Measuring susceptibility to use tobacco in an increasingly complex consumer marketplace: How many questions do we really need?

OBJECTIVE: Predicting which young people are likely to use tobacco in the future is critical for prevention and intervention. Although measures for assessing susceptibility to using tobacco have fulfilled this goal for decades, there is almost no standard for the number of items that should be administered, or which items should be administered for which products. This study explored whether brief but psychometrically sound versions of commonly used susceptibility measures can adequately capture the construct relative to longer measures. METHOD: A sample of young people (N = 451; Mage = 16.5 years; 64% females; 65% White) completed 33 susceptibility items, which are designed to assess susceptibility to use different types of tobacco products (cigarette, smokeless tobacco, vaping products, and little cigars/cigarillos) of various flavors (tobacco, menthol, and sweet). RESULTS: Analysis of these 33 items indicated that asking about the likelihood of using each tobacco product class when a best friend offers it (four items in all) captures 98.5% of information that is captured using the longer set of items; asking the best friend question for each product by each flavor category (11 items in all) captures 99.7% of the information. CONCLUSIONS: Depending on research needs, tobacco use susceptibility can be measured with little loss of information by administering a limited set of items assessing the likelihood that a young person will use a tobacco product if a friend offers it for any product-flavor combination. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Does Reducing the Size of the Tobacco Power Wall Affect Young People's Risk of Future Use of Tobacco Products? An Experimental Investigation.

OBJECTIVE: A ban on tobacco power walls (in-store package displays) is unlikely in the United States because of concerns that such bans violate commercial free speech rights. This experiment evaluated the effectiveness of a more measured strategy for mitigating the influence of the power wall on young people's susceptibility to tobacco use: limiting its size. METHOD: The experiment took place in the RAND StoreLab, a life-sized replica of a convenience store. Participants (N = 275) ages 11-20 years were randomly assigned to shop in a variant of the StoreLab that had either a large (status quo), medium, or small power wall situated behind the checkout counter. Before and after shopping, participants completed measures of risk of future use of unflavored and flavored cigarettes and vaping products. RESULTS: Study condition was unrelated to future risk of smoking unflavored cigarettes, using menthol vaping products, and using sweet-flavored vaping products. Study condition was related to future risk of smoking menthol cigarettes and using unflavored vaping products; compared with exposure to a large power wall, exposure to a small power wall increased the odds of a participant's being at risk for future smoking of menthol cigarettes (odds ratio [OR] = 3.29, 95% CI [1.10, 9.83]) and the odds of a participant's being at risk for using unflavored vaping products (OR = 4.09, 95% CI [1.41, 11.85]). CONCLUSIONS: These findings call into question the viability of reducing the size of the power wall as a singular strategy for dampening its effect on young people's susceptibility to tobacco use.

Doing more with less: A proposal to advance cigarette packaging regulations in the United States.

Cigarette packages are potent marketing tools. Following guidance from the WHO Framework Convention on Tobacco Control, many countries have sought to diminish this marketing power by mandating that (1) large graphic health warnings be affixed to the packages (i.e., text warnings combined with graphic images of the health consequences of smoking) and (2) all packages be fully "plain" in their design (i.e., all packages use the same drab/bland color and font type; no brand logos, other colors, or designs are permitted). Yet, the United States lags other countries in implementing regulations designed to blunt the marketing power of cigarette packages. This is not because of a lack of effort on the part of the Food and Drug Administration, the main governmental body charged with regulating tobacco products in the United States. Rather, it is because the regulatory options that that have been advanced in the country (e.g., graphic health warnings) have not been found - yet - to be legally feasible by its courts. This commentary works through some of the conceptual, practical, and legal issues regarding packaging regulations in the United States. It considers the political and bureaucratic risks involved with issuing new regulations. The overall intent is to prompt our field to think creatively about what is realistic in this regulatory space and to offer a novel perspective that may help move the United States tobacco control community forward in its efforts to reduce the promotional power of cigarette packages.

Does removing menthol cigarettes in convenience stores reduce susceptibility to cigarette smoking? An experimental investigation in young people.

