Differences in Quit Attempts, Successful Quits, Methods, and Motivations in a Longitudinal Cohort of Adult Tobacco Users by Sexual Orientation.

INTRODUCTION: Sexual minority (SM) tobacco users are less likely to successfully quit than heterosexuals, yet little evidence describes cessation behaviors in this population over time. AIMS AND METHODS: Our study investigated quit motivations, attempts, and methods in a longitudinal cohort of adult tobacco users by sexual orientation. Participants (N = 1177) completed interviews every 6 months through 48 months and reported quit attempts (24-hour tobacco free), successful quits (7-day point prevalence abstinence), motivations, and methods. Chi-squared and Fisher's exact tests assessed differences by heterosexual and SM orientation, gender, and quit outcome (attempt-only vs. successful quit). RESULTS: Quit rates were similar for heterosexual and SM adults. Over half attempted to quit at least once over 48 months, but few remained abstinent (SM: 16.9%; heterosexual: 12.1%). Most used nicotine replacement therapy (SM: 31.9%; heterosexual: 26.1%) or tobacco product substitution (SM: 27.7%; heterosexual: 21.2%). Few used quitlines (SM: 4.3%; heterosexual: 1.3%) or Internet-based programs (SM: 6.4%; heterosexual: 1.3%). Quit motivations included health concerns, family, and physical fitness. Participants reporting a successful quit were more likely to report a household member quit smoking than 24-hour quit attempters. Among participants reporting a successful quit, more SM than heterosexual participants reported that a coworker quit smoking (55.6% vs. 33.1%, p = .009). CONCLUSIONS: We found few differences between heterosexual and SM tobacco users in our sample. Many repeatedly attempt to quit, yet few used evidence-based methods. Leveraging online quit programs, health messages, and family members in tailored cessation interventions may help SM and heterosexual tobacco users successfully quit. IMPLICATIONS: SM and heterosexual tobacco users evidenced few differences in quit behaviors. Over 4 years, a majority attempted to quit, with over a third making repeated quit attempts. Nicotine replacement therapy and tobacco product substitution were mostly used during quit attempts; however, more SM than heterosexual men reported using web-based quit programs. Personal health and family concerns were universal motivations to quit, yet SM women also cited physical fitness as a primary motivation. Tobacco users reporting that a household member stopped smoking were more likely to successfully quit. More SM than heterosexual men reported that a coworker quit smoking.

How should we define "rural" when investigating rural tobacco use in the United States?

Purpose: Investigations into rural tobacco-related disparities in the U.S. are hampered by the lack of a standardized approach for identifying the rurality-and, consequently, the urbanicity-of an area. Therefore, the purpose of this study was to compare the most common urban/rural definitions (Census Bureau, OMB, RUCA, and Isolation) and determine which is preferable for explaining the geographic distribution of several tobacco-related outcomes (behavior, receiving a doctor's advice to quit, and support for secondhand smoke policies). Methods: Data came from The Current Population Survey Tobacco Use Supplement. For each tobacco-related outcome, one logistic regression was conducted for each urban/rural measure. Models were then ranked according to their ability to explain the data using Akaike information criterion (AIC). Results: Each definition provided very different estimates for the prevalence of the U.S. population that is considered "rural" (e.g., 5.9% for the OMB, 17.0% for the Census Bureau). The OMB definition was most sensitive at detecting urban/rural differences, followed by the Isolation scale. Both these measures use strict, less-inclusive criteria for what constitutes "rural." Conclusions: Overall, results demonstrate the heterogeneity across urban/rural measures. Although findings do not provide a definitive answer for which urban/rural definition is the best for examining rural tobacco use, they do suggest that the OMB and Isolation measures may be most sensitive to detecting many types of urban/rural tobacco-related disparities. Caveats and implications of these findings for rural tobacco use disparities research are discussed. Efforts such as these to better understand which rural measure is appropriate for which situation can improve the precision of rural substance use research.

Adverse effects of electronic cigarettes on the disease-naive oral microbiome.

