Availability of snus and its sale to minors in a large Minnesota city.

INTRODUCTION: Previous studies examining tobacco retailers' compliance with youth tobacco access policies have mostly evaluated retailers' likelihood of selling cigarettes to minors, and none have evaluated the likelihood of selling snus (a new smokeless tobacco product) to minors. We assessed the availability of snus and the likelihood of selling snus to adolescents in tobacco retailers in a large city in Minnesota. METHODS: We randomly selected 71 eligible retailers located in a large city in Minnesota, and assessed the availability of snus through Camel snus retailer listings and phone inquiry. Purchase attempts by an underage buyer were used to assess the likelihood of selling snus to minors. χ2 tests were used to examine the store and neighbourhood characteristics associated with availability of snus. RESULTS: We found that 31 retailers (43.7%) carried snus in the store, and 4 (12.9%) sold snus to the underage buyer. Retailers who sold gasoline were more likely to carry snus in the store (p<0.01). Neighbourhood demographic characteristics were not associated with availability of snus (p>0.10). CONCLUSIONS: Prevalence of snus sales to minors appeared to be higher than that of cigarette sales to minors according to the 2011 Synar report. Futures studies are needed to determine whether tobacco retailers are more likely to sell snus than cigarettes to minors. Interventions such as public and retailer policies are needed to reduce the likelihood of tobacco retailers selling snus to minors.

Young adults' favorable perceptions of snus, dissolvable tobacco products, and electronic cigarettes: findings from a focus group study.

OBJECTIVES: We explored young adults' perceptions of snus (spitless moist snuff packed in porous bags), dissolvable tobacco products, and electronic cigarettes and intention to try these products. METHODS: We conducted 11 focus group discussions involving a total of 66 young adults (18-26 years old) on these new tobacco products (e.g., harmfulness, potential as quit aids, intention to try) held between July and December 2010. We analyzed discussions using a thematic approach. RESULTS: Participants generally reported positive perceptions of the new products, particularly because they came in flavors. Few negative perceptions were reported. Although some participants believed these products were less harmful than cigarettes and helpful in quitting smoking, others thought the opposite, particularly regarding electronic cigarettes. Participants also commented that these products could be gateways to cigarette smoking. Half of the participants, including a mix of smokers and nonsmokers, admitted they would try these products if offered by a friend. CONCLUSIONS: Young adults perceive the new tobacco products positively and are willing to experiment with them. Eliminating flavors in these products may reduce young adults' intentions to try these products.

Can we assess blood alcohol levels of attendees leaving professional sporting events?

BACKGROUND: We measured blood alcohol content (BAC) levels of attendees at professional sporting events and assessed the factors associated with higher BACs. METHODS: We conducted BAC tests of 362 adult attendees following 13 baseball games and three football games. We ran multivariate analyses to obtain factors associated with the risk of having a higher BAC. RESULTS: In this assessment, 40% of the participants had a positive BAC, ranging from 0.005 to 0.217. Those who reported tailgating before the event had 14 times the odds of having a BAC > 0.08 and those under age 35 had nearly 8 times the odds of having a BAC > 0.08 (both compared to a zero BAC). Attendees of Monday night football games were more likely to have positive BACs compared to attendees at all other games. CONCLUSIONS: We found that it is feasible to assess BAC levels of attendees at professional sporting events. Our findings suggest that a significant number of attendees at professional sporting events may have elevated BAC levels, particularly young adults and those who participated in tailgating activities. Further research using a representative sample is warranted to confirm the findings from this preliminary study.

Smoke-free laws in bars and restaurants: does support among teens and young adults change after a statewide smoke-free law?

OBJECTIVE: We assessed changes in levels of support for smoke-free bars and restaurants among teens and young adults before and after implementation of a statewide smoke-free law. METHODS: We measured support for smoke-free bars and restaurants among teens and young adults aged 16-24 years living in Minnesota (n=2,785) and five comparison states (n=404), up to 12 months before and up to six months after Minnesota's smoke-free law went into effect in October 2007. We compared changes in support among three subgroups-Minnesota participants who lived with a previous local smoke-free law, Minnesota participants who did not live with a previous local smoke-free law, and participants from the comparison states-before and after Minnesota's statewide smoke-free law went into effect. RESULTS: Support for smoke-free restaurants and bars among participants in Minnesota and comparison states increased after Minnesota's smoke-free law went into effect. Minnesotans, both those living with and without a previous local smoke-free law, showed similar increases in support for smoke-free restaurants as participants in comparison states. However, Minnesotans living without a previous local law showed larger increases in support for smoke-free bars than both those in comparison states and those living in Minnesota with a previous local smoke-free law. CONCLUSIONS: Our study employed a more robust design than similar studies and focused on the teen and young adult population. Our results will help advocates and policy makers demonstrate how public support for smoke-free laws increases following smoke-free legislation, particularly among those who were not previously living with a local smoke-free law.

