low- and Middle-Income Countries.

INTRODUCTION: Cigarettes designed to have less smoke smell were developed by the tobacco industry to supposedly reduce negative qualities. Cigarettes with marketing claims communicating these designs have been sold in high-income countries and marketing of "less smoke smell" terms on cigarette packaging can promote cigarette use. It is unclear to what extent they have been marketed in low- and middle-income countries (LMICs). AIMS AND METHODS: The Tobacco Pack Surveillance System (TPackSS) systemically collected tobacco packs available in 14 LMICs with high tobacco use between 2013 and 2017. We coded 4354 packs for marketing appeals, including claims related to smoke smell. We describe "less smoke smell" and similar claims found on these packs and compare across country and tobacco manufacturers. RESULTS: Phrases communicating less smoke smell were present on packs purchased in nine of 14 LMICs, including Bangladesh, Brazil, China, India, Mexico, Philippines, Russia, Ukraine, and Vietnam. The most commonly (74.1%) used terminology was "less smoke smell," "LSS," or a combination of the two. Packs from Russia had the most prevalent use (11.8%) of such claims. Companies using these terms across 21 brands included Japan Tobacco International (JTI), British American Tobacco (BAT), Philip Morris International (PMI), and other smaller companies. JTI accounted for 70.9% of packs with such terms. CONCLUSIONS: Some of the world's largest tobacco companies are communicating less smoke smell on packs in LMICs. Less smoke smell and similar phrases on packaging should be prohibited because they can enhance the appeal of cigarettes. IMPLICATIONS: Tobacco companies are using "less smoke smell" and similar phrases on cigarette packs in LMICs. These claims have the potential to increase the appeal of smoking and promote cigarette use. Countries should consider policies to restrict attractive labeling claims, in accordance with the WHO Framework Convention on Tobacco Control (FCTC) Article 13 guidelines, which recommends restrictions on attractive design elements on tobacco packaging.

Beyond Gutka: Evidence of Illegal Smokeless Tobacco in Rural and Semi-urban Areas in India.

INTRODUCTION: Gutka, a popular smokeless tobacco (SLT) product combining chewing tobacco, areca nut, and spices, was banned by states in India beginning in 2012. Gutka can be recreated by the user mixing twin packets of tobacco and spice mixtures. We examine the availability of premixed gutka, the sale of twin packets (chewing tobacco and spice mixture sold together but in separate packets) and whether SLT was sold without legally mandated health warning labels (HWLs), without the printed maximum retail price (MRP), and above the MRP. AIMS AND METHODS: In October/November of 2017, unique SLT packets were purchased using a systematic protocol in 25 localities with populations under 50 000 across five Indian states. Purchase information (location, twin packets, price paid) and packaging information (SLT type, printed MRP, type of HWL) were used to assess legality. RESULTS: Of the 240 purchases of unique SLT packets, three were premade gutka. Twin packets were half of the sample, sold in every state, and illegally sold in Maharashtra where they were banned. Over half (62%) of single packets and 27% of twin packets did not feature a legal HWL. While only 5% of packets did not have a printed MRP, 29% of single packets, and 38% of twin packets were sold illegally for more than the MRP. CONCLUSIONS: SLT without the proper HWL or sold above the MRP were common. Twin packets were widely available. India should consider a country-wide restriction to ban single serving tobacco packets that would decrease affordability. IMPLICATIONS: This study is the earliest and that first outside of Mumbai that we are aware of to present evidence of tobacco products being sold above the MRP in India. While finding little evidence of premade gutka being sold, we found twin packets (chewing tobacco and spice mixture packets sold together) are widely available even in Maharashtra, which has a policy in place to ban twin packets. This study also finds evidence of SLT products sold without the correct HWL and without a MRP listed which shows that implementation and enforcement of regulations are as important as passing regulations.

Exploring peer navigation and support in the quality of HIV care experiences of female sex workers in the Dominican Republic.

