Self-Reported Food Security in Adolescents with Type 1 Diabetes: Association with Hemoglobin A1c and Mental Health Symptoms Independent of Household Food Security.

BACKGROUND: Typically, child exposure to food insecurity is assessed by caregiver reports of household food security. Child report has the potential for greater accuracy because it pertains only to the child whose experiences may differ from caregiver reports. OBJECTIVE: We assessed if adolescent-reported food insecurity was associated with levels of hemoglobin A1c (HbA1c), acute diabetes-related complications, depressive symptoms, and disordered eating behaviors in adolescents with type 1 diabetes, independently from household food security. METHODS: In a cross-sectional analysis of the multicenter SEARCH for Diabetes in Youth Cohort Study (phase 4, 2016-2019) including 601 adolescents aged 10-17 y with type 1 diabetes and their caregivers, household food security, and adolescent-reported food security were assessed using the 18-item Household Food Security Survey Module and the 6-item Child Food Security Assessment questionnaire. Age-stratified (10-13 and 14-17) regression models were performed to estimate independent associations, adjusting for sociodemographics, clinical factors, and household food security. RESULTS: Food insecurity was reported by 13.1% (n = 79) of adolescents and 15.6% (n = 94) of caregivers. Among adolescent-caregiver dyads, 82.5% (n = 496) of reports were concordant and 17.5% (n = 105) discordant, Cohen's κ= 0.3. Adolescent-reported food insecurity was not independently associated with HbA1c, diabetic ketoacidosis, and severe hypoglycemia, including in age-stratified analyses. Adolescent-reported food insecurity was independently associated with elevated odds of depressive symptoms [odds ratio (OR): 3.6; 95% confidence interval (CI): 1.3, 10.3] and disordered eating behaviors (OR: 2.5, 95% CI: 1.4, 4.6) compared with adolescents reporting food security; these associations remained in both age groups for disordered eating behaviors and in the older group for depressive symptoms. CONCLUSIONS: Adolescents with type 1 diabetes may experience food insecurity differently than caregivers. Adolescent-reported food insecurity was independently associated with depressive symptoms and disordered eating behaviors and thus may be an important attribute to assess in addition to household food security in adolescents with type 1 diabetes.

Properties of the Household Food Security Survey Module Scale in Young Adults with Diabetes.

BACKGROUND: The Household Food Security Survey Module (HFSSM) was not tailored to people with chronic diseases or young adults (YAs). OBJECTIVES: We aim to evaluate whether the 18-item HFSSM meets assumptions underlying the scale among YAs with diabetes. METHODS: Data from 1887 YAs with youth-onset type 1 diabetes or type 2 diabetes were used from the SEARCH for Diabetes in Youth Study, 2016-2019, and on 925 who returned for the SEARCH Food Security Cohort Study, 2018-2021, all of whom had completed the HFSSM. Guttman scaling properties (affirmation of preceding less severe items) and Rasch model properties (probability to answer an item based on difficulty level) were assessed. RESULTS: Items 3 (balanced meals) and 6 (eating less than one should) were affirmed more frequently than expected (nonmonotonic response pattern). At 1.2%-3.5%, item nonresponse was rare among type 1 diabetes but higher among type 2 diabetes (range: 3.1%-10.6%). Items 9 (not eating the whole day) and 3 did not meet the Guttman scaling properties. Rasch modeling revealed that item 3 had the smallest difficulty parameter. INFIT indices suggested that some responses to item 3 did not match the pattern in the rest of the sample. Classifying household food insecurity (HFI) based on items 1 and 2 compared with other 2-item combinations, including item 3, revealed a substantial undercount of HFI ranging from 5% to 8% points. CONCLUSIONS: Use of the HFSSM among YAs with diabetes could potentially result in biased HFI reporting and affect estimates of HFI prevalence in this population.

Preexposure Prophylaxis Uptake Among Spanish-Speaking Transgender Women: A Randomized Controlled Trial in North and South Carolina, 2019-2022.