BACKGROUND: Evidence for the effectiveness of menthol cigarette bans comes mostly from studies of adults that smoke. This experiment evaluated whether the absence of menthol products from a convenience store influenced young people's susceptibility to cigarette smoking after they shopped in the store. METHODS: This experiment took place in the RAND StoreLab (RSL), a life-sized research convenience store. A three-group, between-subjects design was used. Study conditions differed in the mix of flavored tobacco products the RSL displayed: 1) All tobacco-, sweet-, and menthol-flavors displayed; 2) only tobacco- and menthol-flavors displayed; and 3) only tobacco-flavors displayed. Participants were randomly assigned to shop in the RSL under one of these conditions and after shopping, completed measures of their susceptibility to cigarette smoking, one measure for menthol cigarettes and one for unflavored cigarettes (scores on each susceptibility measure was dichotomized: 0 = not susceptible; 1 = susceptible). RESULTS: Multivariable logistic regression assessed the main effects of condition on susceptibility to smoking menthol and unflavored cigarettes. There was no condition effect on susceptibility to smoking unflavored cigarettes. However, removing menthol-flavored products significantly increased participants' susceptibility to smoking menthol cigarettes compared to when all flavored products were available (OR = 3.66, 95% CI [1.33, 10.03]). This significant effect was only found among young people with some pre-existing risk of cigarette smoking (OR = 5.92, 95% CI [1.81, 19.39]). CONCLUSION: Results suggest the need to consider that menthol bans could unintentionally increase the appeal of menthol cigarettes among youth already at risk of smoking.

An experimental evaluation of the effects of banning the sale of flavored tobacco products on adolescents' and young adults' future nicotine vaping intentions.

BACKGROUND: Some U.S. states and municipalities have banned the sale of flavored tobacco products to help curb youth vaping. However, evidence supporting such bans is limited. This experiment tested whether removing flavored tobacco products from a retail setting diminished adolescents' (ages 11-20) future intentions to use vaping products. METHODS: The study was implemented in the RAND StoreLab, a life-sized model convenience store. The display of flavored tobacco products in the store was manipulated with these conditions: 1) tobacco, sweet, and menthol/mint flavors displayed; 2) only tobacco and menthol/mint displayed; and 3) only tobacco flavors displayed. Participants were randomly assigned to shop in one of these conditions and completed measures of future vaping intentions post-shopping. Separate logistic regression models assessed effect of condition on future intentions to use different flavors (tobacco-, menthol/mint-, and sweet-flavored) and any flavor (composite score across flavor categories) of vaping products. RESULTS: Study condition was not associated with intentions to use menthol/mint-, sweet-flavored, or any flavor. Compared to the condition in which all flavored products were displayed, removing menthol/mint- and sweet-flavored products significantly increased future intentions to use tobacco-flavored vaping products (OR = 3.97, 95 % CI [1.01, 15.58], p < .05). This effect was only observed among adolescents with history of vaping (OR = 11.30, 95 % CI [1.42, 89.96], p = .02). CONCLUSIONS: Flavor bans may not affect adolescents' intentions to use menthol/mint, sweet, or "any" flavor of vaping products but may increase intentions to use tobacco-flavored products for teens who have already started vaping.

Additive impact of multiple point-of-sale tobacco control policies on youth tobacco-related outcomes.

Objectives: The tobacco industry utilizes tactics to increase youth awareness, exposure, access and use of tobacco. To address these tactics, municipalities in Massachusetts have passed point-of-sale policies including: 1) restricting flavored tobacco (FTR), 2) restricting cigar package sizes and prices (CPPR), 3) banning tobacco in pharmacies (PB), and 4) raising the minimum legal sales age of tobacco to 21 (MLSA 21). This study evaluated whether more policies, and a combination of policies addressing all three industry tactics, are associated with more favorable youth tobacco-related outcomes. Study design: This study was a cross-sectional survey. Methods: Municipalities were selected based on number of policies and similarity of municipality and tobacco retailer characteristics. The final sample included: Somerville with all four policies, Worcester with two policies (MLSA 21 and PB), and New Bedford with one policy (PB). Surveys were administered to youth in a public high school in each municipality. Multivariable models were used to compare tobacco-related outcomes between municipalities with varying numbers of policies. Results: After adjusting for individual-level demographics, we observed a protective effect of having more policies on flavored tobacco initiation and tobacco exposure and awareness. A protective effect of number of policies on tobacco use was not found, but associations were primarily in the expected direction. Current tobacco users in Somerville had higher odds of menthol use compared to New Bedford. Conclusions: Implementing multiple policies addressing varied industry tactics may be effective for youth tobacco prevention. Including menthol in FTRs may help improve youth tobacco-related outcomes.