Six percent of Americans, including 3 million high schoolers, use e-cigarettes, which contain potentially toxic substances, volatile organic compounds, and metals. We present the first human study on the effects of e-cigarette exposure in the oral cavity. By interrogating both immunoinflammatory responses and microbial functional dynamics, we discovered pathogen overrepresentation, higher virulence signatures, and a brisk proinflammatory signal in clinically healthy e-cigarette users, equivalent to patients with severe periodontitis. Using RNA sequencing and confocal and electron microscopy to validate these findings, we demonstrate that the carbon-rich glycol/glycerol vehicle is an important catalyst in transforming biofilm architecture within 24 hours of exposure. Last, a machine-learning classifier trained on the metagenomic signatures of e-cigarettes identified as e-cigarette users both those individuals who used e-cigarettes to quit smoking, and those who use both e-cigarettes and cigarettes. The present study questions the safety of e-cigarettes and the harm reduction narrative promoted by advertising campaigns.

A Multi-level Model to Understand Cervical Cancer Disparities in Appalachia.

The Appalachian region experiences higher incidence and mortality due to cervical cancer compared with other regions of the United States. The goal of the Ohio State University Center for Population Health and Health Disparities (CPHHD), called the Community Awareness Resources and Education (CARE) project, was to understand reasons for this disparity. The first wave (2003-2008) of funding included three projects focusing on the known risk factors for cervical cancer, lack of screening, smoking, and infection with human papillomavirus (HPV). On the basis of the results of these projects, the second wave (2011-2017) included four projects, designed to address a multi-level model of factors contributing to cervical disparities in Appalachia. The results of these projects were then used to refine a multi-level model that explains cervical cancer disparities in Appalachia. Future funded projects will take these multi-level explanations for cervical disparities and focus on implementation science strategies to reduce the burden of cervical cancer morbidity and mortality in Appalachia.See all articles in this Special Collection Honoring Paul F. Engstrom, MD, Champion of Cancer Prevention.

Cost-Effectiveness of Community-Based Tobacco Dependence Treatment Interventions: Initial Findings of a Systematic Review.

INTRODUCTION: Scientific literature evaluating the cost-effectiveness of tobacco dependence treatment programs delivered in community-based settings is scant, which limits evidence-based tobacco control decisions. The aim of this review was to systematically assess the cost-effectiveness and quality of the economic evaluations of community-based tobacco dependence treatment interventions conducted as randomized controlled trials in the United States. METHODS: We searched 8 electronic databases and gray literature from their beginning to February 2018. Inclusion criteria were economic evaluations of community-based tobacco dependence treatments conducted as randomized controlled trials in the United States. Two independent researchers extracted data on study design and outcomes. Study quality was assessed by using Drummond and Jefferson's economic evaluations checklist. Nine of 3,840 publications were eligible for inclusion. Heterogeneity precluded formal meta-analyses. We synthesized a qualitative narrative of outcomes. RESULTS: All 9 studies used cost-effectiveness analysis and a payer/provider/program perspective, but several study components, such as abstinence measures, were heterogeneous. Study participants were predominantly English speaking, middle aged, white, motivated to quit, and highly nicotine dependent. Overall, the economic evaluations met most of Drummond and Jefferson's recommendations; however, some studies provided limited details. All studies had a cost per quit at or below $2,040 or an incremental cost-effectiveness ratio (ICER) at or below $3,781. When we considered biochemical verification, sensitivity analysis, and subgroups, the costs per quit were less than $2,050 or the ICERs were less than $6,800. CONCLUSION: All community-based interventions included in this review were cost-effective. When economic evaluation results are extrapolated to future savings, the low cost per quit or ICER indicates that the cost-effectiveness of community-based tobacco dependence treatments is similar to the cost-effectiveness of clinic-based programs and that community-based interventions are a valuable approach to tobacco control. Additional research that more fully characterizes the cost-effectiveness of community-based tobacco dependence treatments is needed to inform future decisions in tobacco control policy.

