Association of racial discrimination in health care settings and use of electronic cigarettes to quit smoking among Black adults.

INTRODUCTION: Black people are disproportionately burdened by tobacco-related diseases and are less successful at cigarette cessation with current treatments. We know little about the effectiveness of e-cigarettes as a smoking cessation method compared to currently approved methods in Black adults who smoke. Many Black adults report experiencing racial discrimination in health care, but if discrimination is related to utilization of smoking cessation aids including e-cigarettes and success with smoking cessation in this population is unclear. Therefore, this exploratory study aimed to understand how negative experiences and racial discrimination in health care influence use of e-cigarettes for cigarette cessation and success with cigarette cessation among Black adults. METHODS: The study interviewed 201 Black adults who used cigarettes and tried to quit in their lifetime from the Family and Community Health Study in 2016. The study asked if they had tried and successfully quit cigarettes with e-cigarettes vs. other methods (support groups, medications, nicotine replacement therapies, call-in help lines, cold turkey [quit on their own], counseling) and asked about their negative experiences and racial discrimination in health care. We performed separate logistic regressions that evaluated the association of negative experiences and racial discrimination in health care with 1) use of e-cigarettes for cigarette cessation vs. other quitting methods and 2) success with cigarette cessation using any method among Black adults while controlling for age, sex, socioeconomic status, health insurance status, and age of onset of cigarette use. RESULTS: More reported negative experiences and racial discrimination in health care were associated with ever trying to quit with e-cigarettes compared to other methods (OR:1.75, 95 % CI [1.05-2.91]), but negative experiences and racial discrimination in health care were not associated with cigarette quitting success. Interestingly, trying e-cigarettes was associated with being less successful at quitting compared to using other methods to quit smoking (OR: 0.40, 95 % CI [0.20, 0.81]). CONCLUSIONS: These results suggest that educating health care professionals that anticipated discrimination in health care settings may be driving Black adults who smoke to engage in non-evidence-based smoking cessation practices, such as e-cigarettes instead of those that are evidence-based, and may be more effective in this population.

Association of Non-Cigarette Tobacco Advertisements and Racial Discrimination With Non-Cigarette Tobacco Product Use Among Black Adults.

INTRODUCTION: Black communities are targeted by more cigarette advertisements than White communities and racial discrimination among Black people is related to cigarette use. However, little is known about these factors with non-cigarette tobacco product use among Black adults. Therefore, this study assessed the association of non-cigarette advertisement exposure and racial discrimination with use of non-cigarette tobacco products among Black adults. AIMS AND METHODS: Black adults (n = 533) from The Family and Community Health Study in 2016 were asked if they had seen advertisements for e-cigarettes, snus pouches, filtered cigars, large cigars, cigarillos, dissolvable tobacco, smokeless tobacco, hookah, and tobacco pipe and if they used these in the past month. For products with the highest past month use and significant correlations with advertisement exposure, separate logistic regression models were performed that evaluated the association between advertisement exposure, racial discrimination, and non-cigarette tobacco product use while controlling for cigarette use, sex, socioeconomic status, and age. RESULTS: Use of cigarillos, large cigars, and hookah were higher than other non-cigarette tobacco products assessed. Logistic regressions revealed that more advertisement exposure in the past month was associated with higher odds of using cigarillos, large cigars, and hookah (p < .01). More experiences of racial discrimination were associated with past month cigarillo use, but not hookah or large cigars (p < .01). CONCLUSIONS: Non-cigarette tobacco advertisement exposure was associated with the use of non-cigarette tobacco products. Experiences of racial discrimination were associated with the most used non-cigarette tobacco product among Black adults, cigarillos. IMPLICATIONS: This is the first time that a specific type of cigar (ie cigarillos) has been associated with experiences of racial discrimination among Black adults. Efforts to reduce non-cigarette tobacco marketing and eradicate exposure to racial discrimination among Black adults may aid in eliminating tobacco-related health disparities.

Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift.

INTRODUCTION: To eliminate tobacco-related disparities, tobacco control research would benefit from a paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s, has the potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use, and improve our ability to address persistent tobacco-related health disparities. AIMS AND METHODS: In this commentary, we outline the rationale and recommendations for incorporating intersectionality into equity-minded tobacco control research. These recommendations arose from intersectionality webinars organized by the Health Disparities (now Health Equity) Network of the Society for Research on Nicotine & Tobacco (SRNT) in 2019 and 2020. RESULTS: Specifically, we propose that eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. We summarize priority actions for the tobacco control research field to achieve health equity through the intersectionality framework including acknowledging that structural factors, racism and power dynamics shape lived experiences, integrating critical theoretical frameworks and intersectionality scholarship into research questions, and embracing collaborative community-based approaches at every level of the research process. CONCLUSIONS: Through these actions, our field can take concrete steps to fundamentally improve our approach to conducting research to achieve health equity. IMPLICATIONS: Intersectionality is a valuable tool to align our field with our pursuit of health equity. The recommendations aim to improve methods of equity-focused tobacco control, prompt ongoing dialogue on the utility of this tool, and shift paradigms in how the research process is conducted at every level among stakeholders, including researchers, journal editors and reviewers, funders, practitioners, and policy makers.

Centering racial justice for Black/African American and Indigenous American people in commercial tobacco product regulation.

Although overall health in the United States (US) has improved dramatically during the past century, long-standing health inequities, particularly the unequal and unjust burden of tobacco-related disease and death among racialized populations, persist. A considerable gap exists in our understanding of how commercial tobacco product regulations and policies cause and/or exacerbate race-based health inequities among Black/African American (B/AA) and Indigenous American people. The purpose of this paper is to 1) describe how existing US commercial tobacco regulatory policies may contribute to structural racism and undermine the full benefits of tobacco prevention and control efforts among B/AA and Indigenous American groups; and 2) initiate a call to action for researchers and regulators of tobacco products to examine policies using an equity lens. These actions are imperative if empirically-informed regulation of commercial tobacco products is to address health equity.

Racial/Ethnic Disparities Across Indicators of Cigarette Smoking in the Era of Increased Tobacco Control, 1992-2019.

INTRODUCTION: This study compared tobacco use and cessation for African Americans (AA), Asians/Pacific Islanders (API), Hispanics/Latinos (H/L), American Indian/Alaskan Natives (AI/AN), and non-Hispanic Whites (NHW) in the United States to California (CA), the state with the longest continually funded tobacco control program. The purpose of this study was to identify tobacco use disparities across racial/ethnic groups across time. METHODS: Cigarette use prevalence (uptake and current use), consumption (mean number of cigarettes smoked per day [CPD]), and quit ratios were calculated across survey years, and trends were examined within each race/ethnic group and comparing between CA and the United States, utilizing the 1992-2019 Tobacco Use Supplements to the Current Population Survey. RESULTS: Prevalence decreased for all race/ethnic groups. Current use among CA NHW showed significant decline compared with US counterparts, whereas US H/L showed greater decline than CA counterparts. CPD decreased by approximately 30% across race/ethnic groups, with CA groups having lower numbers. The greatest decrease occurred among AA in CA (average 10.3 CPD [95% confidence interval (CI): 10.3, 12.6] in 1992/1993 to 3 CPD [95% CI: 2.4, 3.7] in 2018/2019). Quit ratios increased from 1992/1993 to 2018/2019 for CA H/L 52.4% (95% CI: 49.8, 53.0) to 59.3 (95% CI: 55.8, 62.5) and CA NHWs 61.5% (95% CI: 60.7, 61.9) to 63.8% (95% CI: 63.9, 66.9). CONCLUSIONS: Although overall prevalence decreased over time for each racial/ethnic group, declines in CA outpaced the United States only for NHWs. Reductions in CPD were encouraging but the quit ratio points to the need to increase tobacco control efforts toward cessation. IMPLICATIONS: The successes in reduced cigarette use uptake and prevalence across time for both California and the rest of the United States were observed largely among non-Hispanic White populations. Although reductions in the number of cigarettes smoked per day are a notable success, particularly among the Californian African Americans, efforts to support quitting across racial/ethnic groups, especially marginalized groups, need to be prioritized.

