Engaging Appalachian Youth: Lessons Learned From a Virtual Tobacco Prevention and Advocacy Training.

Engaging youth is recommended as a key component of comprehensive tobacco control to bring voice to youth perspective and to connect to community impact. Yet, limited research exists to showcase practical lessons learned in supporting skill development and engagement of youth. This practice note describes how a tailored prevention and advocacy virtual training can serve to engage and empower rural Appalachian high school students to participate in tobacco control efforts. Specifically, we describe the implementation and practical lessons learned from a two-session virtual tobacco prevention and advocacy training led by college facilitators. Participating high school students (N = 20) strongly agreed that tobacco use was a major problem facing their community and that addressing tobacco use should be prioritized. After participating in the training, students' interpersonal confidence improved and participation in self-reported advocacy increased. Students also liked the virtual platform, interaction with college students, and the opportunity to apply information learned. Youth-focused tailored training promotes skill-building and enhances self-efficacy to engage in tobacco control. Youth engagement should be integral to supporting community health initiatives, including tobacco prevention.

Engagement With a Youth Community Advisory Board to Develop and Refine a Facebook HPV Vaccination Promotion Intervention (#HPVvaxtalks) for Young Black Adults (18-26 years old).

Human papillomavirus (HPV) vaccination rates remain suboptimal among young Black adults (18-26 years). Research focused on HPV vaccination among young Black adults is limited. Guided by the Theory of Planned Behavior, we developed #HPVvaxtalks, a theoretically grounded and culturally appropriate Facebook intervention in collaboration with a youth community advisory board (YCAB) to increase awareness of HPV risk factors, risk perception, HPV vaccine-related knowledge, vaccination intention, and uptake for Black individuals. Engagement with YCAB members fostered opportunity to discuss priorities reflecting the community's interest and make #HPVvaxtalks more relevant. This article describes the YCAB engagement and collaborative process in the development and refinement of posts/messages for #HPVvaxtalks. Five young Black adults (18-26 years of age) were invited to become members of a YCAB. YCAB reviewed the preliminary version of #HPVvaxtalks intervention materials and provided critiques and suggestions for refinement. Following the completion of the collaborative process, YCAB members completed individual interviews to reflect on the process. Feedback from YCAB participants focused on the relevance, engagement, clarity, and organization of the content and the media utilized. Participants suggested using "memes" to improve cultural relevance and engagement for young Black individuals. All YCAB members expressed satisfaction with the development process. Collaboration with a YCAB was crucial in developing a culturally relevant and acceptable #HPVvaxtalks intervention, which includes 40 messages/posts for young Black adults. Undergoing the iterative process of intervention development and refinement with the priority population can be an essential component in the design and implementation of health promotion activities.

Centering equity in flavored tobacco ban policies: Implications for tobacco control researchers.

To achieve equity in protection from poor health outcomes due to tobacco use, tobacco control policies and interventions need to affect socially disadvantaged groups more strongly than advantaged groups. Flavored tobacco bans have been seen as a policy with this potential. However, tobacco control researchers, in close concert with policy advocates, need to consider how to center equity throughout the policy process to achieve equitable outcomes from banning flavored tobacco. In this commentary, we outline the rationale for how and why tobacco control researchers should consider equity throughout the policy process to help fully achieve the potential of flavored tobacco ban policies. These recommendations emerged from a presentation at the Vermont Center on Behavior and Health 2021 Conference. Specifically, we focus on recommendations for tobacco control researchers to center equity including partnering with communities in agenda setting, examining how various policy formulations or exemptions may increase or decrease disparities, determining where flavor policies need to reach and whether policies are equitably reaching all populations disproportionately burdened by flavored tobacco, assessing whether policy implementation/enforcement is carried out equitably to maximize policy benefits, and evaluating policy impact with as much granularity as possible. Considering the entire policy process is central to enhancing equitable outcomes from banning flavored tobacco. Tobacco control researchers can play a key role in ensuring that these policies are viewed through an equity lens to, not just improve population health, but also to reduce harms to those disproportionately burdened by use of flavored products.

PATH to understanding cannabis and nicotine initiation and co-use among emerging adults.