Quitting Behaviors Among Dual Cigarette and E-Cigarette Users and Cigarette Smokers Enrolled in the Tobacco User Adult Cohort.

PURPOSE: We examined quitting behaviors among a cohort of dual users (cigarettes and electronic cigarettes [e-cigarettes]) and exclusive cigarette smokers for: (1) cigarette smoking reduction, (2) quit attempts, (3) abstinence from cigarettes, and (4) abstinence from all tobacco products. METHODS: Participants enrolled in the Tobacco User Adult Cohort and categorized as "daily" user of cigarettes and "daily" or "some days per week" use of e-cigarettes (ie, dual users; n = 88) or "daily" user of cigarettes only (ie, cigarette smokers; n = 617) served as the analytic sample. Participants were interviewed face to face every 6 months, through 18 months. Data on self-reported current product(s) used, cessation interest, quit attempts and abstinence from cigarettes, and all tobacco products were collected. RESULTS: No difference in reduction of cigarette consumption over time was noted between groups. Rates of reporting an attempt to quit all tobacco products (≥ 24 hours of not using any tobacco in an attempt to quit) also did not differ by group. Compared to cigarette smokers, dual users were more likely to report abstinence from cigarettes at 6 months (OR = 2.54, p = .045) but not at 12 or 18 months. There was no significant difference in abstinence from all tobacco products by group at 6, 12, or 18 months. CONCLUSIONS: Although dual use of e-cigarettes has been cited as a potential cessation tool for cigarette smokers, our findings indicated that this association was only observed in the short term. We also found no evidence of any association between dual use and eventual abstinence from all tobacco products. IMPLICATIONS: Our study observed that, in the natural environment, dual users of cigarettes and e-cigarettes were more likely than cigarette smokers to quit cigarettes in the short term but no more likely to quit using cigarettes and all tobacco products over time.

Tobacco product transition patterns in rural and urban cohorts: Where do dual users go?

INTRODUCTION: Understanding diverse tobacco product consumption represents a crucial area for tobacco regulatory science. With the increase in dual/poly use of tobacco products, transition patterns among exclusive and dual users are of considerable interest. We describe transition patterns of dual users over 18 months. METHODS: A cohort of 145 adults in urban and rural Ohio who reported dual tobacco product use at least some days/week was enrolled during 2014-17. Participants completed follow-up interviews every six months where they were classified into one of five categories: 1) exclusive combustible, 2) exclusive smokeless, 3) exclusive e-cigarette, 4) dual (at least 2 of the previous 3 categories), and 5) less than some days/week. Participants categorized as exclusive and dual (1-4) used their products at least some days per week. Separately within the rural and urban cohorts, 6, 12, and 18 month transition probabilities between the categories were estimated. RESULTS: The probability of remaining a dual user after 6 months is 43% in the rural and 37% in the urban cohort. The decline continues through 18 months with 24% of rural and 22% of urban dual users remaining in the category. The probability of a dual user consuming combustibles and e-cigarettes transitioning to exclusive combustible use in 6 months is over 50% in both the rural and urban cohorts. CONCLUSIONS: Dual use is an unstable state with users being more likely to transition to exclusive combustible use than to remain in the dual use category. Transitions are similar in the rural and urban cohorts.

Variations in support for secondhand smoke restrictions across diverse rural regions of the United States.