Alcohol control policies and practices at professional sports stadiums.

OBJECTIVE: Alcohol-related problems such as assaults and drinking-driving at or near professional sporting events are commonly reported in the media. An important strategy to reduce such problems may be the use of alcohol control policies at sports stadiums. The objective of this study was to examine alcohol control policies and practices at professional sports stadiums in the U.S. METHODS: We conducted a telephone survey of food/beverage managers from 66 of the 100 U.S professional sports stadiums that house a professional hockey, basketball, baseball, and/or football team. The survey consisted of 18 items pertaining to policies regulating alcohol sales and consumption. RESULTS: Most managers indicated that their stadium had a range of alcohol control policies and practices. For example, all or nearly all reported their stadium allows no more than two alcoholic beverages per sale and their alcohol servers are required to check age identification of patrons who appear younger than age 30. In contrast, only about half prohibit servers younger than 21 years of age from selling alcohol both in seating areas and at concession booths, and approximately one-third designate sections of their stadiums as alcohol-free. CONCLUSIONS: Although we found that some alcohol control policies appear to be common across stadiums, others are uncommon, leaving room for potential areas of improvement in reducing or preventing alcohol-related problems at professional sporting events. The results provide an important starting point for identifying policies that can be evaluated to determine their effectiveness in reducing alcohol-related injuries and deaths at sporting events.

Law enforcement practices in the first two states in U.S. to legalize recreational marijuana.

BACKGROUND: There is a lack of research regarding law enforcement practices where recreational marijuana sales are legal. Given that legalization of recreational marijuana is expanding, lessons learned from areas with existing legalization can help inform future practices. This pilot study is an evaluation of enforcement of marijuana laws in the first two states in the U.S. to legalize sales of recreational marijuana, Colorado and Washington, several years post legalization. METHODS: We surveyed a random sample of local law enforcement agencies in the two states (25 agencies per state). We also attempted to survey the state-level marijuana enforcement agency but only Washington responded. Surveys focused on youth marijuana use, youth access to marijuana, and impaired driving but included other topics. Chi-square tests assessed differences between states (p < .05). RESULTS: All local agencies reported underage use was somewhat or very common in their jurisdictions. Thirty percent of local agencies conducted enforcement targeting underage use/possession. Twenty percent of agencies overall conducted underage compliance checks at licensed stores, with more agencies conducting checks in Colorado (32%) than Washington (8%; p = .03). Most agencies in both states reported marijuana-impaired driving was somewhat or very common in their jurisdictions. One local agency in each state specifically targeted marijuana-impaired driving. The state-level agency in Washington reported that their agency is the one primarily responsible for enforcing marijuana retail laws and they conducted routine underage compliance checks at all licensed marijuana stores three times per year. CONCLUSION: Our findings indicate that marijuana enforcement can be improved regarding sales/provision to underage youth and impaired driving in these states, particularly given that underage use and impaired driving are perceived to be common. Larger studies with additional jurisdictions and types of agencies (e.g., highway patrol) are warranted.

Barriers to Quitting Smoking Among Young Adults: The Role of Socioeconomic Status.

PURPOSE: The aims of this analysis were to explore how self-reported barriers to quitting vary by socioeconomic status (SES) among young-adult smokers and to assess their relationship to quitting. DESIGN: This analysis uses 2 waves of telephone-survey data from the Minnesota Adolescent Community Cohort study. SETTING: Midwestern United States. PARTICIPANTS: Participants (n = 419) were smokers aged 17 to 24 years. MEASURES: Socioeconomic status was estimated using the highest level of education completed by the participants' parents. Demographics, smoking behavior, and perceived barriers to quitting were collected via survey questions. ANALYSIS: Differences in barriers by SES were assessed using prevalence ratios (PRs). Relative risks were calculated to assess the association between barriers and quitting status 1 year later, testing for effect modification by SES. RESULTS: Compared to the high SES group (n = 314), the low SES group (n = 105) was more likely to report several barriers to quitting; however, only the risk of gaining weight was significantly more common (PR: 1.38 [1.05-1.83]). There were no significant associations between barriers and quitting status 1 year later, but the number of cigarettes per day was consistently related to the likelihood of quitting 1 year later, regardless of SES. CONCLUSION: Despite the limited generalizability to racially diverse populations and different geographic locations, the results suggest perceived barriers may not differ by SES or predict quitting among young adults; however, nicotine dependence may play an important role.

A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation.

BACKGROUND: Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings. OBJECTIVES: We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care. METHODS: Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts. RESULTS: 1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm3, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones. CONCLUSIONS: This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.

Effects of communities, neighborhoods and stores on retail pricing and promotion of beer.