Objectives. To evaluate Chicas Creando Acceso a la Salud (Girls Creating Access to Health; ChiCAS), a Spanish-language, small-group intervention designed to increase preexposure prophylaxis (PrEP) use, consistent condom use, and medically supervised gender-affirming hormone therapy use among Spanish-speaking transgender Latinas who have sex with men. Methods. Participants were 144 HIV-negative Spanish-speaking transgender Latinas, aged 18 to 59 years, living in North and South Carolina. From July 2019 to July 2021, we screened, recruited, and randomized them to the 2-session ChiCAS intervention or the delayed-intervention waitlist control. Participants completed assessments at baseline and 6-month follow-up. Follow-up retention was 94.4%. Results. At follow-up, relative to control participants, ChiCAS participants reported increased PrEP use (adjusted odds ratio [AOR] = 4.64; 95% confidence interval [CI] = 1.57, 13.7; P < .006). However, ChiCAS participants did not report increased use of condoms or medically supervised gender-affirming hormone therapy. ChiCAS participants reported increases in knowledge of HIV (P < .001), sexually transmitted infections (P < .001), and gender-affirming hormone therapy (P = .01); PrEP awareness (P < .001), knowledge (P < .001), and readiness (P < .001); condom use skills (P < .001); and community attachment (P < .001). Conclusions. The ChiCAS intervention was efficacious in increasing PrEP use among Spanish-speaking, transgender Latinas in this trial. (Am J Public Health. 2024;114(1):68-78. https://doi.org/10.2105/AJPH.2023.307444).

Relative efficacy of cigarillo warning statements in text and pictorial formats: An experimental study among a sample of US young adults.

INTRODUCTION: Health warning labels (HWLs) communicate the health risks of cigar use and can decrease use when on cigar packages. This study assessed the relative efficacy of six FDA-proposed individual warning statements in text and pictorial format. METHODS: A sample of young adults (ages 18-29) were randomized to a text or pictorial warning condition on generic cigarillo packages. The warning statements were about lung cancer and heart disease; cancers of the mouth and throat; secondhand smoke; not a safe alternative; nicotine/addiction; and harm to baby. Negative emotional reactions, cognitive elaboration, and perceived message effectiveness (PME) were assessed for each warning using linear mixed models. RESULTS: Of the 661 participants, 47.3% reported ever cigarillo smoking, 32.7% current smoking, and 20% were susceptible. In the pictorial format, cancers of the mouth and throat elicited lower levels of anxiety compared to secondhand smoke, not a safe alternative, nicotine/addiction, and harm to baby (ps<0.001). Pictorial HWLs with human imagery induced high anxiety, sadness, fear, and guilt reactions (p<0.001) and higher PME (p=0.011) compared to pictorial HWLs with diseased body parts. Compared to the text HWL cancers of the mouth and throat, the text HWL harm to baby elicited higher anxiety (p=0.003), sadness (p=0.002) and PME (p<0.001). CONCLUSIONS: Pictorial HWLs depicting people or human imagery, rather than images of diseased organs or body parts, to represent health effects elicited the most negative emotional reactions, such as anxiety and guilt, and higher PME. Including such images and texts highlighting effects on vulnerable populations like babies can better communicate cigarillo health risks, aiming to curb cigarillo use among young people. IMPLICATIONS: The study suggests that pictorial health warning labels (HWLs) with human imagery significantly enhance the communication of cigarillo smoking risks compared to images of diseased organs. These HWLs evoke stronger emotional responses, particularly anxiety and guilt, and higher perceived message effectiveness by depicting a recognizable person. Furthermore, text-only warnings describing the smoking effect on vulnerable populations such as babies might have a higher impact on young adults. This evidence supports a strategic shift in FDA policies to include such impactful images and texts, which could potentially lead to a significant reduction in cigarillo use among young people. Our findings underscore the urgent need for continued research and implementation of these enhanced warning labels to improve public health outcomes.