Significant disparities exist between rural-urban U.S. POPULATIONS: Besides higher smoking rates, rural Americans are less likely to be protected from SHS. Few studies focus across all regions, obscuring regional-level differences. This study compares support for SHS restrictions across all HHS regions. DATA: 2014/15 TUS-CPS; respondents (n = 228,967): 47,805 were rural residents and 181,162 urban. We examined bi-variates across regions and urban-rural adjusted odds ratios within each. Smoking inside the home was assessed along with attitudes toward smoking in bars, casinos, playgrounds, cars, and cars with kids. Urban respondents were significantly more supportive of all SHS policies: (e.g. smoking in bars [57.9% vs. 51.4%]; support for kids in cars [94.8% vs. 92.5%]. Greatest difference between urban-rural residents was in Mid-Atlantic (bar restrictions) and Southeast (home bans): almost 10% less supportive. Logistic regression confirmed rural residents least likely, overall, to support SHS in homes (OR = 0.78, 95% CI 0.74, 0.81); in cars (OR = 0.87, 95% CI 0.79, 0.95), on playgrounds (OR = 0.88, 95% CI.83, 0.94) and in bars OR = 0.88, 95% CI 0.85, 0.92), when controlling for demographics and smoking status. South Central rural residents were significantly less likely to support SHS policies-home bans, smoking in cars with kids, on playgrounds, in bars and casinos; while Heartland rural residents were significantly more supportive of policies restricting smoking in cars, cars with kids and on playgrounds. Southeast and South Central had lowest policy score with no comprehensive state-level SHS policies. Understanding differences is important to target interventions to reduce exposure to SHS and related health disparities.

Characteristics of the Tobacco User Adult Cohort in Urban and Rural Ohio.

OBJECTIVES: Identifying characteristics associated with the use of new and emerging tobacco products is a priority. The enumeration and baseline characteristics of a new cohort of adult tobacco users are described. METHODS: Residents, ≥18 years of age, in urban Franklin County, or one of 6 rural Appalachian counties, and who were exclusive users of combustible, smokeless (SLT), or electronic nicotine delivery systems (ENDS) tobacco products, or were dual users, were targeted for recruitment. Participants were interviewed in-person at baseline on sociodemographic characteristics, tobacco product use, and cognitive/affective and purchasing factors. RESULTS: We recruited 1210 participants (urban, N = 595; rural, N = 615). Urban participants were less likely to use tobacco daily, began using tobacco later, used tobacco for less time, and had higher cessation interest. ENDS users were significantly less likely to have made a quit attempt than users of other tobacco products. Duration of tobacco use and nicotine dependence also differed by product type. CONCLUSION: This cohort's enumeration allowed us to compare factors associated with tobacco product preferences and the use of novel products. The inclusion of rural Appalachia-a region with high tobacco use and disease burden-may provide additional insights into the implementation of tobacco control interventions.

The role of travel distance and price promotions in tobacco product purchase quantity.

INTRODUCTION: Rural Americans are particularly vulnerable to tobacco price reducing promotions are known to be directed to and used by vulnerable populations. Tobacco purchasing decisions, such as unit quantity purchased, may vary by rurality, by price promotion use, and possibly by the interaction between the two. Purchase decisions are likely to affect tobacco use behavior. Therefore, explanation of variation in tobacco purchase quantity by factors associated with rural vulnerability and factors that fall under the regulatory scope of the Tobacco Control Act (TCA) of 2009 could be of value to regulatory proposals intended to equitably benefit public health. METHODS: Our sample included 54 combustible tobacco users (298 purchase events) and 27 smokeless tobacco users (112 purchase events), who were asked to report all tobacco purchases on a smartphone application. We used an ecological momentary assessment methodology to collect data about tobacco users' purchasing patterns, including products, quantity purchased, and use of price promotions. A parent cohort study provided relevant data for home-outlet distance calculation and covariates. Our analysis examined associations between our outcome-purchase quantity per purchase event-and distance from participant's home to the nearest outlet, whether a price reducing promotion was used, and the interaction of these two factors. RESULTS: Combustible users showed an increased cigarette pack purchase quantity if they lived further from an outlet and used a price promotion (i.e., an interaction effect; RR = 1.70, 95% CI [1.11, 2.62]). Smokeless users purchased more units of snuff when they used price promotions (RR = 1.81, 95% CI [1.02, 3.20]). CONCLUSIONS: Regulatory action that imposes restrictions on the availability or use of price promotions could alter the purchasing behavior of rural Americans in such a way that makes it easier to reduce tobacco use or quit. Such action would also restrict flexibility in the price of tobacco products, which is known as a powerful tobacco control lever.