OBJECTIVES: The purpose of this study was to describe the characteristics and age of initiation of nicotine and cannabis use, with a particular focus on the emerging adult period (ages 18-24 years) and concurrent use of nicotine with cannabis. DESIGN: A secondary analysis of Population Assessment of Tobacco and Health (PATH). SAMPLE: 32,078 participants from a nationally representative study of tobacco use and health outcomes. MEASUREMENT: Variables of interest included ever use, regular use and age of initiation (first-time use) of nicotine (including tobacco) and/or cannabis and selected demographic factors. RESULTS: Ever-use of nicotine was associated with a 13-fold increase in the likelihood of having ever used cannabis. Among those who reported cannabis use, 96.4% had also used nicotine. While initiation in adolescence was most common, 27.1% of those who use nicotine and 34.9% of those who use cannabis initiated during emerging adulthood. Among regular users of nicotine, 41.5% began regular use in emerging adulthood. CONCLUSIONS: These findings underscore the continued susceptibility of emerging adults to initiation of these substances. Co-use of nicotine and cannabis is an understudied phenomenon in emerging adults with significant potential to cause harm and should be a public health priority.

Training Appalachian Kentucky Youth Cancer Advocates.

OBJECTIVES: Kentucky has the highest cancer incidence and mortality rates in the United States, with the Appalachian region experiencing the highest of those rates. Cancer advocacy, which is defined as providing support to cancer patients and their communities, represents a means of decreasing the cancer cases in Appalachian Kentucky. This exploratory study examined the effects of advocacy training and experiential learning on Appalachian high school students' cancer advocacy attitudes and self-efficacy. METHODS: The design of this study was a mixed-methods, one-group repeated measure with a group of participants from the Appalachian Career Training in Oncology (ACTION) Program (N = 9). The study assessed advocacy attitudes and self-efficacy before and after participants were provided advocacy training and participated in an advocacy event. RESULTS: Participating students' attitudes and self-efficacy did not substantially change following the training and their participation in an advocacy event. Through their comments after the event, however, students seem eager to use their voices to influence the actions of state legislators. At the same time, they worry about the apathy of their community members to their cancer advocacy message. CONCLUSIONS: Youth represent potentially powerful agents of advocacy that could help address the cancer burden in Kentucky. Participants in this study likely overestimated their advocacy abilities before learning more about advocacy and participating in the process. As such, additional trainings are likely necessary to increase students' self-efficacy, encourage them to share their stories, and help them overcome perceived barriers.

Readiness for Tobacco-Free Policy in a Statewide University System.

Background. Almost 2,000 campuses have adopted tobacco-free (TF) policies across the United States. However, there is not a systematic process to help campuses implement successful policies. Readiness assessments can help provide assistance as campuses work to implement successful policies. Purpose. We assessed readiness for TF policies among campuses of a statewide university system and determined factors associated with readiness. Participants. Stakeholders from 23 campuses without 100% TF policies were invited to participate in an online survey. Method. System administrators provided contacts for five to eight stakeholders per campus. Included in the analysis were 10 of 23 campuses (43.5%) with at least three stakeholders completing the survey. Results. Of the 10 campuses, one was in Preplanning, five were in Preparation, and four were in the Initiation stage of readiness. Political Climate was the highest scored dimension on seven campuses (0.74-1.0); Resources was the lowest on eight campuses (0.0-0.67). Campus size and county rurality were each associated with one dimension score. Conclusions. Despite being part of a statewide university system, campuses are in varying stages of readiness for TF policies. Stage-based strategies to advance TF campus policies must be implemented to set campuses up for successful policies.

Readiness to Adopt Physical Activity Policies in Rural Communities.

The purpose was to explore community readiness to adopt physical activity (PA) policies by adapting and pilot testing an online survey (Physical Activity Readiness Survey [PARS]). PARS was adapted from the previously tested Community Readiness Survey-Short. In February/April 2016, key informants (N = 17) involved in PA activities from two rural communities were invited to complete the PARS, representing six dimensions: knowledge, leadership, resources, community climate, existing voluntary PA policies, and political climate. First, participants were asked to respond to a presurvey to screen for overall readiness for up to four evidence-based PA policies. A main survey readiness score (0-6) was determined by averaging the key informants' ratings across items: Raw scores were rescaled to range from 0 to 1, and dimension scores were summed. Participants identified two PA policies in the presurvey: neighborhood availability and point-of-decision prompts. For both policies, political climate had the highest dimension score (1.0) and the knowledge dimension scored lowest (0.05-0.38). Overall readiness scores ranged from 3.19 to 3.62, revealing the preparation stage for both policies. Readiness for the two PA policies were similar, but specific dimension scores varied by policy type and community, reinforcing the need for tailored interventions.