Waterpipe Tobacco Brands and Flavors Sold Online in the USA.

INTRODUCTION: Flavor additives are commonly used in combustible tobacco products to mask harshness and increase appeal. However, research on the availability of flavored waterpipe tobacco (WT) is lacking, yet is important to support implementation of policies. METHODS: We completed a comprehensive online search in 2020 to identify WT brands and flavors sold online in the USA. We conducted a descriptive content analysis categorizing flavors as explicit (i.e., clear taste/flavor) or concept (i.e., no clear taste/flavor); and coded for 23 flavor descriptors (e.g., fruit, mint/menthol, tobacco). Flavor names were double-coded and discrepancies were resolved by a third coder. RESULTS: We identified 66 WT brands with 118 product lines (i.e., sub-brands). We found 2953 flavors, including 1871 unique flavors. Brands averaged 45 flavors (range: 1-183). Almost three quarters (73.5%, n = 2171) used explicit flavor names and 26.5% (n = 782) used concept flavor names. Concept flavors varied widely, and included names such as 1001 Nights and California Dream. The most common flavor descriptors were fruit (54.1%) and mint/menthol (12.5%). Tobacco was rarely (0.2%) used as a flavor descriptor. Flavor descriptors also included location (10.7%), color (11.1%), candy (6.3%), cool/ice (5.3%), and alcohol (5.5%). CONCLUSIONS: WT is available in 1871 unique flavors, likely contributing to product appeal and use. Like other tobacco products, fruit and mint/menthol are common flavors. Given the significant health consequences associated with WT smoking and the role of flavors in product use, regulatory action specifically targeting WT flavors is urgently needed.

Household Food Insecurity and Cognition in Youth and Young Adults with Youth-Onset Diabetes.

Objective: We evaluated the association of household food insecurity (FI) with cognition in youth and young adults with type 1 diabetes (T1D) or type 2 diabetes (T2D). Design: In this cross-sectional study, age-adjusted scores for composite Fluid Cognition, and sub-domain scores for Receptive Language and Inhibitory Control and Attention, were modeled stratified by diabetes-type using linear regression, with FI in the past year as the predictor, controlling for covariates. Tests for processing speed, inhibitory control/attention, working memory, episodic memory, and cognitive flexibility were administered to measure composite Fluid Cognition score. The NIHT-CB Picture Vocabulary Test was used to assess Crystallized Cognition score and rapid identification of congruent versus noncongruent items were used to assess Inhibitory Control and Attention score. Setting: The SEARCH for Diabetes in Youth study, representative of 5 U.S. states. Participants: Included 1574 youth and young adults with T1D or T2D, mean age of 21 years, mean diabetes duration of 11 years, 51% non-Hispanic white, and 47% had higher HbA1c levels (>9% HbA1c). Results: Approximately 18% of the 1,240 participants with T1D and 31% of the 334 with T2D experienced FI. The food-insecure group with T1D had a lower composite Fluid Cognition score (ß= -2.5, 95% confidence interval (CI)= -4.8, -0.1) and a lower Crystallized Cognition score (ß= -3.4, CI= -5.6, -1.3) than food-secure peers. Findings were attenuated to non-significance after adjustment for demographics. Among T2D participants, no associations were observed. In participants with T1D effect modification by glycemic levels were found in the association between FI and composite Fluid Cognition score but adjustment for socioeconomic characteristics attenuated the interaction (p=0.0531). Conclusions: Food-insecure youth and young adults with T1D or T2D did not have different cognition compared to those who were food-secure after adjustment for confounders. Longitudinal research is needed to further understand relations amongst these factors.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults.

BACKGROUND: The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings. METHODS: Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME). RESULTS: Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46). CONCLUSIONS: Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

Point-of-Sale Health Communication Campaigns for Cigarillos and Waterpipe Tobacco: Effects and Lessons Learned from Two Cluster Randomized Trials.