Impact of Presence of Children on Indoor Tobacco Restrictions in Households of Urban and Rural Adult Tobacco Users.

OBJECTIVES: Secondhand smoke exposure in children is changing as a result of new public policy and electronic nicotine products (e-cigarettes). We examined factors related to self-imposed indoor household tobacco restrictions, with emphasis on children in the household and associations with combustible and noncombustible product use. METHODS: A cross-sectional survey of urban and rural Ohio adult tobacco users classified participants as exclusive combustible users, smokeless tobacco (SLT) users, e-cigarette users, or dual users. They were further stratified according to combustible or noncombustible product use and the presence of indoor tobacco use restrictions. Multiple logistic regression determined factors associated with indoor tobacco restrictions. RESULTS: A total of 1210 tobacco users participated, including 25.7% with children living in the home. Half allowed combustible and two thirds allowed noncombustible tobacco use indoors. Urban location (odds ratio [OR] = 1.58), younger age (OR = 0.88 per 5 year), male sex (OR = 1.40), college education (OR = 1.40), household income of more than $15,000 (OR = 1.78), and being married (OR = 2.43) were associated with a higher likelihood of banning combustible products indoors. SLT (OR = 8.12) and e-cigarette (OR = 5.85) users were more likely to have indoor bans compared to combustible users. Children in the household (OR = 1.89), older age (OR = 1.12 per 5 years), and nonwhite race (OR = 1.68) were associated with a higher likelihood of banning noncombustible products indoors. Combustible (OR = 4.54) and e-cigarette (OR = 3.04) users were more likely than SLT users to have indoor bans. CONCLUSIONS: Indoor restrictions on tobacco use remain infrequent in homes with children and are associated with user type and socioeconomic factors. Public policy should target modifiable risk factors for in-home secondhand smoke exposure.

Smoking behaviors of adults with developmental disabilities and their direct support professional providers.

BACKGROUND: People with developmental disabilities are not immune from the addictive effects and poor health outcomes associated with cigarette use. Direct support professionals often play a large role in the social environments of people with developmental disabilities and the literature suggests that one's environment can influence behavior. OBJECTIVES: To examine the relationship between the smoking behaviors of people with developmental disabilities and their direct support professional providers. Two exploratory aims of the study were to assess how direct support professionals facilitate smoking behaviors and to describe the use of home smoking policies. METHODS: The Ohio Department of Disabilities' online provider search database was used to randomly select participants. A total of 398 direct support professionals completed an online survey about smoking. Direct support professionals served as proxy reporters for the smoking behaviors of those with developmental disabilities. Descriptive statistics were calculated and Chi-Square tests were used. RESULTS: Findings suggest that there was no significant relationship (χ12 = 0.300, p = 0.584) between the current smoking behaviors of people with developmental disabilities and their direct support providers. Direct support professionals were most likely to facilitate smoking behaviors by allowing people with developmental disabilities to smoke in front of them and waiting for them to finish smoking before moving on to a new activity. Approximately 46% of people with developmental disabilities were reported to have some type of home smoking policy. CONCLUSIONS: Future research is needed to better understand the reasons why people with developmental disabilities initially start smoking and continue to smoke.

The impact of a federal cigarette minimum pack price policy on cigarette use in the USA.

BACKGROUND: Increasing cigarette prices reduce cigarette use. The US Food and Drug Administration has the authority to regulate the sale and promotion-and therefore the price-of tobacco products. OBJECTIVE: To examine the potential effect of federal minimum price regulation on the sales of cigarettes in the USA. METHOD: We used yearly state-level data from the Tax Burden on Tobacco and other sources to model per capita cigarette sales as a function of price. We used the fitted model to compare the status quo sales with counterfactual scenarios in which a federal minimum price was set. The minimum price scenarios ranged from $0 to $12. RESULTS: The estimated price effect in our model was comparable with that found in the literature. Our counterfactual analyses suggested that the impact of a minimum price requirement could range from a minimal effect at the $4 level to a reduction of 5.7 billion packs sold per year and 10 million smokers at the $10 level. CONCLUSION: A federal minimum price policy has the potential to greatly benefit tobacco control and public health by uniformly increasing the price of cigarettes and by eliminating many price-reducing strategies currently available to both sellers and consumers.

