Evaluations of compliance with California's first tobacco sales bans and tobacco marketing in restricted and cross-border stores.

INTRODUCTION: Beverly Hills and Manhattan Beach were the first California cities to end tobacco sales. Previous research assessed retailers' perceptions of the laws. This study is the first to evaluate compliance (Study 1), assess whether branded or unbranded tobacco cues remain, and examine cigarette price/discounts in cross-border stores (Study 2). METHODS: Each of four data collectors requested Marlboro or e-cigarettes (randomly assigned) in all restricted stores (n=33) until four attempts were exhausted or a violation occurred. Follow-up visits recorded whether former tobacco retailers advertised tobacco or contained unbranded cues. In a random sample of 126 cross-border stores (half within 1 mile of no-sales cities and half 2-4 miles away), data collectors recorded price of Marlboro and presence of cigarette discounts. Mixed models (stores within tracts), tested for differences between near and far stores, adjusting for store type and median household income. RESULTS: Compliance was 87.5%: three stores sold Marlboro ($8, $10, $10) and one sold Puff Bar ($16). Tobacco-branded items and unbranded tobacco cues remained in one store each. Mean Marlboro price was $10.61 (SD=1.92) at stores within 1 mile of no-sales cities, averaging y0.73 more than at stores farther away (p<0.05). However, odds of advertising cigarette discounts did not differ between stores nearby and farther from no-sales cities. CONCLUSION: Nearly all retailers complied with tobacco sales bans within 6 to 12 months of implementation. In addition, retail tobacco marketing was nearly eliminated in the two cities. There was no evidence of price gouging for Marlboro cigarettes in cross-border stores. IMPLICATIONS: Evidence from two early adopters of tobacco sales bans suggests that such local laws can be implemented effectively in California, although results from these high-income cities in a state with a strong tobacco control record limits generalizability. Enforcement involving routine purchase attempts rather than visual inspection for tobacco products is recommended. Although Beverly Hills and Manhattan Beach are each surrounded by communities where tobacco sales persist, there was no evidence of price gouging for cigarettes or greater presence of discounts in cross-border stores. Evaluations of the economic impacts and public health benefits of tobacco sales bans are much needed.

Changes in the Point-of-Sale Among Vape Shops in Six U.S. Metropolitan Areas Over Time, 2018-2021.

INTRODUCTION: E-cigarette retail surveillance is needed during regulatory changes, like the U.S. increasing minimum legal sales age to 21 (T21) and flavor restrictions (2019 and 2020) and certain state/localities increasing related restrictions. AIMS AND METHODS: We examined regulatory compliance (eg, minimum-age signage), promotional strategies (eg, health claims), and products at 2 timepoints among vape shops across six U.S. metropolitan statistical areas (MSAs; Atlanta, Boston, Minneapolis, Oklahoma City, San Diego, Seattle). In summer 2018, pairs of trained auditors assessed randomly selected shops (n = ~30/MSA). In fall 2021, audits were conducted among 2018 shops (if open and allowed) and additional randomly selected shops (n = ~20/MSA). Data from 179 shops in 2018 and 119 in 2021 (43 from the 2018 sample) were compared. RESULTS: There were decreases (p < .01) in the proportion of shops with (1) minimum-age signs (90.5% vs. 73.9%), (2) their own e-liquid brand (68.2% vs. 44.5%), onsite vaping (73.2% vs. 46.2%), counter seating (65.2% vs. 34.5%), and e-liquid sampling (90.0% vs. 33.6%), and (3) signs with product/price promotions (89.9% vs. 65.5%), health/cessation claims (29.1% vs. 12.6%), and cartoon imagery (27.4% vs. 11.8%). The proportions selling wet/dry vaporizers (26.4% vs. 39.5%), CBD products (23.3% vs. 71.4%), and pipes/glassware/papers (18.4% vs. 52.9%) increased. In 2021, many sold THC (12.6% e-liquids, 62.2% other products) and kratom (40.3%). CONCLUSIONS: With increasing restrictions (eg, on flavors, sampling, and T21), fewer shops sold their own e-liquid brands or accommodated onsite use/sampling, but fewer also posted minimum-age signage. Notably, more offered cannabis-related products. These changes underscore the need for comprehensive surveillance to assess regulatory impact. IMPLICATIONS: The past 6 years marked increasing e-cigarette sales restrictions in the United States, yet limited research has examined the implications for tobacco specialty shops selling e-cigarettes. This study found that, from 2018 to 2021, there were significant decreases in the proportion of vape shops with their own e-liquid, onsite vaping, e-liquid sampling, lounge/counter seating, and price promotions, as well as minimum-age signs. There were increases in the proportion selling cannabis-derived products and related paraphernalia. Tobacco control research and regulatory agencies must consider how tobacco specialty stores have evolved alongside legislative changes that impact them and consumers.