Many adolescents and young adults hold erroneous beliefs that cigarillos and waterpipe tobacco (WT) are safer than cigarettes, contributing to use. Communication campaigns can correct misperceptions and increase risk beliefs. We tested point-of-sale (POS) communication campaigns focused on chemical exposure for cigarillos and WT. We conducted two cluster randomized trials at 20 gas stations with convenience stores (10 stores for cigarillos, 10 for WT) in North Carolina between June and November 2017. Within each trial, stores were randomly assigned to either the intervention (campaign messages displayed) or a no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 adolescents and young adults (ages 16-25) per store, at baseline and follow-up. There were 978 participants (mean age = 20.9 years) in the cigarillo trial, and 998 participants (mean age = 21.0 years) in the WT trial. Rates of campaign exposure were low (26% for cigarillos; 24.3% for WT). The cigarillo campaign increased knowledge that ammonia is in cigarillo smoke (p < .01). There were also significant increases in knowledge about ammonia and cyanide in cigarillo smoke and arsenic in WT smoke (p < .05) in the sub-sample who reported exposure to the campaign. No differences were found in outcome expectancies, product attitudes, worry about chemical exposure, or behavioral intentions in either campaign. Garnering attention for communication campaigns in saturated POS environments, often dominated by tobacco advertising, is challenging. Our study demonstrates the feasibility of anti-tobacco campaigns at the POS and points to several lessons learned for future POS campaigns.

The Development and Testing of a Point-of-Sale E-Cigarette Health Communication Campaign.

Adolescents and young adults continue to use e-cigarettes, and communication campaigns are needed to decrease use among these populations. We developed and tested a point-of-sale communication campaign focused on e-cigarette chemical exposure. We developed messages based on formative research and tested them (versus text-only messages) in a nationally-representative online survey among adolescents and young adults (16-25) (Phase 1). Based on survey findings, we selected a message focused on nicotine and brain development for the point-of-sale trial (Phase 2). We then conducted a cluster-randomized trial at six gas stations with convenience stores, randomly assigned to the intervention (messages displayed) or no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 participants (ages 16-25) per store, at baseline and a four-week follow-up. Phase 1 included 1,636 participants in the online study. Intervention messages were rated as more attention grabbing than plain text messages (p < .05), though were rated similarly on other outcomes. Exposure to intervention messages resulted in larger changes from pre- to posttest for beliefs about addiction and relative harms versus cigarettes (p < .05). Phase 2 included 586 participants in the point-of-sale study. Real-world campaign exposure was low (31.8%), and no differences were found between conditions. E-cigarette prevention messages focused on nicotine's impact on brain development show promise. However, garnering attention for communication campaigns in saturated point-of-sale environments, often dominated by tobacco advertising, is challenging. Future efforts should utilize additional communication channels to directly target adolescents and young adults.

Health Care Transition to Adult Care in Type 1 Diabetes: Associations With Student and Employment Status-The SEARCH for Diabetes in Youth Study.

Successful transition from a pediatric to adult diabetes care provider is associated with reduced ambulatory diabetes care visits and increased acute complications. This study aimed to determine whether the degree of independence in diabetes care and the rate of acute complications after transition to adult diabetes care were associated with individuals' student or employment status. Nonstudents were found to be less likely than students to be independent with diabetes care, and employed nonstudents were at lower risk of diabetic ketoacidosis than unemployed nonstudents. Additional support may be needed for young adults who are not students or are unemployed to improve independence and reduce the risk for acute complications.

Inequalities in Glycemic Control in Youth with Type 1 Diabetes Over Time: Intersectionality Between Socioeconomic Position and Race and Ethnicity.