OBJECTIVE: This study examines how communities, neighborhoods and stores influence retail pricing and promotion of beer. METHOD: In the year 2000, trained field staff conducted observations in 2,024 retail alcohol stores in 160 communities throughout the contiguous United States. Based on a nationally representative sample of schools, we selected communities defined by the school's catchment area, or the vicinity from which the majority of students are drawn. We randomly selected off-sale alcohol retail establishments from a complete list of stores likely to sell tobacco or alcohol in the selected communities. Beer price and promotions are based on observations of Miller and Budweiser beer brands in the stores. Neighborhoods are defined by the store's census block. We used cross-sectional, hierarchical regression models and mixed methods procedures to analyze data. RESULTS: Community, neighborhood and store characteristics were related to beer price; however, only community and store characteristics were predictive of beer promotions. CONCLUSIONS: Overall, the pricing and promotion of beer vary systematically by some characteristics of communities, neighborhoods and stores, but not significantly by the number of young people populating a neighborhood. In addition, pricing and promotion of Budweiser and Miller beers, in particular, do not appear to target racial minority populations. Because of the significant effect of store characteristics, public health agencies and advocates might focus prevention efforts on collaborations with liquor control agencies to reduce variations in pricing and promotion of beer, which ultimately encourage risky drinking behaviors. Further studies are needed to examine the effects of pricing and promotion on alcohol-related social problems.

Young adults' support for adult-ratings for movies depicting smoking and for restrictions on tobacco magazine advertising.

INTRODUCTION: Smoking images in movies and tobacco advertisements in magazines are influential on adolescent smoking behaviors, and restrictions of these advertising strategies can reduce the prevalence of adolescent smoking. We assessed young adults' level of support for adult ratings for movies depicting smoking and for restrictions on tobacco magazine advertising. METHODS: Young adults from the U.S. Midwest were surveyed between 2010-2011 (n=2622). We assessed their level of support for (a) adult-rating all movies depicting smoking, and (b) restrictions on tobacco magazine advertising. Multivariate regression models were used to investigate the characteristics associated with higher level of support for these policies. RESULTS: Overall, 34% of the participants favored adult ratings for movies with smoking images, and 68% favored restrictions on tobacco magazine advertising. Characteristics associated with higher level of support differed somewhat by policy. CONCLUSION: Further educating young adults about the influence of smoking images in movies on adolescent smoking may be necessary to gain more support for the policy. With the majority supporting restrictions on tobacco magazine advertising, it may be possible to tighten these restrictions to further protect adolescents. Future research is needed to identify how tobacco control advocates can frame these issues to gain further public support.

Cigarette use among young adults: comparisons between 2-year college students, 4-year college students, and those not in college.

OBJECTIVE: To examine cigarette smoking among young adults based on education status. PARTICIPANTS: Community-based sample of 2,694 young adults in the United States METHODS: The authors compared 3 groups--those not in college with no college degree, 2-year college students/graduates, 4-year college students/graduates--on various smoking measures: ever smoked, smoked in past month, smoked in past week, consider self a smoker, began smoking before age 15, smoked over 100 cigarettes in lifetime, ever tried to quit, and plan to quit in next year. RESULTS: The authors found that for nearly all the smoking measures, the 4-year college group was at lowest risk, the noncollege group was at highest risk, and the 2-year college group represented a midpoint. Differences between groups remain after adjusting for parents' education and other potential confounding factors. CONCLUSIONS: Smoking behaviors clearly differ between the 2-year, 4-year, and no college groups. Interventions should be tailored for each group.

Sources of cigarettes among adolescent smokers: Free or purchased?

BACKGROUND: Few studies have described youth cigarette sources in terms of whether the cigarettes were free or purchased. Understanding the different ways youth obtain tobacco can guide development of interventions to more effectively reduce youth smoking. PURPOSE: To determine the propensity for youth to purchase cigarettes versus obtain cigarettes for free, and the factors associated with each obtainment method. METHODS: Our sample included 812 youth ages 12-17 who reported ever smoking a whole cigarette. Our outcome was the source of the last cigarette smoked (purchased vs. free) and independent variables included demographics, smoking behaviors, and smoking status of parents/siblings/friends. We conducted logistic regression to assess relationships between outcome and independent variables. RESULTS: Eighty-four percent of youth obtained their last cigarette for free and 16% purchased their last cigarette. Youth who smoked less and had less weekly spending money were more likely to have obtained their last cigarette for free. DISCUSSION: Youth smokers appear to have a high propensity to obtain their cigarette for free, particularly those who smoke relatively infrequently. TRANSLATION TO HEALTH EDUCATION PRACTICE: Interventions that target sources of free cigarettes have the potential to reduce the progression of youth smoking at a critical stage in its development.

Short-term effects of a comprehensive, statewide smokefree law on perceived opportunities to smoke.