Longer-Term Impact of the Flavored Tobacco Restriction in Two Massachusetts Communities: A Mixed-Methods Study.

INTRODUCTION: In response to high rates of youth tobacco use, many states and localities are considering regulations on flavored tobacco products. The purpose of this study was to assess whether flavored tobacco restrictions (FTRs) in Massachusetts curb youth tobacco use over time and whether a dose-response effect of length of policy implementation on tobacco-related outcomes exists. AIMS AND METHODS: Using a quasiexperimental design, two municipalities with a FTR (adopting municipalities) were matched to a comparison municipality without a FTR. Surveys were administered before (December 2015) and after (January and February 2018) policy implementation to high school students in these municipalities (more than 2000 surveys completed at both timepoints). At follow-up, adopting municipalities had a policy in place for 1 and 2 years, respectively. In 2019, focus groups were conducted with high school students in each municipality. RESULTS: Increases seen in current tobacco use from baseline to follow-up were significantly smaller in adopting municipalities compared to the comparison (-9.4% [-14.2%, -4.6%] and -6.3% [-10.8%, -1.8%], respectively). However, policy impact was greater in one adopting municipality despite shorter length of implementation. Focus groups indicated reasons for differential impact, including proximity to localities without FTRs. CONCLUSIONS: Restrictions implemented in adopting municipalities had positive impacts on youth tobacco awareness and use 1-2 years postimplementation. Policy impact varies depending on remaining points of access to flavored tobacco, as such policy effectiveness may increase as more localities restrict these products. IMPLICATIONS: In response to high rates of youth flavored tobacco use (including flavored vape products), federal, state, and localities have passed FTRs that reduce availability of flavored tobacco in youth-accessible stores. Previous research has found that FTRs may curb youth tobacco use in the short-term; however, the long-term effectiveness remains unknown.This is the first study to show FTRs can curb youth tobacco use and reduce youth awareness of tobacco prices and brands even 2 years after policy passage. Municipality-specific factors, including proximity to localities without FTRs, may attenuate policy impact, highlighting the importance of widespread policy adoption.

Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study: sequential mixed-methods study protocol in Michigan, USA.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is a common, life-threatening event encountered routinely by first responders, including police, fire and emergency medical services (EMS). Current literature suggests that there is significant regional variation in outcomes, some of which may be related to modifiable factors. Yet, there is a persistent knowledge gap regarding strategies to guide quality improvement efforts in OHCA care and, by extension, survival. The Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study aims to fill these gaps and to improve outcomes. METHODS AND ANALYSIS: This mixed-methods study includes three aims. In aim I, we will define variation in OHCA survival to the emergency department (ED) among EMS agencies that participate in the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) in order to sample EMS agencies with high-survival and low-survival outcomes. In aim II, we will conduct site visits to emergency medical systems-including 911/dispatch, police, non-transport fire, and EMS agencies-in approximately eight high-survival and low-survival communities identified in aim I. At each site, key informant interviews and a multidisciplinary focus group will identify themes associated with high OHCA survival. Transcripts will be coded using a structured codebook and analysed through thematic analysis. Results from aims I and II will inform the development of a survey instrument in aim III that will be administered to all EMS agencies in Michigan. This survey will test the generalisability of factors associated with increased OHCA survival in the qualitative work to ultimately build an EPOC Toolkit which will be distributed to a broad range of stakeholders as a practical 'how-to' guide to improve outcomes. ETHICS AND DISSEMINATION: The EPOC study was deemed exempt by the University of Michigan Institutional Review Board. Findings will be compiled in an 'EPOC Toolkit' and disseminated in the USA through partnerships including, but not limited to, policymakers, EMS leadership and health departments.