Widening disparities in cigarette smoking by race/ethnicity across education level in the United States.

Reducing tobacco use is an important public health objective. It is the largest preventable cause of death and disease, yet inequalities remain. This study examines combined educational and racial/ethnic disparities in the United States related to cigarette smoking for the three largest racial/ethnic groups (African Americans, Hispanics/Latinos, and non-Hispanic Whites). Data included nine Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) conducted in the United States from 1992/1993-2018 for four smoking metrics: ever smoking rates, current smoking rates, consumption (cigarettes per day), and quit ratios. Across all TUS-CPS samples, there were 9.5% African Americans, 8.8% Hispanics/Latinos, and 81.8% non-Hispanic Whites who completed surveys. Findings revealed that lower educational attainment was associated with increased ever and current smoking prevalence over time across all racial/ethnic groups, and education-level disparities within each race/ethnicity widened over time. Disparities in ever and current smoking rates between the lowest and highest categories of educational attainment (less than a high school education vs. completion of college) were larger for African Americans and non-Hispanic Whites than Hispanics/Latinos. Non-Hispanic Whites had the highest cigarette consumption across all education levels over time. College graduates had the highest quit ratios for all racial/ethnic groups from 1992 to 2018, with quit ratios significantly increasing for Hispanics/Latinos and non-Hispanic Whites, but not African Americans. In conclusion, educational disparities in smoking have worsened over time, especially among African Americans and Hispanics/Latinos. Targeted tobacco control efforts could help reduce these disparities to meet public health objectives, although racial/ethnic disparities may persist regardless of educational attainment.

Impact of the Society for Research on Nicotine and Tobacco Health Disparities Network's Scholarship on Professional Development of Its Recipients.

INTRODUCTION: Diversifying the workforce is an important strategy to reducing health disparities. Since 2007, the Society for Research on Nicotine and Tobacco (SRNT) Health Disparities Network has funded a travel scholarship to promote inclusion, professional development, and diversity among investigators interested in tobacco-related health disparities research. This study examined indicators of productivity among former scholarship recipients.Methods: Scholarship recipients between 2007 and 2014 were invited to complete a survey online. The survey assessed demographic characteristics, academic productivity, and perceived professional benefit resulting from the scholarship.Results: Of the 117 scholarships recipients, 89 (77%) responded. Respondents were 67% female and had a mean age of 37.8 years. Twenty eight percent were African American, 25% Asian American, and 17% Latino. Most respondents worked in academia (80%) and nearly three-quarters (74%) reported publishing manuscripts on tobacco-related disparities, with a mean of 3.8 (SD 4.4) disparities-related publications since receiving the scholarship. Respondents' work focused on a wide range of health disparities topics and nearly all respondents reported that the scholarship removed barriers to attending the meeting and reported professional benefit from receiving the travel scholarship. Following receipt of the SRNT travel scholarship, a diverse group of scientists demonstrated scholarly productivity, professional development, and advancement of health disparities research. Similar efforts are encouraged in other professional societies. IMPLICATIONS: This study examines the productivity of early career recipients of the SRNT Health Disparities Scholarship. Results suggest that the investment in annual travel scholarships by a professional organization is an important support system for emerging scientists from diverse backgrounds. This investment may help to advance the science of health disparities and engage researchers in an area where there are critical gaps in the research workforce.

The Casualties Left Behind in Tobacco's Cinders of Combustion.