BACKGROUND: Despite evidence on peer navigation's association with positive HIV outcomes, such as engagement in HIV care and antiretroviral therapy (ART) initiation, the mechanisms through which peer navigation may influence these outcomes have been less explored. The purpose of this study is to describe the role of peer navigation and support on enhancing the quality of HIV treatment and care services experienced by female sex workers (FSWs). METHODS: Survey data was derived from a quantitative cohort (n = 211) of FSWs living with HIV in the Dominican Republic and complemented with data from two rounds of in-depth interviews (IDIs) from a qualitative subsample (n = 20 per round). Descriptive statistics and multivariable logistic regressions were used to explore the association between peer navigation and relational aspects of care and overall satisfaction of the quality of HIV treatment and care. Thematic analysis was employed to code and synthesize textual data from IDIs. RESULTS: 41.2% of the participants reported having had contact with a peer navigator in the last 6 months. Qualitative data revealed that peer navigation and support was instrumental in assisting FSWs linkage to HIV care after diagnosis, elevating FSWs' ability to access more comprehensive clinical care facilities, and promoting agency by improving FSWs' skills to more strategically and effectively engage with the clinic environment and health care providers. Peer navigation was positively associated with experiencing more respectful treatment by clinic staff (AOR: 6.65, 95% CI: 2.32-19.02), and greater satisfaction with overall HIV care services (AOR: 2.57, 95% CI: 1.77-3.74). CONCLUSION: Promoting the full integration of peer navigation into healthcare structures is a strategic approach to enhance the quality of HIV care experienced by FSWs and improve their HIV-related outcomes.

Patient-reported outcomes in RA care improve patient communication, decision-making, satisfaction and confidence: qualitative results.

OBJECTIVE: To evaluate the impact of integrating patient-reported outcomes (PROs) into routine clinics, from the perspective of patients with RA, clinicians and other staff. METHODS: We conducted a prospective cohort study using a mixed methods sequential explanatory design at an academic arthritis clinic. RA patients completed selected Patient-Reported Outcomes Measurement Information System measures on tablets in the waiting room. Results were immediately available to discuss during the visit. Post-visit surveys with patients and physicians evaluated topics discussed and their impact on decision making; patients rated confidence in treatment. Focus groups or interviews with patients, treating rheumatologists and clinic staff were conducted to understand perspectives and experiences. RESULTS: Some 196 patients and 20 rheumatologists completed post-visit surveys at 816 and 806 visits, respectively. Focus groups were conducted with 24 patients, 10 rheumatologists and 4 research/clinic staff. PROs influenced medical decision-making and RA treatment changes (38 and 18% of visits, respectively). Patients reported very high satisfaction and treatment confidence. Impact on clinical workflow was minimal after a period of initial adjustment. PROs were valued by patients and physicians, and provided new insight into how patients felt and functioned over time. Reviewing results together improved communication, and facilitated patient-centred care, shared decision making, and the identification of new symptoms and contributing psychosocial/behavioural factors. CONCLUSION: PRO use at RA visits was feasible, increased understanding of how disease affects how patients feel and function, facilitated shared decision-making, and was associated with high patient satisfaction and treatment confidence.

Smoke and Scan: A Content Analysis of QR Code-Directed Websites Found on Cigarette Packs in China.