BACKGROUND: Racial/ethnic health inequities have been well-documented among youth and young adults with type 1 diabetes (T1D), yet little is known about how socioeconomic position (SEP) intersects with the risk marker of race/ethnicity to predict inequities in longitudinal glycemic control. PURPOSE: To identify patterns of SEP, race/ethnicity, and clinical characteristics that differentiate hemoglobin A1c (HbA1c) trajectories among youth and young adults after T1D diagnosis. METHODS: The SEARCH for Diabetes in Youth cohort includes youth with diabetes diagnosed from 2002 to 2006 and 2008 who were followed through 2015. We analyzed data from 1,313 youth and young adults with T1D with ≥3 HbA1c measures. Classification tree analysis identified patterns of baseline demographic, SEP, and clinical characteristic that best predicted HbA1c trajectories over an average of 8.3 years using group-based trajectory modeling. RESULTS: Two HbA1c trajectories were identified: Trajectory 1 (77%) with lower baseline HbA1c and mild increases (from mean 7.4% to 8.4%) and Trajectory 2 (23%) with higher baseline HbA1c and major increases (from 8.5% to 11.2%). Race/ethnicity intersected with different SEP characteristics among non-Hispanic white (NHW) than in non-whites. Public health insurance predicted high-risk Trajectory 2 membership in non-whites, whereas parental education, household structure, diagnosis age and glucose checking frequency predicted membership for NHW youth and young adults. Two characteristics, race/ethnicity and parental education alone identified 80% of the Trajectory 2 members. CONCLUSIONS: Race/ethnicity intersects with multiple SEP and clinical characteristics among youth and young adults with T1D, which is associated with particularly high risk of poor long-term glycemic control.

Decreases in smoking and vaping during COVID-19 stay-at-home orders among a cohort of young adults in the United States.

In Spring 2020, most US states and territories implemented stay-at-home orders to slow transmission of the novel coronavirus SARS-CoV2, the cause of COVID-19. Little is known about the impact of stay-at-home orders on tobacco and nicotine use including among young adults. The current study examined participants (N = 1727) completing three recent survey waves from a longitudinal cohort of young adults recruited in 2010 from North Carolina and Virginia, USA: Wave 13 (Spring 2019), Wave 14 (Fall 2019), and Wave 15 (Spring 2020) to assess changes in cigarette and e-cigarette use. We conducted logistic regression analyses to compare the odds that participants reported smoking or vaping in Wave 14 relative to Wave 13 to establish if there was a trend of use pre-pandemic. Then, we conducted logistic regression analyses to compare the odds that participants reported smoking or vaping in Wave 15 relative to Wave 14 to determine the impact of COVID-19 stay-at-home orders. When comparing the odds of reporting tobacco use at Wave 14 to Wave 13, no differences emerged (p > 0.05). However, when comparing tobacco use at Wave 15 to Wave 14, participants had 40% lower odds of reporting past 30-day cigarette use (p = 0.02) and 50% lower odds of reporting past 30-day e-cigarette use (p < 0.01). The current study provides initial evidence that young adults may have reduced their tobacco and nicotine use during the stay-at-home orders. However, more work is needed to determine the long-term impact of the COVID-19 pandemic on tobacco use and cessation in this population.

Household food insecurity is associated with diabetic ketoacidosis but not severe hypoglycemia or glycemic control in youth and young adults with youth-onset type 2 diabetes.

OBJECTIVE: To examine the association between household food insecurity (HFI), glycemic control, severe hypoglycemia and diabetic ketoacidosis (DKA) among youth and young adults (YYA) with youth-onset type 2 diabetes. RESEARCH DESIGN AND METHODS: This cross-sectional study included 395 YYA with type 2 diabetes from the SEARCH for Diabetes in Youth Study (2015-2019). HFI was reported by young adult participants or parents of minor participants via the US Household Food Security Survey Module. Glycemic control was assessed by HbA1c and analyzed as a continuous and categorical variable (optimal: <7.0%, suboptimal: ≥7.0%-9.0%, poor: >9.0%). Acute complications included self-reported severe hypoglycemia or DKA in the last 12 months. Adjusted logistic and linear regression were used for binary and continuous outcomes, respectively. RESULTS: Approximately 31% reported HFI in the past 12 months. Mean HbA1c among those with HFI was 9.2% compared to 9.5% without HFI. Of those with HFI, 56% had an HbA1c >9.0% compared to 55% without HFI. Adjusted models showed no associations between HFI and glycemic control. Of those with HFI, 14.4% reported experiencing DKA and 4.7% reported severe hypoglycemia. YYA with HFI had 3.08 times (95% CI: 1.18-8.06) the odds of experiencing DKA as those without HFI. There was no association between HFI and severe hypoglycemia. CONCLUSIONS: HFI was associated with markedly increased odds of DKA but not with glycemic control or severe hypoglycemia. Future research among YYA with type 2 diabetes should evaluate longitudinally whether alleviating HFI reduces DKA.