PURPOSE: This paper 1) defines the scope of tobacco-related health disparities; 2) reviews population-based approaches aimed to eliminate disparities- Medicaid, the U.S. Preventive Health Service Task Force, and the Family Smoking Prevention and Tobacco Control Act; and 3) discusses their potential role in reducing tobacco use and lung cancer disparities. RECENT FINDINGS: The implementation of population-based approaches aimed to reduce tobacco use and chronic diseases has been inequitable. The poor are predominately affected by limited access to comprehensive tobacco cessation coverage. Moreover, lung cancer screenings reveal that those disproportionately excluded are African Americans who have the highest lung cancer incidence and mortality in the United States. The potential impact of the Family Smoking Prevention and Tobacco Control Act is unclear, but the proposed rule to ban menthol combustible and not non-combustible tobacco products could potentially contribute to a cycle of addiction in disadvantaged communities. Alternative solutions, including civil rights litigation, should be investigated. SUMMARY: Eliminating tobacco-related health disparities is a health, social justice, civil rights, and ethical issue that deserves immediate attention and equitable policy solutions.

Social media e-cigarette exposure and e-cigarette expectancies and use among young adults.

A vast majority of U.S. young adults use social media such as Facebook and Instagram daily. Research suggests that young adults are commonly exposed to e-cigarette-related marketing or user-generated content on the social media they use. Currently, however, there is limited empirical evidence as to how social media e-cigarette exposure is associated with e-cigarette use beliefs and behavior. In particular, limited evidence exists to support the proposition that social media e-cigarette exposure is uniquely associated with e-cigarette use, even after adjusting for the effects of e-cigarette use in young adults' in-person or 'offline' social networks. This study was conducted to test the hypotheses that 1) social media e-cigarette exposure is associated with e-cigarette use outcome expectancies and current e-cigarette use; and 2) the association between social media and e-cigarette use is linked via outcome expectancies. We collected cross-sectional data from a sample of 470 young adult college students in Hawaii. Hypotheses were tested by fitting a structural equation model to the data. The model accounted for the associations of demographic variables, cigarette smoking history, as well as e-cigarette use in individuals' actual social networks with expectancies and behavior. Results indicated that social media e-cigarette exposure was associated with current e-cigarette use indirectly through two of the four positive outcome expectancies examined, namely, positive "smoking" experience and positive sensory experience. We discuss the implications of the findings in the context of tobacco control efforts.

Associations Between Cigarette Print Advertising and Smoking Initiation Among African Americans.

OBJECTIVES: The objective of this study was to examine changes in the annual number of cigarette advertisements in magazines with a predominantly African-American audience following the broadcast ban on tobacco, and whether fluctuations in cigarette print advertising targeting African Americans during the late-1970s until the mid-1980s were associated with declines in smoking initiation. DESIGN: We tabulated the annual number of cigarette advertisements from magazines with large African-American readerships (Ebony, Essence, and Jet) from 1960 to 1990. Advertisements were coded depending on whether they featured African-American models. We calculated the incidence rate of regular smoking initiation from 1975 to 1990 for African-American 14-25 years old using data from the 1992-1993, 1995-1996, 1998-1999, and 2001-2002 Tobacco Use Supplements of the Current Population Survey. We examined whether trends in smoking initiation coincided with trends in cigarette advertising practices among African Americans. RESULTS: The annual aggregated number of printed cigarette advertisements in Ebony, Essence, and Jet magazines increased at least five-fold starting in 1971, following the broadcast ban on cigarette advertising. A decrease in the percentage of ads by Brown & Williamson that showed African-American models was positively correlated (r = 0.30) with declines in the incidence rate of smoking initiation among African Americans from the late-1970s to the mid-1980s. CONCLUSION: The tobacco industry adapted quickly following the broadcast ban on cigarettes by increasing print advertising in African-American magazines. However, changes in print advertising practices by were associated with declines in smoking initiation among African Americans from the late-1970s to mid-1980s.

Tobacco use disparities by racial/ethnic groups: California compared to the United States.