INTRODUCTION: Quick Response codes, or "QR" codes, are used widely in China-for mobile payment, marketing, public transportation, and various other applications. In this study, we examined the content of websites linked from QR codes on cigarette packs collected in China. AIMS AND METHODS: In February 2017, 738 unique cigarette packs were collected from five Chinese cities (Beijing, Guangzhou, Shanghai, Kunming, and Chengdu) using a systematic protocol. Cigarette packs were coded for presence of QR codes on packaging. Packs containing QR codes were then scanned using the WeChat app. Websites sourced from QR codes were coded for required verification, website type, age- and health-related statements, engagement strategies, and marketing appeals. RESULTS: From the sample of 738 unique packs, 109 packs (14.8%) had a QR code on the packaging. The QR codes were linked to 24 unique websites of which 23 could be analyzed. All 23 unique websites were either brand-specific or social media websites; none focused on health or quit information. Of the 23 websites, only three (13.0%) websites had age-restricted site access and just six (26.1%) had any mention of health-related risks associated with product usage. Engagement strategies and/or marketing appeals were found on 20 (87.0%) websites. CONCLUSIONS: The Chinese tobacco industry uses QR codes on cigarette packaging to link to web-based marketing content including social media recruitment, contests and giveaways, and product advertisement. It is important to understand where packs send consumers online and what messages they receive, and to consider QR codes on packaging when drafting policy. IMPLICATIONS: Scanning QR codes in China is a commonplace activity. The authors are aware of no published studies on the role QR codes play on the marketing of cigarette packs, in China or elsewhere. This study demonstrates QR codes on cigarette packs can expose users and nonusers to cigarette marketing on interactive websites and protobacco social media pages, mostly without restrictive access or health warnings. This is an area that health authorities can consider regulating, given that this is a channel through which the tobacco industry can communicate with current and potential consumers.

Maternal Knowledge, Attitudes, and Behavioral Intention after Exposure to Injury Prevention Recommendations in the News Media.

INTRODUCTION: Injury prevention recommendations are frequently presented in the media. Parental understanding and response to these recommendations remain uninvestigated. METHODS: A nationally representative sample of 1,081 mothers completed a cross-sectional survey measuring knowledge, attitudes, and behavioral intention after watching/reading video news stories and print articles on two child safety topics. RESULTS: Of the 1,081 respondents, 33% reported hearing little about injury prevention in the media in the past 30 days, and 32% reported never hearing about injury prevention. Nearly one-half (46%) reported the injury prevention studies they had previously read or heard about in the media were confusing to them at least some of the time. The proportion of mothers who recalled the correct key statistic presented in the story varied by safety topic and medium in which the story was presented. A greater proportion of mothers correctly recalled information from the story narrative than the statistics. Mothers also rated the most interesting part of the story differently based on safety topic and medium. A small proportion were not planning to follow the safety recommendations after viewing the news story. CONCLUSIONS: There are gaps in making injury news stories understandable and memorable for mothers in order to encourage behavioral change.

A randomized pilot trial of a couple-based intervention addressing sexual concerns for breast cancer survivors.

The purpose was to test the feasibility, acceptability, and preliminary efficacy of a 4-session couple-based Intimacy Enhancement (IE) intervention addressing breast cancer survivors' sexual concerns delivered via telephone. Twenty-nine post-treatment breast cancer survivors reporting sexual concerns and their intimate partners were randomized (2:1) to the IE intervention or to an educational control condition, both of which were delivered by trained psychosocial providers. Feasibility and acceptability were measured through recruitment, retention, session completion, and post-intervention program evaluations. Couples completed validated sexual, relationship, and psychosocial outcome measures at pre- and post-intervention. Between-group effect sizes and 95% confidence intervals were calculated using the Hedges g. Data supported intervention feasibility and acceptability. For survivors, the IE intervention had medium to large positive effects on all sexual outcomes and most psychosocial outcomes. Effects were less visible for relationship outcomes and were similar but somewhat smaller for partners. The IE intervention demonstrated feasibility, acceptability, and promise in addressing breast cancer survivors' sexual concerns and enhancing their and their partners' intimate relationships and psychosocial well-being. Implications for Psychosocial Oncology Practice The IE intervention demonstrated feasibility and acceptability, suggesting it could be well-received by breast cancer survivors with sexual concerns and their partners. Effects of the IE intervention on breast cancer survivors' sexual concerns and on their and their partners' intimate relationships and psychosocial well-being could not be attributed to therapist time and attention. Interventions that psychosocial providers can use to address breast cancer survivors' sexual concerns are important to the growing number of breast cancer survivors living for many years after their diagnosis.

Promoting Bike Helmet Safety for Urban Children Through a Culturally Tailored Educational Video Intervention.