Early Childhood Behavioral and Academic Antecedents of Lifetime Opioid Misuse among Urban Youth.

OBJECTIVE: Opioid misuse has become an epidemic in the United States. In the present study, we examine potential malleable early childhood predictors of opioid misuse including whether childhood achievement, aggressive behavior, attention problems, and peer social preference/likability in first grade predicted opioid misuse and whether these relationships differed depending on participant sex. METHOD: Data are drawn from three cohorts of participants (N = 1,585; 46.7% male) recruited in first grade as part of a series of elementary school-based, universal preventive interventions conducted in a Mid-Atlantic region of the US. In first grade, participants completed standardized achievement tests, teachers reported on attention problems, and peers nominated their classmates with respect to their aggressive behavior and social preference/likability. At approximately age 20, participants reported on their misuse of opioids defined as lifetime use of heroin or misuse of prescription opioids. RESULTS: Higher levels of peer nominations for aggressive behavior in first grade predicted a greater likelihood of opioid misuse. An interaction between participant sex and attention problems was observed such that females higher in attention problems were more likely to misuse opioids, particularly prescription opioids, than females lower in attention problems. An interaction was also found between participant sex and peer likability such that males lower in peer-nominated likability were more likely to misuse opioids relative to males higher in likability. CONCLUSION: Given the malleable nature of attention problems, aggression, and social skills in early childhood, prevention programs that target these behaviors during this developmental period may attenuate risk for opioid misuse.

Cigar Harm Beliefs and Associations with Cigar Use among Young Adults.

BACKGROUND: Cigar use, including little cigars and cigarillos (LCCs) and large traditional cigars, continues to harm young adults. Research on harm beliefs about cigars, particularly large cigars, is sparse. The current study examined cigar harm beliefs and associations with cigar use. Methods: Data are from a 2019 survey of a young adult cohort study recruited in fall 2010. Participants were asked questions about their beliefs about the harm of LCC and large cigar use. Those reporting ever use of cigars were asked how frequently they inhale the smoke into their lungs. Results: Participants (N = 1910) were 51.9% female with a mean age of 26.7 (SD = 0.6). Ever cigar use was 44.2% for large cigars and 43% for LCCs. Compared to those who have never used large cigars or LCCs, those reporting ever use of large cigars or LCCs reported lower harm beliefs about inhaling harmful chemicals and becoming addicted (ps <.0001). Those who reported higher harm beliefs also reported inhaling the smoke into their lungs more frequently for large cigars and LCCs (ps<.05). Conclusions: Cigar use harm beliefs were lower among participants reporting ever use of cigars compared to those reporting never use. Contrary to predictions, those reporting greater harm beliefs were more likely to report inhaling smoke more frequently than those with lower harm beliefs.

Waterpipe Tobacco Warnings: An Experimental Study Among a Nationally Representative Sample of US Young Adults.