The relationship between type of telephone service and smoking cessation among rural smokers enrolled in quitline tobacco dependence treatment.

Quitlines are successful tools for smoking cessation, but no known study has examined whether type of phone service (cell phone only (CPO) vs. landline (LL)) impacts quitline utilization, quit attempts, and sustained cessation. This report details an observational study examining the association between phone service and quitline utilization and cessation among Ohio Appalachian adults willing to quit smoking and enrolled in a cessation trial from 2010 to 2014. A secondary analysis was conducted with data obtained from smokers enrolled in the Ohio Tobacco Quitline arm of a group randomized trial (n = 345). The intermediate outcome variables included number of calls, cumulative total call length, average call length, verified shipments of NRT, and 24-hour quit attempt. The primary outcome measure was biologically confirmed 7-day point prevalence abstinence from tobacco at 3, 6, and 12 months post treatment. Participants with LL service, on average, made almost one more call to the quitline and spoke 17.2 min longer over the course of treatment than those with CPO service. Those with LL service were more likely to receive a second 4-week supply of NRT. Phone service status was not associated with average quitline call length, receiving at least one NRT shipment, having made one quit attempt at the end of treatment, or biochemically confirmed abstinence at 3, 6, or 12-month follow-up. Participants with LL services completed more counseling calls, accrued a longer cumulative length, and received more NRT when compared with CPO service participants. However, type of phone service did not deter abstinence outcomes.

Depression, Smoking, and Ego-Centric Social Network Characteristics in Ohio Appalachian Women.

Depression is a serious, costly, and debilitating disorder that is understudied in rural women. Studies show that depression is associated with low social integration and support, but few studies investigate the relationship between depression and social network characteristics. This study examined the associations among women from three Ohio Appalachian counties enrolled in a health study, which aimed to collect information for a future social network smoking cessation intervention. An address-based sampling method was used to randomly select and recruit 404 women. A cross-sectional survey and interview were used to collect information about demographic, psychosocial, behavioral factors, and ego-centric social network characteristics, which are variables derived from an individual (ego) and her first degree contacts (alters). The CES-D scale assessed depressive symptoms. A multivariable logistic regression analysis described the association between these factors and participants with depression (defined as CES-D≥16). Higher network density, or greater number of relationships among alters divided by the total amount of alters, reduced the risk for depression (OR = 0.84, 95% confidence interval [CI] 0.73-0.95). Additionally, women with a high percentage of smoking alters were at greater risk for depression (OR = 1.19, 95% CI 1.02-1.39). Other factors associated with risk for depression included perceived stress score (OR = 1.34, 95% CI 1.24-1.45), loneliness score (OR = 1.37, 95% CI 1.05-1.80), and days with poor physical health (OR = 1.06, 95% CI 1.02-1.11). Findings suggest that psychosocial factors and social networks should be considered when addressing depression in clinical practice.

A Descriptive Report of Electronic Cigarette Use After Participation in a Community-Based Tobacco Cessation Trial.