The Association Between Hospital Occupancy and Mortality Among Medicare Patients.

BACKGROUND: Hospital crowding is a major challenge facing US health care systems, but few studies have evaluated the association between inpatient occupancy and patient mortality. The objective of this study was to determine how increasing hospital occupancy is associated with the likelihood of inpatient and 30-day out-of-hospital mortality using a novel measure of inpatient occupancy. METHODS: The researchers conducted a retrospective, observational study using secondary data from the California Office of Statewide Health Planning and Development, including nonfederal, acute care facilities from 1998 to 2012. Using measures of relative hospital occupancy, the researchers ran logistic regressions to assess the relationship between increasing hospital occupancy and inpatient mortality and 30-day out-of-hospital mortality among Medicare patients age 65 years and older with myocardial infarction, heart failure, or pneumonia. RESULTS: Higher admission day occupancy (odds ratio [OR] = 0.96, 95% confidence interval [CI]: 0.94-0.99) and higher discharge day occupancy (OR = 0.62, 95% CI: 0.60-0.64) were associated with decreased inpatient mortality. Thirty-day out-of-hospital mortality increased with higher discharge day occupancy (OR=1.28, 95% CI: 1.24-1.32) but was unrelated to admission day occupancy. CONCLUSION: This study found a counterintuitive relationship between admission and discharge day occupancy and inpatient mortality. Higher discharge day occupancy appears to displace deaths into the outpatient setting. Understanding why higher inpatient occupancy is associated with lower overall mortality merits investigation to inform best practices for inpatient care in busy hospitals.

Short-Term Impact of a Flavored Tobacco Restriction: Changes in Youth Tobacco Use in a Massachusetts Community.

INTRODUCTION: To counter the high prevalence of flavored tobacco use among youth, many U.S. localities have passed policies that restrict youth access to these products. This study aims to evaluate the short-term impact of a flavored tobacco restriction policy on youth access to, and use of, flavored tobacco products in a Massachusetts community. METHODS: A community with the policy (Lowell) was matched to a community without the policy (Malden) with similar demographics, retailer characteristics, and point-of-sale tobacco policies. Product inventories were assessed in tobacco retailers in the 2 communities, and surveys were administered to high school-aged youth in those communities. Inventories and surveys were conducted around the time the policy took effect in October 2016 (baseline) and approximately 6 months later (follow-up); all data were analyzed in 2017. Chi-squared tests and difference-in-difference models were used to estimate the impact of the policy on flavored tobacco availability and youth perceptions and behaviors related to flavored tobacco use. RESULTS: Flavored tobacco availability decreased significantly in Lowell from baseline to follow-up periods by 70 percentage points (p<0.001), whereas no significant changes in flavored tobacco availability were seen in Malden. In addition, current use of both flavored and non-flavored tobacco decreased in Lowell, but increased in Malden from baseline to follow-up; these changes were significantly different between communities (flavored tobacco: -5.7%, p=0.03; non-flavored tobacco: -6.2%, p=0.01). CONCLUSIONS: Policies that restrict the sale of flavored tobacco have the potential to curb youth tobacco use in as few as 6 months.

Graphic health warning posters increase some adolescents' future cigarette use susceptibility by changing normative perceptions of smoking: A case of mediated moderation.