Rapid-response surveillance of the first US test market for VLN cigarettes.

INTRODUCTION: VLN King menthol and non-menthol are the first combustible cigarettes to receive US Food and Drug Administration (FDA) authorisation as modified risk tobacco products. Focusing on the first retail test market, this study characterised VLN advertising, product placement, discounts and price. METHODS: All Chicago-area Circle K stores (n=133) were telephoned to assess whether they sold VLN. Single-pack price of non-menthol was obtained in 57 of 100 stores that sold VLN. In fall 2022, trained data collectors visited those 57 stores to assess VLN product placement, advertising, discounts and prices. Paired t-tests compared observed VLN price with telephone price and to price of other cigarette brands. RESULTS: Nearly all stores (91.1%) displayed exterior advertisements for VLN, and 41.1% displayed interior advertising, with 8.9% of stores advertising VLN in the power wall but never in the header row. VLN cigarettes were displayed in the power wall exclusively and among high-nicotine cigarettes. Some VLN marketing claims were not FDA-authorised. VLN advertised a sweepstakes offer and rewards programme. Most stores (85.7%) offered VLN discounts. VLN was priced like a premium brand (mean=$10.90, SD=$1.53), and prices obtained by telephone did not differ from observed prices several months later. CONCLUSIONS: Retail marketing strategies for VLN mimic those for high-nicotine cigarettes. Deviations from FDA-authorised marketing claims were evident. Surveillance in future test markets is recommended to assess compliance with marketing claims and examine relative price and discount offers. Of interest is how premium-priced, low-nicotine cigarettes stand to compete in a market dominated by cheaper high-nicotine cigarettes.

Vape shop and consumer activity during COVID-19 non-essential business closures in the USA.

INTRODUCTION: Vaping and vape shops pose risk for COVID-19 and its transmission. OBJECTIVES: We examined vape shop non-compliance with state-ordered business closures during COVID-19, changes in their marketing and experiences among consumers. METHODS: As part of a longitudinal study of vape retail in six metropolitan statistical areas (MSAs; Atlanta, Boston, Minneapolis, Oklahoma City, San Diego and Seattle), we conducted: (1) legal research to determine whether statewide COVID-19 orders required vape shops to close; (2) phone-based and web-based surveillance to assess vape shop activity in March-June 2020 during shelter-in-place periods; and (3) a concurrent online survey of e-cigarette users about their experiences with vape retail. RESULTS: Non-essential business closure varied in timing/duration across states and applied to vape shops in California, Massachusetts, Minnesota, Oklahoma (for a brief period) and Washington (Georgia's orders were ambiguous). Surveillance analysis focused on the five MSAs in these states. Of 156 vape shops, 53.2% were open as usual, 11.5% permanently closed and 3.8% temporarily closed; 31.4% offered pick-up/delivery services. Among survey respondents (n=354, M age =23.9±4.6; 46.9% male, 71.8% white, 13.0% Hispanic), 27.4% worried their vape shop would close/go out of business during COVID-19; 7.3% said their vape shop did so. Few noticed increases in vape product delivery options (7.3%), discounts/price promotions (9.9%) and/or prices (9.3%). While 20.3% stockpiled vape products, 20.3% tried to reduce use and 15.8% tried to quit. CONCLUSIONS: Many vape shops were non-compliant with state COVID-19 orders. E-cigarette users were as likely to stockpile vape products as to attempt to reduce or quit using e-cigarettes.