Tobacco-Free Ambassador Partnership: Empowering Youth Advocates in Appalachian Communities.

Kentucky youth (14.3%) smoke more cigarettes as compared to the U.S. average (8.8%), and Appalachian communities suffer disproportionately from tobacco-related diseases such as lung cancer. Training youth to become advocates is an effective strategy to improve health equity. This article describes the development and impact of a youth advocacy program to promote tobacco control policies in Appalachian Kentucky. Phase I (2017-2018): two ½-day trainings followed by monthly meetings with one high school (n = 20 youth). Trainings provided information on tobacco use, consequences, industry tactics, evidence-based tobacco control, and advocacy skills. Results provided support for expansion to Phase II (2018-20119): A 1-day training followed by monthly information sharing implemented in three counties (N = 80). Youth were surveyed before and 6-months posttraining during both phases. Phase I: At posttraining, 85% of youth believed they could reduce the amount of tobacco use in their community versus 66% at baseline. More students tried at least once to convince school or government officials to be more concerned about tobacco use (77% vs. 47%). Phase II: More students supported tobacco policies at posttraining survey and realized policies are an effective strategy to reduce tobacco use. At posttraining survey, students reported greater interpersonal confidence talking with others about tobacco-related issues, with a 24% increase in confidence talking with adults in their communities, as well as greater advocacy self-efficacy. Youth in Appalachia demonstrate desire to influence tobacco use and policy to improve health equity. Findings reinforce the need for collaborative public health interventions to promote ongoing training and support for youth living in high-risk communities.

Short- and Long-Term Effects of a Tobacco-Free Executive Order on Employee Tobacco Use.

Smoke-free workplace policies encourage cessation, reduce tobacco consumption, and shift the pro-tobacco norm. However, no research exists evaluating the impact of mandated tobacco-free policies on government property. The purpose of our study was to examine short- and long-term effects of a tobacco-free policy (executive order 2014-747) implemented in November 2014, prohibiting tobacco use on state executive property. Cross-sectional online surveys were administered at two time points to a total of 27,000 employees of the executive branch of the Commonwealth of Kentucky. The short-term evaluation (March 2015) comprised 4,170 employees and the long term (August 2015) included 3,070. Tobacco use, plans to quit using tobacco, personal characteristics, whether the county of their workplace was covered by a smoke-free policy, and social norms for tobacco use were assessed 4- and 9-month post-policy implementation. Current tobacco use and plans to quit were compared between short- and long-term evaluations using multiple logistic regression with relevant covariates included. Controlling for demographics and employment location, employees reported lower rates of tobacco use and higher rates of planning to quit in the long term than in the short term. Tobacco-free policies reduce tobacco use prevalence and promote plans to quit, particularly over time. We found differences in tobacco use prevalence and plans to quit using tobacco products from 4 to 9 months after the policy took effect, as reported by employees following implementation of the tobacco-free policy. These findings support the potential for avoiding long-term health care costs as a result of reduced tobacco use from these policies. Nurses can play an important advocacy and policy evaluation role to promote and assess the impact of tobacco-free policies.

University students' perceived risk of and intention to use waterpipe tobacco.

Emerging tobacco product use is increasing. We evaluated factors associated with perceived risk of and intention to use waterpipe tobacco by surveying students at a large university in the southeastern U.S. (N = 667). Proportional odds modeling assessed whether demographic characteristics and social acceptability are associated with perceived risk of waterpipe tobacco use; and if these factors and perceived risk are related to intention to use waterpipe tobacco. Participants who perceived waterpipe tobacco to be more socially acceptable had lower odds of perceiving it as risky (95% confidence interval [CI] 0.50-0.68). Compared with never users, former tobacco users and current users had lower odds of perceiving waterpipe tobacco use as risky (95% CI 0.38-0.80 and 0.28-0.63, respectively). Similarly, students with greater perceived social acceptability scores had higher odds of intending to use waterpipe tobacco (95% CI 1.41-2.63), while those who perceived greater risk had lower odds of intending to use it (95% CI 0.34-0.64). Compared with never users, former users had higher odds of intending to use waterpipe tobacco (95% CI 1.42-7.21). Among those who had ever used waterpipe tobacco, 90% reported 'to socialize' as the most frequent reason for deciding to do so. Findings underscore the need for future prevention efforts.