Prior work suggests that exposure to graphic health warning posters (GWPs) at retail point-of-sale may increase future cigarette smoking susceptibility in adolescents who are already at risk for future smoking, but not among committed never-smokers. However, little is known about what psychological mechanisms may account for this effect of GWPs on at-risk youths. Participants (N = 441) aged 11-17 years were randomized to experimental shopping conditions in a life-sized model convenience store, in which GWPs were absent ("status quo"; n = 107) or visibly displayed near the check-out area (n = 334). Participants completed pre- and post- "shopping" measures of future smoking susceptibility, descriptive and injunctive smoking norms, and perceived harms of smoking. A series of linear regression analyses assessed whether norms and harms differentially mediated the effect of experimental condition on future smoking susceptibility in committed never smokers compared with at-risk youths. Tests showed evidence for mediated moderation of the effect of GWP exposure on future smoking susceptibility, such that changes in injunctive norms (i.e., greater perceived social disapproval)-but not descriptive norms or perceived smoking harms-partially accounted for the effect of GWPs on smoking susceptibility in at-risk youths (average causal mediation effect: B = 0.51 [0.14-1.22], p = .02), but not among committed never smokers. For adolescents already at risk of future smoking, GWPs increase perceptions of cigarettes as less socially acceptable, which may increase susceptibility to future smoking in this group. Future work should examine reactance to antismoking messaging among youth at risk for future smoking. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Federally Qualified Health Center Strategies for Integrating Care with Hospitals and Their Association with Measures of Communication.

BACKGROUND: Federally qualified health centers have aligned clinical services and systems with local hospitals, but little is known about the specific care integration strategies health centers use or their impact on care. A research team examined the use of strategies by health centers to integrate care with hospitals and emergency departments (EDs) and their association with performance on measures of health center-hospital communication. METHODS: A Web-based survey was administered to health center medical directors in 12 states and Washington, DC, in 2017. The survey collected 10 self-reported measures of communication between health centers and hospitals/EDs and the extent to which health centers used different strategies to improve care integration. Health center and market characteristics that predict higher vs. lower integration activity were examined, and logistic regression was used to assess the relationship between integration activity and communication. RESULTS: Between 56% and 81% of health centers participated in quality improvement projects, health promotion initiatives, guideline alignment, or executive meetings with hospitals; far fewer established notification agreements regarding hospital/ED utilization. Health centers that were larger, were located in rural areas or states with Accountable Care Organization programs, reported fewer staff shortages, and had fewer minority patients were associated with greater integration activity. Higher levels of integration activity were associated with better performance on most communication measures in both inpatient and ED settings (p < 0.05). Integration activity was not associated with health centers' receipt of notifications after patients' ED visits. CONCLUSION: Health centers differ in the use of strategies to integrate care with hospitals. Overall, integration activity is associated with better communication.

Differential item functioning of the CAHPS® In-Center Hemodialysis Survey.

PURPOSE: End-stage renal disease patients' experience of care is an integral part of the assessment of the quality of the care provided at hemodialysis centers and is needed to promote patient choice, quality improvement, and accountability. The purpose of this study is to evaluate the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS®) survey and its equivalence in different age, gender, race, and education subgroups. METHODS: The ICH-CAHPS survey was administered to 1454 patients from 32 dialysis facilities. For the characteristics compared, the sample had 756 participants younger than 65 years old, 739 men, 516 Black, 567 White, and 970 with less than high school diploma. Three different patient experience constructs were studied including nephrologist's communication and caring, quality of care and operations, and providing information to patients. We used item response theory analysis to examine the possibility of differential item functioning (DIF) by patient age, gender, race, and education separately after controlling for the other DIF characteristics and additional confounding variables including survey mode, mental, and general health status as well as duration on dialysis. RESULTS: The three constructs studied were unidimensional and no major DIF was observed on the composites. Some non-equivalences were observed when confounders were not controlled for, suggesting that such covariates can be important factors in understanding the possibility of disparity in patients' experience. CONCLUSIONS: The ICH-CAHPS is a promising survey to elicit hemodialysis patients' experience that has good psychometric properties and provides a standardized tool for assessing age, gender, race, or education disparity.

Differences in Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey Scores by Recency of the Last Visit: Implications for Comparability of Periodic and Continuous Sampling.