BACKGROUND: Waterpipe tobacco (WT) smoking by young adults remains high and misperceptions are common. Product warnings can increase knowledge of harms and reduce use. The goal of this study was to test warning statements, including the FDA-required nicotine warning (prior to implementation), on young adults' thinking about harms of and discouragement from WT smoking. METHODS: We conducted a between-subjects experiment in a nationally representative telephone survey of 1152 young adults aged 18-29. Participants were randomly assigned to hear one of five warning statements and reported how much, on a 4-point scale, the warning made them think about the harms and discouraged them from WT smoking. RESULTS: The sample was 36.8% female, 57.8% white, 20.2% Black, 24.1% Hispanic, with a mean age of 23.2 (SE = 0.25). Under half (43.5%) had ever smoked WT. There were significant differences among the statements on both thinking about harms (p < .0001) and discouragement (p < .0001). The FDA-required "nicotine" warning led to the lowest thinking about harms (M = 2.85, SE = 0.08) and was the least discouraging (M = 2.86, SE = 0.08), while the "100 cigarettes" warning resulted in the greatest thinking about harms (M = 3.62, SE = 0.05) and was the most discouraging (M = 3.56, SE = 0.06). CONCLUSIONS: The nicotine warning resulted in the lowest levels of thinking about harms and discouragement from WT smoking, suggesting limited impact. However, a warning focused on comparing smoke inhalation from WT smoking to cigarettes seems promising. Warnings should cover a broad range of WT health effects, and possibly comparisons to cigarettes. Findings also have implications for the content of international waterpipe warnings. IMPLICATIONS: This study indicates that the nicotine warning is the least effective at making young adults think about the harms of and discouraging WT smoking. The FDA and other countries should consider requiring warnings to cover a broader range of health harms, misperceptions, and possibly comparisons to cigarettes.

Developing Pictorial Cigarillo Warnings: Insights From Focus Groups.

INTRODUCTION: The Food and Drug Administration (FDA) selected six text-only warnings for cigarillos to be implemented on packaging and advertising. Pictorial warnings are more effective at discouraging cigarette use than text-only warnings, yet no research exists for cigarillos. We sought to understand what types of images might be most effectively paired with the cigarillo text warnings to inform broad principles for developing pictorial warnings, with a focus on young adults, who have the highest rate of cigarillo use. METHODS: We conducted five focus groups with a total of N = 30 young adult cigarillo users and susceptible nonusers (53% female, 50% White, and 33% Black). Participants were shown four to eight unique images for each of the six text statements and were asked about visual-verbal congruency, emotional and cognitive reactions, and perceived effectiveness of each image. Sessions were recorded and transcribed; two investigators independently coded transcripts for emergent themes. RESULTS: Participants reported images that were graphic or "gross" would best grab attention and discourage use of cigarillos. Participants preferred images that were a direct illustration of the information in the warning text, rather than abstract images that required more cognitive effort to understand. Participants also highlighted that including people in the images, especially youth and young adults making eye contact, helped them relate to the warnings, garner their attention, and positively influence their reactions. CONCLUSIONS: We identified several principles to inform the selection of images to pair with the FDA-required cigarillo text statements. These insights may also apply to pictorial warnings for other tobacco products. IMPLICATIONS: This focus group study identified principles for selecting images to develop pictorial warnings for the six FDA text-only cigarillo warnings. We found that young adult cigarillo users and susceptible nonusers preferred images that were graphic and gross, believable, congruent to the warning text, and included people. Images that match young adults' visual expectations of a disease and are emotion-provoking may be most effective in pictorial warnings and highlight challenges for developing pictorial warnings for health effects that do not have a visible health consequence.

Changes in knowledge, perceptions and use of JUUL among a cohort of young adults.