Students' Beliefs About and Perceived Effectiveness of a Tobacco-Free Campus Policy.

Tobacco-free (TF) college campus policies have potential to be a high-impact tobacco control strategy. The purposes of the study presented here were to (a) determine the demographic and personal characteristics associated with students' beliefs about and perceived effectiveness of a TF campus policy and (b) assess whether tobacco use status and exposure to secondhand smoke (SHS) predicted beliefs and perceived effectiveness. Five thousand randomly selected students from a large southeastern university were invited by e-mail to participate in an online survey in April 2013, three and a half years after policy implementation. Students held positive beliefs about the policy (average rating 84% of the maximum possible score). Sixty-one percent believed that the policy was successful at reducing SHS exposure; and 40% thought the policy encouraged quitting. Males were less likely than females to believe the policy was effective in reducing SHS exposure and encouraging quitting. Lower undergraduates were more likely to perceive the policy as less effective in reducing SHS exposure; international students were more likely than domestic students to perceive the policy as more effective at encouraging quitting. Students most exposed to SHS were less likely to perceive the policy was effective. Compared with nonusers, those who smoked cigarettes were less likely to perceive the policy as effective in encouraging quitting. Tailored messaging regarding policy benefits are necessary. Perceived effectiveness of TF policies may be related to compliance with the policy and should be further investigated. Objective measures of effectiveness and tobacco use behaviors are needed to fully measure the success of TF campus policies.

Polytobacco Use Among College Students.

INTRODUCTION: Use of more than one tobacco product among college students is increasing in popularity, leading to nicotine addiction and additional health risks. The study (1) examined polytobacco use patterns among college students who had ever used tobacco; and (2) assessed the sociodemographic and personal factors associated with current polytobacco use, compared to current single product use and former tobacco use among college students. METHODS: Of 10,000 randomly selected college students from a large public university in the Southeast, a sample of 1593 students age 18 or older completed an online survey assessing tobacco use and attitudes. Ever tobacco users were included in this study (n = 662, or 41.6% of survey completers). RESULTS: About 15% of ever users reported current polytobacco use, and more than 70% of polytobacco users smoked cigars, little cigars, or clove cigarettes in combination with one or more products. Cigarettes were the most commonly-used product among single users, followed by hookah. Males, underclassmen, and students with greater acceptance of cigarette use were more likely to be polytobacco users. Race/ethnicity was marginally related to polyuse status, with white/non-Hispanics 28% less likely to be polytobacco users versus single product users. CONCLUSIONS: Polytobacco users were more likely than single users to consume emerging tobacco products, (ie, hookah and electronic cigarettes). Males, underclassmen, and racial/ethnic minorities were more at risk for polytobacco use. As young people are particularly prone to nicotine addiction, there is a need to further investigate polytobacco use among college students.

e-Cigarette Use and Perceived Harm Among Women of Childbearing Age Who Reported Tobacco Use During the Past Year.

BACKGROUND: The prevalence of electronic cigarette use grows. Amid increased e-cigarette use nationwide, this paper attempts to identify underlying risk factors for the most vulnerable populations. OBJECTIVE: The purpose of the study was to assess predictors of e-cigarette use among female current and former tobacco users of childbearing age-specifically to determine whether demographic factors, pregnancy status, conventional cigarette smoking, and perceived e-cigarette harm are associated with e-cigarette use. Reasons for using e-cigarettes were also measured. METHODS: A cross-sectional, correlational design was used; 194 current and former female tobacco users, 18-45 years of age, from two university-affiliated prenatal clinics and one women's health clinic in Kentucky took part. Slightly more than half were pregnant. Age, race/ethnicity, education, pregnancy status, use history for cigarettes and e-cigarettes, and perception of health hazard from e-cigarettes were measured, and associations with e-cigarette use were made with Mann-Whitney U-tests or Spearman's rank correlations. Predictors of e-cigarette use were determined using proportional odds modeling. RESULTS: Most current e-cigarette users were also current cigarette smokers (88%). Nearly half of current and former e-cigarette users were pregnant. Most women perceived e-cigarettes as a minor (38%) or moderate (31%) health hazard. In the proportional odds model, younger women were at greater risk for e-cigarette use, whereas minority women and those who were pregnant were less likely to be e-cigarette users. DISCUSSION: Pregnant women were less likely to be more recent e-cigarette users, compared with nonpregnant women. However, nearly all current e-cigarette users were dual tobacco users, including pregnant women. It is both imperative and timely to determine the impact of e-cigarette use on maternal and infant health, thus improving healthcare provider confidence to discuss the health implications of e-cigarette use with their patients.