Racial/ethnic disparities in cigarette use and cessation persist. This study compared cigarette consumption and former smoking trends in California (CA) with the rest of the United States (US) by racial/ethnic categories of non-Hispanic White, Black, Hispanic/Latino, and Asian/Pacific Islander groups. Data were analyzed from the 1992 to 2011 Tobacco Use Supplement to the Current Population Survey. Consumption levels across decades were examined and adjusted logistic regression models were fit to compare across CA and US. Results indicated steady declines in ever smoking prevalence for all groups with much lower magnitudes of change among US Blacks and Whites compared to their CA counterparts. After controlling for age, gender, and education, CA had significantly fewer heavy smokers (OR=0.45, 95% CI:0.38-0.54), more light and intermittent smokers (LITS; OR=1.68, 95%CI: 1.45-1.93), and a greater proportion of former smokers (OR=1.35, 95%CI: 1.24-1.48) than the rest of US. Data were stratified by race/ethnicity and the patterns shown were mostly consistent with CA performing statistically better than their US counterparts with the exception of Black LITS and Asian/Pacific Islander former smokers. California's success in reducing tobacco use disparities may serve as a prime example of tobacco control policy for the country. CA and the US will need to continue to address tobacco use and cessation in the context of the growing diversity of the population.

E-cigarette advertising exposure and implicit attitudes among young adult non-smokers.

BACKGROUND: This study tested whether exposure to e-cigarette advertising affects the subliminal-spontaneous or automatic-attitudes towards e-cigarettes as a more pleasant or safer alternative to cigarettes among non-smoking young adults. METHODS: 187 young adult (mean age=21.9; SD=4.1) current non-smokers who had never used an e-cigarette were randomly assigned to one of the 3 conditions that involved viewing magazine advertisements. Two of the 3 conditions were experimental conditions where thematically different [harm-reduction ("Health") vs. social enhancement ("Social") focused] e-cigarette ads were interspersed among ads of everyday objects. The third condition was the control condition in which participants viewed ads of everyday objects only. Participants provided data on explicit (e.g., harm perceptions) and implicit [e.g., Implicit Association Test (IAT), Affect Misattribution Procedure (AMP)] measures after viewing the ads. RESULTS: Relative to the Control condition, participants in the Social condition showed 2.8 times higher odds of being open to using an e-cigarette in the future. Participants in the Health condition showed significantly higher implicit attitudes towards e-cigarettes as a safer alternative to cigarettes than participants in the Control condition. E-cigarette stimuli elicited more positive spontaneous affective reactions among participants in the Social condition than participants in the Health condition. CONCLUSIONS: E-cigarette ads may implicitly promote e-cigarettes as a reduced-harm cigarette alternative. Marketing of e-cigarette use as a way to enhance social life or self-image may encourage non-smoking young adults to try e-cigarettes. Findings may inform regulations on e-cigarette marketing.

Working to Eliminate Cancer Health Disparities from Tobacco: A Review of the National Cancer Institute's Community Networks Program.

INTRODUCTION: In 2005, the National Cancer Institute funded the Community Networks Program (CNP), which aimed to reduce cancer health disparities in minority racial/ethnic and underserved groups through community-based participatory research, education, and training. The purpose of this study was to describe the CNP model and their tobacco-related work in community-based research, education, and training using a tobacco disparities research framework. METHODS: We conducted a comprehensive review of the CNP tobacco-related activities including publications, published abstracts, research activities, trainee pilot studies, policy-related activities, educational outreach, and reports produced from 2005-2009. Two authors categorized the tobacco-related activities and publications within the framework. RESULTS: Although there was no mandate to address tobacco, the CNPs produced 103 tobacco-related peer-reviewed publications, which reflects the largest proportion (12%) of all CNP cancer-related publications. Selected publications and research activities were most numerous under the framework areas "Psychosocial Research," "Surveillance," "Epidemiology," and "Treatment of Nicotine Addiction." Thirteen CNPs participated in tobacco control policymaking in mainstream efforts that affected their local community and populations, and 24 CNPs conducted 1147 tobacco-related educational outreach activities. CNP activities that aimed to build research and infrastructure capacity included nine tobacco-related pilot projects representing 16% of all CNP cancer-related pilot projects, and 17 publications acknowledging leveraged partnerships with other organizations, a strategy encouraged by the CNP. CONCLUSIONS: The CNP is a promising academic-community model for working to eliminate tobacco-related health disparities. Future efforts may address scientific gaps, consider collaboration across groups, assess the extent of operationalizing community-based participatory research, and improve common tracking measures.