BACKGROUND: Patient experience data can be collected by sampling patients periodically (eg, patients with any visits over a 1-year period) or sampling visits continuously (eg, sampling any visit in a monthly interval). Continuous sampling likely yields a sample with more frequent and more recent visits, possibly affecting the comparability of data collected under the 2 approaches. OBJECTIVE: To explore differences in Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey (CG-CAHPS) scores using periodic and continuous sampling. RESEARCH DESIGN: We use observational data to estimate case-mix-adjusted differences in patient experience scores under 12-month periodic sampling and simulated continuous sampling. SUBJECTS: A total of 29,254 adult patients responding to the CG-CAHPS survey regarding visits in the past 12 months to any of 480 physicians, 2007-2009. MEASURES: Overall doctor rating and 4 CG-CAHPS composite measures of patient experience: doctor communication, access to care, care coordination, and office staff. RESULTS: Compared with 12-month periodic sampling, simulated continuous sampling yielded patients with more recent visits (by definition), more frequent visits (92% of patients with 2+ visits, compared with 76%), and more positive case-mix-adjusted CAHPS scores (2-3 percentage points higher). CONCLUSIONS: Patients with more frequent visits reported markedly higher CG-CAHPS scores, but this causes only small to moderate changes in adjusted physician-level scores between 12-month periodic and continuous sampling schemes. Caution should be exercised in trending or comparing scores collected through different schemes.

Do graphic health warning labels on cigarette packages deter purchases at point-of-sale? An experiment with adult smokers.

This experiment tested whether the presence of graphic health warning labels on cigarette packages deterred adult smokers from purchasing cigarettes at retail point-of-sale (POS), and whether individual difference variables moderated this relationship. The study was conducted in the RAND StoreLab (RSL), a life-sized replica of a convenience store that was developed to evaluate how changing POS tobacco advertising influences tobacco use outcomes during simulated shopping experiences. Adult smokers (n = 294; 65% female; 59% African-American; 35% White) were assigned randomly to shop in the RSL under one of two experimental conditions: graphic health warning labels present on cigarette packages versus absent on cigarette packages. Cigarette packages in both conditions were displayed on a tobacco power wall, which was located behind the RSL cashier counter. Results revealed that the presence of graphic health warning labels did not influence participants' purchase of cigarettes as a main effect. However, nicotine dependence acted as a significant moderator of experimental condition. Graphic health warning labels reduced the chances of cigarette purchases for smokers lower in nicotine dependence but had no effect on smokers higher in dependence.

An exponential effect persistence model for intensive longitudinal data.

We develop an effect persistence model for intensive longitudinal data under a general assumption of an exponential loss of association between exposure and outcome over time. The working model proposed may be useful for understanding the complexity of phenomena for which subjects can be repeatedly exposed to an intervention or a naturally occurring event, while, the effect of any one exposure is expected to diminish over time. Under the main assumption, we specify a semilinear model with extensions to generalized linear models. These methods are motivated by, and applied to, data from a study of adolescent exposure to prosmoking advertisement in which the impact of prosmoking media exposure on young adults' susceptibility to smoking is assessed along with the decay of the effect over time. We investigate the performance of the proposed method when the model assumptions are correctly specified or not. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Exposure to the Tobacco Power Wall Increases Adolescents' Willingness to Use E-cigarettes in the Future.

INTRODUCTION: Adolescents' e-cigarette use is now more prevalent than their combustible cigarette use. Youth are exposed to e-cigarette advertising at retail point-of-sale (POS) locations via the tobacco power wall (TPW), but no studies have assessed whether exposure to the TPW influences susceptibility to future e-cigarette use. METHODS: The study was conducted in the RAND Store Lab (RSL), a life-sized replica of a convenience store developed to experimentally evaluate how POS advertising influences tobacco use risk under simulated shopping conditions. In a between-subjects experiment, 160 adolescents (M age = 13.82; 53% female, 56% white) were randomized to shop in the RSL under one of two conditions: (1) TPW located behind the cashier (n = 80); or (2) TPW hidden behind an opaque wall (n = 80). Youths rated willingness to use e-cigarettes ("If one of your best friends were to offer you an e-cigarette, would you try it?"; 1 = definitely not, 10 = definitely yes) before and after exposure. Linear regression assessed differences in pre-post changes in willingness to use across conditions. RESULTS: Ever-use of e-cigarettes was 5%; use of cigarettes was 8%; use of both e-cigarettes and cigarettes was 4%. There were no differences between TPW conditions on these or other baseline variables (eg, age, gender). Compared to the hidden condition, TPW exposure was associated with greater increases in willingness to use e-cigarettes in the future (B = 1.15, standard error [SE] = 0.50, p = .02). CONCLUSIONS: Efforts to regulate visibility of the TPW at POS may help to reduce youths' susceptibility to initiating e-cigarettes as well as conventional tobacco products like cigarettes. IMPLICATIONS: Past work suggests that exposure to the TPW in common retail settings, like convenience stores, may increase adolescents' susceptibility to smoking cigarettes. This experimental study builds upon prior research to show that exposure to the TPW at retail POS similarly increases adolescents' willingness to use e-cigarettes in the future. Efforts to regulate the visibility of the TPW in retail settings may help to reduce youths' susceptibility to initiating nicotine and tobacco products, including e-cigarettes.