Comparing two observational measures to evaluate compliance with tobacco-free campus policy.

Despite potential benefits of tobacco-free campus policies, compliance remains a challenge. Observational measures hold the most promise in determining compliance with these policies. There is need for further study to determine validity of observational measures of compliance with tobacco-free campus policies. The purpose of this study was to determine the validity of two observational measures of compliance with a tobacco-free campus policy: direct observation of violators and cigarette butts. Data collection took place over a 1-year time period. Direct observation was operationally defined as the number of observed violators in hot spots. A cigarette butt protocol previously found to be reliable was used to count the number of butts in campus hot spots. Results indicated a positive relationship between number of violators observed per visit and number of cigarette butts collected. Although most of the hot spots exhibited two or fewer violators per visit and 100 butts or fewer per collection, the data points outside this range supported a positive association between observed violators per visit and cigarette butts. The findings support that direct observation of violators is a valid measure of compliance compared to cigarette butts. Given available resources, using one or the other as evaluation measures is warranted.

The role and impact of nurses in American elementary schools: a systematic review of the research.

School nurses are tasked with the critical job of keeping students safe and well. Due to competing demands for resources in schools, the impact of school nurses must be demonstrated to secure their jobs. A systematic review of the literature from 1937 to 2013 was conducted to show the efficacy of school nursing activities in American elementary schools. While some studies of immunization compliance, attendance rates, body mass index screening, vision screening, and follow-up are promising, results are mixed and additional evidence is needed. The impact of school nurses on educational and health outcomes must continue to be evaluated and more rigorous evaluation methods should be explored. Suggestions for future research and collaborations are discussed.

Tobacco use disparities in rural communities.

PURPOSE: This exploratory study described facilitators and barriers to reducing tobacco disparities in 2 small rural communities and identified ways to reduce tobacco use. METHODS: This was a descriptive design using qualitative methods. We created a resource database for 2 rural Kentucky counties, using a Culture of Health Framework. We recruited 16 organizational stakeholders serving low-socioeconomic populations and conducted focus groups and key informant interviews. We also completed key informant interviews with 7 tobacco users. Lastly, we tailored Community Action Plans for each county based on the data and then solicited feedback from the key stakeholders. FINDINGS: The 2 counties were similar in population size, but County A had fewer resources than County B, and the stakeholders expressed differences toward tobacco use and quitting. County A stakeholders talked most about the protobacco culture and that tobacco users accept the risks of smoking outweighing the benefits of quitting; they also expressed concerns about youth use and the influences of family, society, and industry. County B stakeholders described ambivalence about the health effects of use and quitting. County A's Action Plan identified an opportunity to build Community Health Worker-delivered tobacco treatment into a new school-based health center. County B's Action Plan focused on reaching tobacco users by providing incentives for participation and tailoring messages to different audiences. CONCLUSIONS: Tobacco control resources and stakeholder perspectives vary in small rural communities, implying a need for tailored approaches. Tobacco users in rural areas are a critical population to target with cessation resources.

Examining intention to quit using Juul among emerging adults.

OBJECTIVES: (1) Describe intention to quit, (2) identify relationships between various factors and intention to quit, (3) explore if Theory of Planned Behavior-informed constructs are associated with intention to quit, and (4) discover if descriptive norms strengthen association with intention to quit among emerging adults currently using Juul. Participants: First-year students currently using Juul at a large public university (N = 182). Methods: A November 2018 online survey assessed sociodemographic characteristics, social influences, patterns of use, quit intention, and attitudes, norms, and perceived behavioral control toward Juul. Results: A quarter of participants reported current use, with nearly half intending to quit within six months. Recent quit attempts was the only factor related to intention. Two models were created that showed association with intention to quit, but only perceived behavioral control was individually significant. Conclusions: Cessation-focused campaigns and interventions are needed on college campuses and could be less tailored than prevention.