BACKGROUND: The goal of this study was to assess the effects of Minnesota's comprehensive, statewide smokefree law on young adults' perceived opportunities to smoke in restaurants and bars. PURPOSE: Differential effects of the law were examined for those living with and without previous local smokefree ordinances. METHODS: Telephone surveys were conducted 6-12 months prior, 0-6 months prior, and 0-6 months after Minnesota's statewide smokefree law went into effect. Participants included young adults from a population-based cohort in Minnesota (n = 1446) and from four other Upper Midwest states that serve as a comparison (n = 238). RESULTS: A greater proportion of Minnesota participants (regardless of previous law) reported it was very hard for an adult to find a place to smoke in both restaurants and bars/clubs after the statewide law, compared to the comparison group. Effects were greater among Minnesota participants who did not live with a local smokefree ordinance previously. CONCLUSIONS: Within 6 months of Minnesota's statewide smokefree law, Minnesota young adults, even those who lived with a prior local smoking ordinance, believed it was more difficult for adults to find a place to smoke in restaurants and bars/clubs. Changing perceived opportunities to smoke in the state may be an initial step in changing social norms and smoking behaviors. These results suggest that statewide smokefree laws may provide additional barriers to smoking, beyond those obtained through local ordinances.

Young adult support for clean indoor air laws in restaurants and bars.

This study examined support for clean indoor air (CIA) laws among 2044 young adults in Minnesota during 2006 and 2007. Two-thirds of young adult participants supported restaurant CIA laws and 40% supported bar/club CIA laws. A higher proportion of young adults living with CIA laws supported the laws compared with young adults living without them. Nonsmokers, college students, those with nonsmoking friends, and those living with home smoking bans were consistently more supportive of both CIA laws.

Where do underage college students get alcohol?

Alcohol consumption and related problems are common among underage college students, yet qualitative, in-depth information on how/where these students obtain alcohol is limited. We conducted focus groups pertaining to access to alcohol and related issues with 19 underage college students. They reported that alcohol is easy to obtain from a variety of sources, with friends/acquaintances who are of legal age or those with a false ID being the most common. Parties were also common sources, but "shoulder tapping" (i.e., asking a stranger to purchase alcohol) was not common. Disagreement arose over whether underage fraternity/sorority members have greater access to alcohol than non-Greeks. Our results provide updated information on the various sources of alcohol and associated issues among underage college students.

Propensity for obtaining alcohol through shoulder tapping.

BACKGROUND: Underage youth often obtain alcohol from adults who illegally provide the alcohol. One method for obtaining alcohol from adults is shoulder tapping, where youth approach an adult outside an alcohol establishment and ask the adult to purchase alcohol for them. The goal of this study was to assess what percentage of the general and youth-targeted adult population approached outside of a convenience/liquor store will agree to purchase and then provide alcohol to individuals who appear under age 21. METHODS: We conducted 2 waves of pseudo-underage shoulder tap request attempts, using requesters who were age 21 or older but appeared 18 to 20 years old. In both waves, requests were conducted at randomly selected liquor and convenience stores, requesters explained that the reason they were asking the adult was because they did not have their identification with them, and requesters asked the adults to purchase a 6-pack of beer. During wave 1, we conducted 102 attempts, with the requester approaching the first adult entering the store alone. During wave 2, we conducted 102 attempts where the requester approached the first casually dressed male entering the store alone who appeared to be 21 to 30 years old. RESULTS: During wave 1, 8% of the general sample of approached adults provided alcohol to the pseudo-underage requesters. The odds of adults providing alcohol in urban areas were 9.4 times greater than in suburban areas. During wave 2, 19% of the approached young men provided alcohol to the requesters. No requester, request attempt, establishment, or community characteristics were associated with request attempt outcomes during wave 2. CONCLUSIONS: A small percentage of the general population of adults will agree to provide alcohol to underage youth when approached outside an alcohol establishment. The likelihood of underage youth obtaining alcohol through shoulder tapping increases substantially if the youth approach young men.

Influencing alcohol control policies and practices at community festivals.

The goal of this study was to assess the feasibility and effectiveness of two interventions aimed at reducing alcohol-related risks at community festivals--a training program for festival planners and a community organizing campaign. We randomly selected four festivals for each intervention and had 24 comparison festivals. Our assessment included process evaluation to track and evaluate types of alcohol policies resulting from each of the interventions, pre and post telephone surveys of key festival planners and law enforcement agencies, and pre and post pseudo-underage and pseudo-intoxicated purchase attempts. Analyses showed that both interventions were feasible and were successful in influencing adoption of written policies and improving alcohol-related practices. However, neither intervention appeared to decrease propensity for illegal alcohol sales at these events, likely due, in part, to the short time frame of the interventions. Future research should assess effects of the interventions on alcohol-related problems and effects of enforcement interventions.