Bicycle-related falls are a significant cause of mortality and morbidity. Use of bicycle helmets substantially reduces risk of severe traumatic brain injury but compliance with this safety practice is particularly low in urban children. We recruited eleven 8- to 15-year-old youth to participate in focus groups to inform the creation of a video promoting helmet use. Key emerging themes included that youth were responsible for keeping themselves safe and that most youth had cell phones with cases to protect them. A video was created that linked the concept of use of cases to protect phones to use of helmets to protect heads. Soliciting information from urban youth was helpful for developing this educational video.

A review of paper-based advance care planning aids.

BACKGROUND: Advance care planning (ACP) aids can help prepare patients, family members, and physicians for in-the-moment medical decision-making. We wished to describe the content and approach of paper-based ACP aids in order to characterize existing aids and inform the development of a new ACP aid. METHODS: Paper-based ACP aids were identified through an environmental scan and screened for eligibility. ACP conceptual frameworks and data were gathered via stakeholder engagement and used to inform the coding framework that two investigators used to independently code each aid. A directed content analysis was conducted on these eligible aids. Aids were categorized through a deliberative process with an investigator abstracting general information for each aid. RESULTS: Fifteen aids met the eligibility criteria. They ranged in length from 6 to 78 pages with the average aid written at an eighth-grade reading level. The content analysis revealed that many aids encouraged choosing a surrogate decision maker and informed users about legal medical documents. Fewer than half of the aids facilitated patient clarification of values regarding quality of life issues. The authors identified and termed the following three categories of aids: informative; semi-action oriented; and action-oriented. It was often unclear whether patients contributed to the development or testing of the ACP aids reviewed. CONCLUSIONS: Most existing paper-based ACP aids address legal matters such as completing an advance directive. Only a minority elicited patient values and it was unclear whether any were developed in partnership with patients. Future development of ACP aids should account for patient preferences with a goal of supporting in-the-moment medical decision-making.

Media Messages and Perception of Risk for Ebola Virus Infection, United States.

News media have been blamed for sensationalizing Ebola in the United States, causing unnecessary alarm. To investigate this issue, we analyzed US-focused news stories about Ebola virus disease during July 1-November 30, 2014. We found frequent use of risk-elevating messages, which may have contributed to increased public concern.

Effective patient-provider communication about sexual concerns in breast cancer: a qualitative study.

PURPOSE: Breast cancer patients commonly experience sexual concerns, yet rarely discuss them with clinicians. The study examined patient and provider experiences and preferences related to communication about breast cancer-related sexual concerns with the goal of informing intervention development. METHODS: Patient data (n = 28) were derived from focus groups and interviews with partnered and unpartnered women treated for breast cancer reporting sexual concerns. Provider data (n = 11) came from interviews with breast cancer oncologists and nurse practitioners. Patient and provider data were analyzed separately using the framework method of qualitative analysis. RESULTS: Findings revealed individual and institutional barriers to effective communication about sexual concerns and highlighted key communication facilitators (e.g., a positive patient-provider relationship, patient communication as a driver of provider communication, and vice versa). Patients expressed preferences for open, collaborative communication; providers expressed preferences for focused intervention targets (identifying concerns, offering resources/referrals) and convenient format. A model of effective communication of sexual concerns was developed to inform communication interventions. CONCLUSIONS: Findings suggest that to improve patient-provider communication about sexual concerns, knowledge and skills-based interventions that activate patients and that equip providers for effective discussions about sexual concerns are needed, as are institutional changes that could incentivize such discussions.

Perspectives on learning to cook and public support for cooking education policies in the United States: A mixed methods study.