INTRODUCTION: Smokers are using electronic cigarettes, also known as e-cigarettes, as a cessation aid, despite uncertainty about their efficacy. This report describes the association between use of e-cigarettes before and after cessation treatment and tobacco abstinence at 12 months. It also presents characteristics of e-cigarette users and reasons for use. METHODS: A longitudinal observational secondary analysis of self-reported e-cigarette use was conducted among adult Appalachian smokers enrolled in a community-based tobacco dependence treatment trial (n = 217). Data were collected at baseline, 3, 6, and 12 months following treatment. The primary outcome measure was biochemically-confirmed 7-day point prevalence tobacco abstinence at 12 months post-treatment. RESULTS: One in five participants reported using e-cigarettes post-treatment. Baseline sociodemographic and tobacco-related characteristics did not differ by e-cigarette use. Primary reasons for e-cigarette use included help in quitting, help in cutting down on cigarettes, and not as bad for health. At the 12 month follow-up, tobacco abstinence was significantly lower among post-treatment e-cigarette users (4.7%) than nonusers (19.0%); (OR = 0.21 95% CI: 0.05-0.91, p = .021). Baseline use was not associated with 12-month abstinence. CONCLUSIONS: Among adult Appalachian smokers enrolled in community-based tobacco cessation treatment, use of e-cigarettes post-treatment was associated with lower abstinence rates at 12 months. IMPLICATIONS: This descriptive report of electronic cigarette use after participation in a community-based group randomized tobacco dependence treatment trial adds to the body of science examining e-cigarette use and cessation. Post-treatment e-cigarette use was associated with less success in achieving abstinence at 12 months, as compared to nonuse. At 3 months post-treatment, the majority of those who reported use of e-cigarettes did so to assist with cessation.

Health Warning Labels for Smokeless Tobacco: The Impact of Graphic Images on Attention, Recall, and Craving.

INTRODUCTION: Little research has examined the impacts of graphic health warnings on the users of smokeless tobacco products. METHODS: A convenience sample of past-month, male smokeless tobacco users (n = 142; 100% male) was randomly assigned to view a smokeless tobacco advertisement with a graphic health warning (GHW) or a text-only warning. Eye-tracking equipment measured viewing time, or dwell time, in milliseconds. Following the advertisement exposure, participants self-reported smokeless tobacco craving and recalled any content in the health warning message (unaided recall). Linear and logistic regression analyses evaluated the proportion of time viewing the GHW, craving, and GHW recall. RESULTS: Participants who viewed a GHW spent a significantly greater proportion of their ad viewing time on GHWs (2.87 seconds or 30%), compared to those viewing a text-only warning (2.05 seconds or 24%). Although there were no significant differences by condition in total advertisement viewing duration, those participants viewing a GHW had increased recall of health warning messages compared to the text-only warning (76% had any warning message recall compared to 53%; p < .05). Self-reported craving after advertisement exposure was lower in the GHW compared to text-only condition, but the difference was not statistically significant (a rating of 4.4 vs. 5.3 on a 10-point scale; p = .08). CONCLUSIONS: GHWs attracted greater attention and greater recall of health warning messages compared to text-only warnings among rural male smokeless tobacco users. IMPLICATIONS: Among a sample of rural smokeless tobacco users, GHWs attracted more attention and recall of health warning messages compared to text-only warnings when viewed within smokeless tobacco advertising. These findings provide additional empirical support that GHWs are an effective tobacco control tool for all tobacco products and advertisements.

Dietary and physical activity behaviors of adults with developmental disabilities and their direct support professional providers.

BACKGROUND: People with developmental disabilities lead more sedentary lifestyles, consume poorer diets, as well as have higher rates of chronic conditions such as diabetes and heart disease when compared to members of the general population. Direct support professionals play a large social role in the lives of their clients with developmental disabilities, and thus have the ability to influence the health behaviors of their clients. OBJECTIVES: The overall purpose of this study was to examine the relationship between the dietary and physical activity behaviors of direct support professionals and their clients with developmental disabilities, as well as to assess how direct support professionals facilitate the health behaviors of their clients. METHODS: A statewide random sample of direct support professionals (n = 398) completed an online survey about their own dietary/physical activity behaviors and these same health behaviors of their adult clients with developmental disabilities. Pearson/Spearman correlations were used to examine the relationship between the health behaviors of direct support professionals and their clients with developmental disabilities. RESULTS: Small-to-moderate correlations (ρ or r = 0.127-0.333) between direct support professionals' and clients' behaviors existed for all dietary and physical activity health behaviors except for participation in some sort of moderate-to-vigorous physical activity each week (ρ = 0.098, p = 0.06). CONCLUSIONS: Direct support professionals appear to play a role in the dietary/physical activity behaviors of their clients; however, future research on this topic should also include other key members of the social networks of adults with developmental disabilities such as family members, roommates, and day-habilitation providers.