Disparities in the Population Distribution of African American and Non-Hispanic White Smokers Along the Quitting Continuum.

PURPOSE: To examine disparities and changes over time in the population-level distribution of smokers along a cigarette quitting continuum among African American smokers compared with non-Hispanic Whites. METHODS: Secondary data analyses of the 1999, 2002, 2005, and 2008 California Tobacco Surveys (CTS). The CTS are large, random-digit-dialed, population-based surveys designed to assess changes in tobacco use in California. The number of survey respondents ranged from n = 6,744 to n = 12,876 across CTS years. Current smoking behavior (daily or nondaily smoking), number of cigarettes smoked per day, intention to quit in the next 6 months, length of most recent quit attempt among current smokers, and total length of time quit among former smokers were assessed and used to recreate the quitting continuum model. RESULTS: While current smoking rates were significantly higher among African Americans compared with non-Hispanic Whites across all years, cigarette consumption rates were lower among African Americans in all years. There were significant increases in the proportion of former smokers who had been quit for at least 12 months from 1999 (African Americans, 26.8% ± 5.5%; non-Hispanic Whites, 36.8% ± 1.6%) to 2008 (African Americans, 43.6% ± 4.1%; non-Hispanic Whites, 57.4% ± 2.9%). The proportion of African American former smokers in each CTS year was significantly lower than that of non-Hispanic Whites. CONCLUSIONS: Despite positive progression along the quitting continuum for both African American and non-Hispanic White smokers, the overall distribution was less favorable for African Americans. The lower smoking consumption levels among African Americans, combined with the lower rates of successful smoking cessation, suggest that cigarette addiction and the quitting process may be different for African American smokers.

Smoking Trends and Disparities Among Black and Non-Hispanic Whites in California.

OBJECTIVES: The current study examined disparities in smoking trends across Blacks and non-Hispanic Whites in California. METHODS: Data from the 1996 to 2008 California Tobacco Survey were analyzed to examine trends in smoking behaviors and cessation across Blacks and non-Hispanic Whites. RESULTS: A decrease in overall ever and current smoking was observed for both Black and non-Hispanic Whites across the 12-year time period. A striking decrease in proportions of heavy daily smokers for both Black and non-Hispanic Whites were observed. Proportions of light and intermittent smokers and moderate daily smokers displayed modest increases for Blacks, but large increases for non-Hispanic Whites. Increases in successful cessation were also observed for Blacks and, to a lesser extent, for non-Hispanic Whites. DISCUSSION: Smoking behavior and cessation trends across Blacks and non-Hispanic Whites were revealing. The decline in heavy daily and former smokers may demonstrate the success and effectiveness of tobacco control efforts in California. However, the increase in proportions of light and intermittent smokers and moderate daily smokers for both Blacks and non-Hispanic Whites demonstrates a need for tobacco cessation efforts focused on lighter smokers.

Smokers who try e-cigarettes to quit smoking: findings from a multiethnic study in Hawaii.