Declines in cooking skills in the United States may contribute to poor diet quality and high obesity rates. Little is known about how Americans learn to cook or their support for cooking education policies. The objective of this study was to examine how Americans learn to cook, attributions of responsibility for teaching children how to cook, and public support for policies to teach cooking skills. We used a concurrent, triangulation mixed-methods design that combined qualitative focus group data (from 7 focus groups in Baltimore, MD (N = 53)) with quantitative survey data from a nationally representative, web-based survey (N = 1112). We analyzed focus group data (using grounded theory) and survey data (using multivariable logistic regression). We find that relatively few Americans learn to cook from formal instruction in school or community cooking classes; rather, they primarily learn from their parents and/or by teaching themselves using cookbooks, recipe websites or by watching cooking shows on television. While almost all Americans hold parents and other family members responsible for teaching children how to cook, a broad majority of the public supports requiring cooking skills to be taught in schools either through existing health education (64%) or through dedicated home economics courses (67%). Slightly less than half of all Americans (45%) support increasing funding for cooking instruction for participants in the Supplemental Nutrition Assistance Program (SNAP). Broad public support for teaching cooking skills in schools suggests that schools are one promising avenue for policy action. However, school-based strategies should be complemented with alternatives that facilitate self-learning. More research is needed to identify effective means of teaching and disseminating the key cooking skills and knowledge that support healthy eating.

US State-Level Policy Responses to the Ebola Outbreak, 2014-2015.

CONTEXT: The 2014-2015 Ebola epidemic in West Africa raised concerns about the potential occurrence of an Ebola outbreak in the United States. The federal government and individual states developed guidance and policies to determine how to manage individuals within the United States who may have been exposed to Ebola. DESIGN: A total of 139 documents describing state policies for individuals considered at risk for Ebola and the requirements, as well as restrictions these individuals may be subject to, were systematically identified and analyzed. RESULTS: A wide range of policy responses and variations on quarantine, movement restrictions, exposure categories, and monitoring were found. While the majority of states reflected US Centers for Disease Control and Prevention guidance, some states enacted aggressive quarantine policies and movement restrictions, developed unique categorization strategies, and established more frequent monitoring procedures. CONCLUSIONS: Findings may help public health practitioners and policymakers anticipate what policies could be implemented in response to future infectious disease threats. Furthermore, practitioners and policymakers should assume that some variation in response policies will occur at the state level.

News media coverage of U.S. Ebola policies: Implications for communication during future infectious disease threats.

The Ebola outbreak of 2014-2015 raised concerns about the disease's potential spread in the U.S. and received significant news media coverage. Prior research has shown that news media coverage of policy options can influence public opinion regarding those policies, as well as public attitudes toward the broader social issues and target populations addressed by such policies. To assess news media coverage of Ebola policies, the content of U.S.-focused news stories (n=1262) published between July 1 and November 30, 2014 from 12 news sources was analyzed for 13 policy-related messages. Eight-two percent of news stories mentioned one or more policy-related messages. The most frequently appearing policy-related messages overall were those about isolation (47%) and quarantine (40%). The least frequently mentioned policy-related message described dividing potentially exposed persons into distinct groups based on their level of Ebola risk in order to set different levels of restrictions (5%). Message frequency differed depending on whether news sources were located in an area that experienced an Ebola case or controversy, by news sources' political ideological perspective, and by type of news source (print and television). All policy-related messages showed significant increases in frequency after the first case of Ebola was diagnosed in the U.S. on September 30, 2014, with the exception of messages related to isolation, which showed a significant decrease. Results offer insight into how the news media covers policies to manage emerging disease threats.

Public perceptions of cooking and the implications for cooking behaviour in the USA.

OBJECTIVE: Despite the importance of cooking in modern life, public perceptions about what it means to cook are unknown. We aimed to examine perceptions of cooking and their association with cooking confidence, attitudes and behaviours in the USA. DESIGN: We designed and fielded a nationally representative survey among US adults (n 1112) in April 2015. We used factor analysis to identify perceptions about cooking and multivariate ordered logit and Poisson models to explore associations between those perceptions and cooking confidence, attitudes and behaviours. SETTING: Nationally representative web-based survey of US adults. SUBJECTS: US adults aged ≥18 years. RESULTS: Americans conceptualized cooking in three ways: the use of scratch ingredients, convenience foods and not using heat. Respondents who perceived cooking as including convenience foods were less confident in their ability to cook from scratch (OR=0·52, P<0·001) and less likely to enjoy cooking (OR=0·68, P=0·01) than those who did not. Although individuals who perceived cooking as including only scratch ingredients reported cooking dinner (4·31 times/week) and using packaged/boxed products (0·95 times/week) the least frequently, few notable differences in the frequency of cooking meals were observed. CONCLUSIONS: Cooking frequency is similar among US adults regardless of how they perceive cooking, but cooking confidence and enjoyment are lowest among Americans who perceive cooking as including the use of convenience foods. These insights should inform the development of more specific measures of cooking behaviour as well as meaningful and targeted public health messages to encourage healthier cooking.