OBJECTIVE: E-cigarettes have gained popularity, most recently with pod-style devices, such as JUUL. We examined changes in JUUL awareness, use, perceptions, nicotine content knowledge, number of days a pod lasts and exposure to JUUL retail advertising over a 6-month period in a cohort of young adults. METHODS: In spring and fall 2018, 1836 young adults completed online surveys on tobacco use, including JUUL perceptions and use behaviours. Demographics, tobacco use and JUUL advertising exposure in spring 2018 were examined as predictors of current JUUL use in fall 2018. RESULTS: Ever and current JUUL use doubled in 6 months (5.9% vs 12.7%, p<0.001; 1.6% vs 3.4%, p<0.001). The number of days a JUUL pod lasts significantly changed (p=0.049). Although there was an increase in those reporting JUUL has as much or more nicotine than a pack of cigarettes, 58% are 'not sure' of JUUL's nicotine content. Exposure to JUUL's advertising significantly increased (31.8% to 46.4%; p<0.001). In multivariable models, those perceiving JUUL as or more harmful than cigarettes, and former and never cigarette smokers had significantly lower odds of current JUUL use at 6 months compared with their respective counterparts (p<0.0001). Those reporting exposure to JUUL's advertising had significantly increased odds of current JUUL use 6 months later (p<0.03). CONCLUSIONS: Findings demonstrate changes in knowledge of JUUL's nicotine content, perceptions and use over a short period of time, suggesting frequent measurement is necessary. Additionally, efforts are needed to regulate retail advertising and ensure consumer education about product risks as they are associated with current use.

Stressful life events and transitions in problematic alcohol use involvement among US adults.

OBJECTIVE: We investigated the impact of stressful life events (SLEs) for males and females on transitions in problematic alcohol involvement, both progression and recovery, over a 3-year interval. METHOD: Participants of both Wave 1 (2001-2002) and Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were stratified by sex (14,233 males and 19,550 females). Latent transition analysis estimated the impact of experiencing ≥3 SLE in the year preceding the Wave 1 interview on the probability of transitioning between three empirically-derived stages of alcohol involvement (patterns of alcohol use disorder [AUD] symptoms), across waves. Propensity score methods adjusted for confounding. RESULTS: For males, three or more SLEs were associated with progression from the moderate to the severe problem stage (odds ratio [OR] = 2.23, 95% confidence interval [CI] = 1.17, 4.26). Among those in the severe problem stage, SLEs negatively impacted recovery regardless of sex. Employment/Financial SLEs were associated with a higher odds of transition from the moderate to the no problem stage (OR = 1.60, 95% CI = 1.03, 2.46) and lower odds of transitions from the severe to the moderate problem stage (OR = 0.40, 95% CI = 0.16, 0.99) among males, and from the severe to the no problem stage (OR = 0.26, 95% CI = 0.07, 0.88) among females. CONCLUSION: Stressful life events appear to affect transitions in alcohol involvement over time among those who already have alcohol problems, rather than impacting a transition among those without AUD problems.

Alcohol trajectories and subsequent risk for opioid misuse in a cohort of urban adolescents.

Background: The opioid epidemic is a public health emergency in the US. Alcohol is the most widely used addictive substance among all age groups; however, the contribution of different alcohol use trajectories throughout adolescence and young adulthood to the development of opioid misuse in young adulthood among urban minority youth has not been investigated. Methods: Data are from a study of 580 youth (85% African American, 67% low SES) residing in Baltimore City followed from ages 6-26. Alcohol trajectories were identified between ages 14 and 26 using group-based trajectory modeling. Opioid misuse was defined as using opioid painkillers without a prescription or using heroin between ages 19 and 26. Opioid misuse outcomes were also investigated separately. Logistic regression examined associations of alcohol trajectories with opioid misuse in young adulthood adjusting for socio-demographics, early use of tobacco and cannabis, neighborhood, and peer factors. Results: Six alcohol use trajectories were identified: Young adult increasing (21.4%), adult increasing (19.1%), abstaining (19.1%), experimenting (15.3%), adolescent increasing (14.8%), and adolescent limited (10.2%). In models fully adjusted for covariates, relative to the abstaining trajectory, the adolescent increasing trajectory was associated with an elevated risk of opioid misuse (aOR = 3.3, 95%CI = 1.4, 7.8) and prescription opioid misuse (aOR = 3.9, 95%CI = 1.4, 10.8) in young adulthood. Conclusions: Escalating alcohol use in adolescence and young adulthood is associated with an elevated risk of opioid misuse in young adulthood in a cohort of predominantly African American and socio-economically disadvantaged young people. Tailored interventions should target high levels of alcohol use during these developmental periods to reduce risk for opioid misuse among disadvantaged youth.