Effectiveness of Two Community Health Worker Models of Tobacco Dependence Treatment Among Community Residents of Ohio Appalachia.

INTRODUCTION: Community health workers (CHW) may be effective in the delivery of tobacco dependence treatment with underserved groups. This study evaluated two evidence-based CHW models of treatment. It was hypothesized that smokers assigned to a CHW face-to-face condition would have higher abstinence at 12-month posttreatment than smokers enrolled in CHW referral to a state-sponsored quitline condition. Intrapersonal and treatment-related factors associated with abstinence at 12 months were determined. METHODS: A group-randomized trial was conducted with residents of 12 Ohio Appalachian counties with counties (n = 6) randomized to either a CHW face-to-face (F2F) or CHW quitline (QL) condition. Both conditions included behavioral counseling and free nicotine replacement therapy for 8 weeks. Follow-up data were collected at 3-, 6-, and 12-month posttreatment. Biochemically validated abstinence at 12 months served as the primary outcome. RESULTS: Seven hundred and seven participants were enrolled (n = 353 CHWF2F; n = 354 CHWQL). Baseline sample characteristics did not differ by condition. Using an intent-to-treat analysis (85.4% retention at 12 months), 13.3% of CHWF2F participants were abstinent at 12 months, compared to 10.7% of CHWQL members (OR = 1.28; 95% confidence interval [CI] = 0.810, 2.014; p = .292). No differences in abstinence were noted at 3 or 6 months by condition. Age, marital status, and baseline levels of cigarette consumption, depressive symptoms, and self-efficacy for quitting in positive settings were associated with abstinence, as was counseling dose during treatment. CONCLUSIONS: This research adds to the body of science evaluating the effectiveness of CHW models of tobacco dependence treatment. Both approaches may offer promise in low-resource settings and underserved regions. IMPLICATIONS: This 12-county community-based group-randomized trial in Ohio Appalachia adds to the body of science evaluating the effectiveness of CHW models of tobacco dependence treatment. Both CHW approaches may offer promise in low-resource settings and underserved regions. These findings are useful to national, state, and local tobacco control agencies, as they expand delivery of preventive health care services postadoption of the Affordable Care Act in the United States.

Are retailers compliant with zoning regulations that ban tobacco sales near schools in Changsha, China?

BACKGROUND: Tobacco retail sales are prohibited within 100 m of schools in many large cities in China. However, little is known about the enforcement of this zoning regulation. The objectives of this study were to estimate tobacco retailers' compliance with the regulation, examine the density of tobacco retail stores, describe the types of tobacco products sold in stores and how they are marketed, and determine if there are displays of warning messages in retail stores around schools and in neighbourhoods in Changsha, China. METHODS: Tobacco retail stores located within 200 m of 36 schools and 36 residential neighbourhoods were audited by trained students with a validated audit form. RESULTS: On average, there were about 3 tobacco retail stores within 100 m of the front entrance of schools. The density of the stores and the types of tobacco products sold in the stores were similar near schools and in neighbourhoods. Over one-fourth of the stores had exterior tobacco advertisements. Interior advertising was slightly less prevalent, and it was most prevalent among tobacco shops (62.5%). Tobacco displays that target children were pervasive, with about 83% of tobacco retail stores displaying cigarettes within 1 m of the floor and 59% displaying cigarettes within 0.3 m of toys and candy. About 40% of stores within 100 m of a school had a visible retail licence. Only 19.6% of the stores had a 'smoke-free' sign and 22.2% had a 'no sales to minors' sign. CONCLUSIONS: We observed low enforcement of the regulation that bans tobacco retail sales near schools and high prevalence of tobacco displays that target children in Changsha, China. Chinese officials should act to effectively enforce the regulation bans of tobacco sales near schools. In addition, regulations are urgently needed to limit tobacco marketing practices at the point of sale, especially those targeting youth.