What does cooking mean to you?: Perceptions of cooking and factors related to cooking behavior.

Despite the importance of cooking in American life and evidence suggesting that meals cooked at home are healthier, little is known about perceptions of what it means to cook in the United States. The objective of this study was to describe perceptions of cooking and factors important to how cooking is perceived and practiced among American adults. Seven focus groups (N = 53; 39 female; 35 Black, 16 White, 2 Asian) were conducted from November 2014 to January 2015 in Baltimore City, Maryland. Participants were recruited from two neighborhoods; one with higher median income and access to healthy food and the other with lower income and low access to healthy food. Focus groups were audio recorded, transcribed verbatim and analyzed using a grounded theory approach. Participants' perceptions of cooking varied considerably, regardless of neighborhood income or food access, and spanned a continuum from all scratch cooking to anything made at home. Perceptions of cooking incorporated considerations of whether or how food was heated and the degree of time, effort and love involved if convenience foods were used. Key barriers to cooking included affordability, lack of time, and lack of enjoyment. Key facilitators of frequent cooking included extensive organization and time management to enable participants to incorporate cooking into their daily lives. Cooking is a complex concept and not uniformly understood. Efforts to encourage healthy cooking at home should consider the broad spectrum of activities Americans recognize as cooking as well as the barriers and facilitators to preparing food at home. Public health messages to encourage more frequent cooking should account for the heterogeneity in perspectives about cooking. More research should explore differences in perceptions about cooking in other diverse populations.

Capitalizing on the "teachable moment" to promote healthy dietary changes among cancer survivors: the perspectives of health care providers.

PURPOSE: Although cancer is often thought of as a teachable moment, many cancer survivors do not adhere to behavioral recommendations that might improve their health. This study explored health care providers' perspectives on the importance and feasibility of addressing behavior change, specifically healthy diet, with cancer survivors. METHODS: In-depth interviews were conducted with 33 health care providers who care for posttreatment survivors of breast cancer, prostate cancer, and non-Hodgkin's lymphoma. Interviews were analyzed thematically. RESULTS: Health care providers emphasized the strength of evidence linking diet/obesity to recurrence in their assessment of the importance of promoting dietary change among their survivor patients. Cancer specialists (e.g., oncologists, surgeons) generally brought up dietary change with patients if they considered the evidence to be strong. In contrast, primary care providers viewed health promotion as important for all patients and reported treating cancer survivor patients the same as others when it came to making dietary recommendations. There was a lack of consensus among providers on the best timing to bring up behavior change. Providers described specific subgroups of patients who they saw as more motivated to make behavior changes and patient barriers to making dietary changes. CONCLUSIONS: Health care providers can play an important role in promoting healthy diet among cancer survivors. As the evidence base around diet and cancer recurrence/prognosis grows, it is important that this information is communicated to providers. Strategies such as incorporating behavior change messages into survivor care plans may help standardize recommendations to survivors.

Earned media and public engagement with CDC's "Tips from Former Smokers" campaign: an analysis of online news and blog coverage.

