Acculturation, Hispanic ethnicity, and trust: Verifying and explaining racial/ethnic differences in trust in health providers in North Carolina Medicaid.

Three North Carolina Medicaid surveys conducted from 2000 to 2012 reported increasing numbers of Hispanic children enrolled in Medicaid and much lower trust in providers expressed by their adult caregiver respondents compared with responses for non-Hispanic Black and White children. To verify and explain this apparent trust chasm, we used bivariate and regression analyses. The variables employed included trust (dependent variable); child's race/ethnicity, age, and sex; satisfaction and health status scales; two utilization measures; respondent's age, sex, and education; geographical region; and population density of county of residence. Race/ethnicity was strongly associated with trust (p < .001), controlling for other independent variables. Access, satisfaction, and respondent's age and education were also significant. Our results fit the Behavioral Model for Vulnerable Populations, which maps the role of significant variables in health-seeking behavior. After analyzing the concept of trust, we argue that lower acculturation explains lower Hispanic trust compared with non-Hispanic Blacks. We suggest policies to improve acculturation.

Price, convenience, the buying experience, and other motivations for purchasing tobacco and e-cigarettes online.

INTRODUCTION: Consumers have shifted to online purchases for many products, including tobacco and e-cigarettes. These shifts have occurred alongside internet tobacco purchasing restrictions being proposed and enacted across the US. The aim of this study was to identify motivations for and against purchasing tobacco and e-cigarettes online, to better understand potential impacts or loopholes. METHODS: We surveyed 463 US adults who reported ever purchasing tobacco or e-cigarettes in April 2021, using Amazon's Mechanical Turk. Participants who reported purchasing tobacco or e-cigarettes online were asked to describe their reasons for doing so. Those who reported never purchasing online were asked to describe their reasons. Responses were triple-coded and thematically analyzed. RESULTS: Most respondents (n=330; 71.3%) had purchased tobacco or e-cigarettes online. We identified 14 reasons for purchasing tobacco or e-cigarettes online across four themes: price (cheaper online, discounts, bulk purchases, avoiding taxes), product characteristics (availability, quality), buying experience (convenience, time, COVID-19 concerns, avoiding shame, discretion, avoiding salespersons, reading reviews), and curiosity. We identified 13 reasons for not purchasing tobacco or e-cigarette products online across seven themes: buying experience (convenience, time, discretion, seeing the product), concerns (legality, safety, quality), consumption, price, supporting local, unaware, and uninterested. CONCLUSIONS: Both online and offline purchasers stated price and convenience motivated their choice to purchase tobacco or e-cigarettes online. Though few participants mentioned purchasing illicit products, concerns about legality and quality of online purchases were raised, and there was some awareness that online purchases attracted lower taxation.

Tailored Cigarette Warning Messages: How Individualized Loss Aversion and Delay Discounting Rates Can Influence Perceived Message Effectiveness.

Current text-only cigarette warning labels (long-term, loss-framed messages) may not motivate positive changes in smoking behavior. The current project was a cross-sectional study examining the effects of tailored cigarette warnings on perceived message effectiveness (PME) in adult smokers (n = 512) conducted using Amazon Mechanical Turk (M-Turk) in January-February 2020. Participants were an average age of 40.7 (SD = 11.6), with the majority of the sample being female (62.2%) and White (88.9%). Participants reported smoking an average of 14.6 cigarettes/day (SD = 9.2) with an average FTND score of 4.6 (SD = 2.2). Participants were asked to complete a tobacco use history questionnaire, and mixed gambles and delay discounting tasks before random assignment to one of five message groups. The groups were based on a 2 (gain versus loss framing) ×2 (short-term versus long-term framing) between-subject design; a fifth group served as the control group. All experimental messages reported higher PME scores than the control (p values < 0.001, Cohen's d = 1.88-2.48). Participants with shallower delayed reward discounting and lower loss aversion rates reported higher total PME scores, p values < 0.05. Our findings also suggest that loss aversion rates vary widely among smokers and that individuals are more responsive to messages congruent with their behavioral economic profile. Specifically, smokers who viewed messages congruent with their loss aversion and delay discounting rates reported higher PME scores than those who viewed incongruent messages (p = 0.04, Cohen's d = 0.24). These preliminary findings suggest that anti-smoking campaigns may best impact smokers by tailoring messages based on individual loss aversion and delay discounting rates versus a one-size-fits-all approach.

Adolescent Use and Perceptions of JUUL and Other Pod-Style e-Cigarettes: A Qualitative Study to Inform Prevention.

JUUL, a discrete pod-style e-cigarette, popular among adolescents, delivers high levels of nicotine. Limited research has assessed social and environmental influences that contribute to use of JUUL and other pod-style devices. We examined how these factors, as well as individual characteristics, shape adolescent use. Twenty-nine middle and high school students participated in six focus groups in June 2019 (58.6% female, 65.5% White, 27.6% Hispanic). Groups were stratified by e-cigarette use status and grade to understand perceptions and experiences among groups. Transcripts were coded using thematic analysis for individual, social, and environmental factors contributing to use. Users (n = 13) described their first experience with JUUL as mostly negative, mentioning reactions such as burning in the throat, coughing, wheezing, and headaches. Despite a negative first experience, stress relief and addiction were mentioned as reasons for continued use. Users and non-users identified vaping as a source of disruption to their daily life. Social factors included peer and parental influences, lack of support for quitting, and accessibility. Environmental factors included contrasting messages about long- and short-term health effects of e-cigarettes, as well as a lack of school vaping policy enforcement, health education, medical screenings, and cessation resources. Findings highlight the complex social system that influences adolescent e-cigarette use and have important implications for school and community responses. Strategies to prevent or reduce use may include reviewing existing school tobacco policies, providing counseling and cessation resources, training staff, and increasing knowledge through public education campaigns.

The Voyage of a Navigator An aspiring scholar's inside observations on the Affordable Care Act's rocky roll-out in North Carolina.

North Carolina, a federally facilitated marketplace under the Affordable Care Act (ACA), stumbled in 2013 when opening its health-insurance exchange. Trouble was easy to foresee, as North Carolina had instituted a law barring any state agency from assisting enrollment in health-insurance plans made available through the ACA. Trained workers were needed to help citizens and legal immigrants "navigate" to these plans. Some of these "navigators" could be paid with federal funds, but many others had to work as volunteers. I was one of these volunteer navigators. Much went wrong in training, staffing, and operations, but much still was accomplished. Here I report observations, share assessments, and offer suggestions for similarly complex situations.