Juul use among emerging adults transitioning from high school to college.

Objective: Assess the prevalence, perceptions, sociodemographic/personal factors that influence Juul use among incoming freshmen.Participants: Incoming undergraduate students (N = 1,706) attending a public university in the southeastern U.S.Methods: Cross-sectional survey administered August 2018. Bivariate relationships assessed using chi-square test of association. Multinomial logistic regression to determine factors associated with Juul use status.Results: 41% had ever used Juul, 24% had used within the past month. Among current users, one-third had used 20-30 days. Risk factors for current use: heterosexual orientation (relative to other sexual orientation) AOR = 2.16, 95% CI: 1.20-3.91), those who planned to join sorority/fraternity (relative to those who did not plan to; AOR = 2.15, 95% CI: 1.59-2.90), current smokers (relative to nonsmokers; AOR = 24.39, 95% CI: 7.52-76.92), current marijuana users (compared with nonusers of marijuana; AOR = 6.45, 95% CI: 3.92-10.64) and alcohol users (compared with nondrinkers; AOR = 7.81, 95% CI: 5.75-10.54).Conclusion: Prevention and treatment efforts are needed for emerging adults transitioning to college.

COVID-19 Impact Predicts Diabetes Distress Among Individuals With Type 2 Diabetes.

PURPOSE: The purpose of this study was to determine whether COVID-19 impact and Diabetes Self-Management Education and Support (DSMES) service attendance predicted diabetes distress among individuals with type 2 diabetes during the pandemic. METHODS: Eighty-six adults with type 2 diabetes who either attended (n = 29) or did not previously attend (n = 57) DSMES services completed a cross-sectional survey. Participants' mean age was 57 ± 12.3 years, 50% were female, and 71.3% were diagnosed with diabetes >5 years. The Coronavirus Impact Scale was used to measure impact of the pandemic on daily life. The Diabetes Distress Scale was used to measure distress overall and within 4 subscales (emotional burden, interpersonal distress, physician-related distress, regimen distress). Separate multiple linear regressions were conducted for each outcome, controlling for age, sex, marital status, financial status, and time since diabetes diagnosis. RESULTS: Higher COVID-19 impact predicted higher diabetes-related distress for all subscales and overall. Only the subscale for interpersonal distress was predicted by DSMES attendance, which decreased with DSMES attendance. CONCLUSION: This study identifies a link between the effects of the COVID-19 pandemic and diabetes distress. The findings highlight the negative impact of the pandemic on diabetes distress and the importance of DSMES services for diabetes-related distress. Interventions are needed to reduce psychological distress among this population during public health crises.

The Impact of a Virtual Tobacco Prevention and Advocacy Training Among Youth in Appalachian Kentucky Communities.

BACKGROUND: Engaging youth is an important component of comprehensive tobacco control programs. PURPOSE: This paper describes the impact of a virtual tobacco prevention training program to encourage and prepare youth in Appalachia to support tobacco prevention policies, to strengthen interpersonal confidence to address tobacco use within their communities and enhance advocacy self-efficacy for tobacco control. METHODS: A two-part evidence-informed peer-led tobacco prevention and advocacy training was implemented among 16 high school students from Appalachian counties in Kentucky. The initial training (January 2021) included an overview of the e-cigarette landscape, advocacy skills related to policy change, developing messages to decision makers, and media advocacy. A follow-up session (March 2021) included a breakdown of advocacy skills and overcoming barriers. RESULTS: Overall, participants held strong beliefs that tobacco use is an issue that needs to be addressed in their community. There was a statistically significant average difference in student interpersonal confidence between baseline and post-surveys (t = 2.016, P = .062 < .1). Students who participated in at least 1 of the provided advocacy events indicated higher self-reported advocacy. CONCLUSION: Youth in Appalachia expressed an interest to advocate for stronger tobacco policy in their communities. Youth who participated in the tobacco advocacy policy trainings reported improvements in attitudes, interpersonal confidence, advocacy self-efficacy, and self-reported advocacy. Youth engagement in tobacco policy advocacy is promising and needs to be further supported.