Increased attention to the tobacco power wall predicts increased smoking risk among adolescents.

The purpose of this correlational study was to evaluate the association between attention paid by adolescents to the tobacco power wall and their susceptibility to future smoking. The study was conducted in the RAND Store Lab (RSL), a life-sized replica of a convenience store designed to investigate how tobacco advertising displays in retail point-of-sale environments relate to tobacco use risk and behaviors. In this study, middle and high school students (N = 80) shopped in the RSL while their attention to the tobacco power wall was measured covertly. Before and after shopping in the RSL, participants completed a measure of susceptibility to smoking in the future. Controlling for baseline cigarette smoking susceptibility and other potential confounders, attention toward the tobacco power wall was found to be significantly associated with future smoking susceptibility, p = .046. This finding suggests that policies aimed at decreasing the prominence of power walls in retail outlets should be given careful consideration as ways to reduce the impact of point-of-sale tobacco advertising and promotion on youth smoking susceptibility.

Hospital quality indicators are not unidimensional: A reanalysis of Lieberthal and Comer.

OBJECTIVE: To evaluate the dimensionality of hospital quality indicators treated as unidimensional in a prior publication. DATA SOURCE/STUDY DESIGN: Pooled cross-sectional 2010-2011 Hospital Compare data (10/1/10 and 10/1/11 archives) and the 2012 American Hospital Association Annual Survey. DATA EXTRACTION: We used 71 indicators of structure, process, and outcomes of hospital care in a principal component analysis of Ridit scores to evaluate the dimensionality of the indicators. We conducted an exploratory factor analysis using only the indicators in the Centers for Medicare & Medicaid Services' Hospital Value-Based Purchasing. PRINCIPAL FINDINGS: There were four underlying dimensions of hospital quality: patient experience, mortality, and two clinical process dimensions. CONCLUSIONS: Hospital quality should be measured using a variety of indicators reflecting different dimensions of quality. Treating hospital quality as unidimensional leads to erroneous conclusions about the performance of different hospitals.

Initiation and engagement as mechanisms for change caused by collaborative care in opioid and alcohol use disorders.

BACKGROUND: To assess the mechanism by which a collaborative care (CC) intervention improves self-reported abstinence among primary care patients with opioid and alcohol use disorders (OAUD) compared to treatment as usual. METHODS: Secondary data analysis of SUMMIT, a randomized controlled trial of CC for OAUD. Participants were 258 patients with OAUD receiving primary care at a multi-site Federally Qualified Health Center. Using a mediation analysis decomposition of a total effect into a mediated and a direct effect, we examined the effect of CC on abstinence at six months, attributable to the HEDIS treatment initiation and engagement measures for the total sample, for individuals with alcohol use disorders alone, and for those with a co-morbid opioid use disorder. RESULTS: Although the CC intervention led to an increase in both initiation and engagement, among the full sample, only initiation mediated the effect of the intervention on abstinence (3.8%, CI=[0.4%, 8.3%]; 32% proportion of the total effect). In subgroup analyses, among individuals with comorbid alcohol and opioid use disorders, almost 100% of the total effect was mediated by engagement, but the effect was not significant. This was not observed among the alcohol use disorder only group. CONCLUSIONS: Among primary care patients with OAUDs, treatment initiation partially mediated the effect of CC on abstinence at 6-months. The current study emphasizes the importance of primary care patients returning for a second substance-use related visit after identification. CC may work differently for people with co-morbid opioid use disorders vs. alcohol use disorders alone.