BACKGROUND: In March 2012, the US Centers for Disease Control and Prevention (CDC) launched the first-ever paid national tobacco education campaign. At a cost of US $54 million, "Tips from Former Smokers" (Tips) ran for 3 months across multiple media, depicting the suffering experienced by smokers and their families in graphic detail. The potential impact and reach of the Tips campaign was not limited to that achieved through paid media placements. It was also potentially extended through "earned media", including news and blog coverage of the campaign. Such coverage can shape public understanding of and facilitate public engagement with key health issues. OBJECTIVE: To better understand the contribution of earned media to the public's engagement with health issues in the current news media environment, we examined the online "earned media" and public engagement generated by one national public health campaign. METHODS: We constructed a purposive sample of online media coverage of the CDC's 2012 Tips from Former Smokers television campaign, focusing on 14 influential and politically diverse US news outlets and policy-focused blogs. We identified relevant content by combining campaign and website-specific keywords for 4 months around the campaign release. Each story was coded for content, inclusion of multimedia, and measures of audience engagement. RESULTS: The search yielded 36 stories mentioning Tips, of which 27 were focused on the campaign. Story content between pieces was strikingly similar, with most stories highlighting the same points about the campaign's content, cost, and potential impact. We saw notable evidence of audience engagement; stories focused on Tips generated 9547 comments, 8891 Facebook "likes", 1027 tweets, and 505 story URL shares on Facebook. Audience engagement varied by story and site, as did the valence and relevance of associated audience comments. Comments were most oppositional on CNN and most supportive on Yahoo. Comment coding revealed approximately equal levels of opposition and support overall. We identified four common arguments among oppositional comments: government intrusion on personal behaviors, problematic allocation of governmental spending, questionable science, and challenges regarding campaign efficacy. Supportive comments tended to convey personal stories and emotions. CONCLUSIONS: The Tips campaign received limited coverage on either online news or blog sources, but the limited number of stories generated engagement among online audiences. In addition to the content and volume of blog and news coverage, audience comments and websites' mechanisms for sharing stories via social media are likely to determine the influence of online earned media. In order to facilitate meaningful evaluation of public health campaigns within the rapidly advancing media environment, there is a need for the public health community to build consensus regarding collection and assessment of engagement data.

Dependence measures for non-cigarette tobacco products within the context of the global epidemic: a systematic review.

OBJECTIVES: Validated metrics of tobacco dependence exist, but their value for global surveillance of tobacco dependence and development of tobacco control interventions is not well understood. This paper reviews tobacco dependence metrics for non-cigarette products, and whether measures of tobacco dependence have been validated in low-income and middle-income countries (LMIC). DATA SOURCES: Searches were conducted in PubMed, Scopus, PsycINFO, EMBASE, CINAHL and Global Health databases using variant terms for types of tobacco, dependence, measures and validity/reliability. Articles discussing dependence theories and/or metrics were fully reviewed and synthesised. STUDY SELECTION: Searches yielded 2702 unique articles. Two independent coders identified 587 articles for abstract review, and 229 were subsequently fully reviewed. Findings from 50 eligible papers are summarised. DATA EXTRACTION: An initial thematic analysis concentrated on four concepts: general tobacco dependence, dependence metrics, tobacco dependence in LMIC and dependence on non-cigarette tobacco. DATA SYNTHESIS: Analysis identified 14 distinct tobacco dependence instruments. Existing metrics treat tobacco dependence as multifaceted. Measures have been developed almost exclusively around cigarette smoking, although some validation and application across products has occurred. Where cross-national validation has occurred, however, this has rarely included LMIC. CONCLUSIONS: For purposes of global surveillance of tobacco dependence, there is a compelling need for validated measures to apply universally across social contexts and a multitude of tobacco products. Alternatively, effective tobacco control interventions require validated dependence measures that integrate specific behavioural elements and social context of product use. While different measures of dependence are required to fulfil each of these goals, both have value in addressing the global tobacco epidemic.

Country-of-origin labeling prior to and at the point of purchase: an exploration of the information environment in Baltimore City grocery stores.

The country-of-origin labeling (COOL) law requires United States grocers to indicate the origin and procurement method (farm-raised or wild-caught) for seafood. This study explored the presentation of COOL on fresh, frozen, packaged, and unpackaged seafood in Baltimore City grocery stores. Eight stores were visited bi-monthly to photograph seafood labels, and circulars were collected weekly from fourteen stores over three months. Ninety-six percent of products were labeled correctly. Forty-eight percent of advertisements included COOL. While in-store labels did not highlight COOL, advertising featured references to domestic and wild-caught seafood, signaling to customers that these are high-value product qualities.