OBJECTIVES: We characterized smokers who are likely to use electronic or "e-"cigarettes to quit smoking. METHODS: We obtained cross-sectional data in 2010-2012 from 1567 adult daily smokers in Hawaii using a paper-and-pencil survey. Analyses were conducted using logistic regression. RESULTS: Of the participants, 13% reported having ever used e-cigarettes to quit smoking. Smokers who had used them reported higher motivation to quit, higher quitting self-efficacy, and longer recent quit duration than did other smokers. Age (odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.97, 0.99) and Native Hawaiian ethnicity (OR = 0.68; 95% CI = 0.45, 0.99) were inversely associated with increased likelihood of ever using e-cigarettes for cessation. Other significant correlates were higher motivation to quit (OR = 1.14; 95% CI = 1.08, 1.21), quitting self-efficacy (OR = 1.18; 95% CI = 1.06, 1.36), and ever using US Food and Drug Administration (FDA)-approved cessation aids such as nicotine gum (OR = 3.72; 95% CI = 2.67, 5.19). CONCLUSIONS: Smokers who try e-cigarettes to quit smoking appear to be serious about wanting to quit. Despite lack of evidence regarding efficacy, smokers treat e-cigarettes as valid alternatives to FDA-approved cessation aids. Research is needed to test the safety and efficacy of e-cigarettes as cessation aids.

Unintended consequences of cigarette price changes for alcohol drinking behaviors across age groups: evidence from pooled cross sections.

BACKGROUND: Raising prices through taxation on tobacco and alcohol products is a common strategy to raise revenues and reduce consumption. However, taxation policies are product specific, focusing either on alcohol or tobacco products. Several studies document interactions between the price of cigarettes and general alcohol use and it is important to know whether increased cigarette prices are associated with varying alcohol drinking patterns among different population groups. To inform policymaking, this study investigates the association of state cigarette prices with smoking, and current, binge, and heavy drinking by age group. METHODS: The 2001-2006 Behavioral Risk Factor Surveillance System surveys (n = 1,323,758) were pooled and analyzed using multiple regression equations to estimate changes in smoking and drinking pattern response to an increase in cigarette price, among adults aged 18 and older. For each outcome, a multiple linear probability model was estimated which incorporated terms interacting state cigarette price with age group. State and year fixed effects were included to control for potential unobserved state-level characteristics that might influence smoking and drinking. RESULTS: Increases in state cigarette prices were associated with increases in current drinking among persons aged 65 and older, and binge and heavy drinking among persons aged 21-29. Reductions in smoking were found among persons aged 30-64, drinking among those aged 18-20, and binge drinking among those aged 65 and older. CONCLUSIONS: Increases in state cigarette prices may increase or decrease smoking and harmful drinking behaviors differentially by age. Adults aged 21-29 and 65 and older are more prone to increased drinking as a result of increased cigarette prices. Researchers, practitioners, advocates, and policymakers should work together to understand and prepare for these unintended consequences of tobacco taxation policy.

Multilevel intervention research: lessons learned and pathways forward.

This summary reflects on this monograph regarding multilevel intervention (MLI) research to 1) assess its added value; 2) discuss what has been learned to date about its challenges in cancer care delivery; and 3) identify specific ways to improve its scientific soundness, feasibility, policy relevance, and research agenda. The 12 submitted chapters, and discussion of them at the March 2011 multilevel meeting, were reviewed and discussed among the authors to elicit key findings and results addressing the questions raised at the outset of this effort. MLI research is underrepresented as an explicit focus in the cancer literature but may improve implementation of studies of cancer care delivery if they assess contextual, organizational, and environmental factors important to understanding behavioral and/or system-level interventions. The field lacks a single unifying theory, although several psychological or biological theories are useful, and an ecological model helps conceptualize and communicate interventions. MLI research designs are often complex, involving nonlinear and nonhierarchical relationships that may not be optimally studied in randomized designs. Simulation modeling and pilot studies may be necessary to evaluate MLI interventions. Measurement and evaluation of team and organizational interventions are especially needed in cancer care, as are attention to the context of health-care reform, eHealth technology, and genomics-based medicine. Future progress in MLI research requires greater attention to developing and supporting relevant metrics of level effects and interactions and evaluating MLI interventions. MLI research holds an unrealized promise for understanding how to improve cancer care delivery.