Implementation of a comprehensive flavoured tobacco product sales restriction and retail tobacco sales.

OBJECTIVE: San Francisco's comprehensive restriction on flavoured tobacco sales applies to all flavours (including menthol), all products and all retailers (without exemptions). This study evaluates associations of policy implementation with changes in tobacco sales in San Francisco and in two California cities without any sales restriction. METHODS: Using weekly retail sales data (July 2015 through December 2019), we computed sales volume in equivalent units within product categories and the proportion of flavoured tobacco. An interrupted time series analysis estimated within-city changes associated with the policy's effective and enforcement dates, separately by product category for San Francisco and comparison cities, San Jose and San Diego. RESULTS: Predicted average weekly flavoured tobacco sales decreased by 96% from before the policy to after enforcement (p<0.05), and to very low levels across all products, including cigars with concept-flavour names (eg, Jazz). Average weekly flavoured tobacco sales did not change in San Jose and decreased by 10% in San Diego (p<0.05). Total tobacco sales decreased by 25% in San Francisco, 8% in San Jose and 17% in San Diego (each, p<0.05). CONCLUSIONS: San Francisco's comprehensive restriction virtually eliminated flavoured tobacco sales and decreased total tobacco sales in mainstream retailers. Unlike other US flavoured tobacco policy evaluations, there was no evidence of substitution to concept-flavour named products. Results may be attributed to San Francisco Department of Health's self-education and rigorous retailer education, as well as the law's rebuttable presumption of a product as flavoured based on manufacturer communication.

Assurances of Voluntary Compliance: A Regulatory Mechanism to Reduce Youth Access to E-Cigarettes and Limit Retail Tobacco Marketing.

Objectives. To evaluate assurances of voluntary compliance (AVCs) between state attorneys general and retail chains by assessing e-cigarette sales to underage decoys and tobacco marketing violations in corporate-owned stores (that sign AVCs) and franchise stores (that do not sign AVCs).Methods. Decoys 18 to 19 years of age attempted to purchase e-cigarettes without presenting ID in California convenience stores (n = 540). Auditors characterized the presence and content of age-of-sale signage and advertising for tobacco products. Data were collected and analyzed in 2018.Results. Corporate-owned stores were less likely than were franchise stores to violate ID requests (adjusted odds ratio [AOR] = 0.29; 95% confidence interval [CI] = 0.12, 0.71) and to sell e-cigarettes illegally (AOR = 0.37; 95% CI = 0.15, 0.88). Regardless of AVC category, advertising violations were common in stores (vaping products, 26.3%; other tobacco products, 74.3%).Conclusions. The differences in violation rates found in corporate and franchise stores imply that AVCs could reduce youth access to e-cigarettes. However, merchant education and routine enforcement are needed to better leverage restrictions on retail tobacco marketing in AVCs.Public Health Implications. Strengthening compliance with existing AVCs and establishing new agreements with retailers shown to be in violation through federal or state inspections could reduce youth access to e-cigarettes and exposure to tobacco marketing.

Retail Tobacco Marketing in Rural Versus Nonrural Counties: Product Availability, Discounts, and Prices.

Objectives. To assess tobacco product availability, advertised discounts, and prices in rural and nonrural stores, comparing results for two definitions of rural. Method. This geospatial study linked data from marketing surveillance in a representative sample of licensed tobacco retailers in California (n = 1,276) and categorized rural/nonrural stores at the county and tract levels. Data were collected from January to March, 2017, and mixed-models analyses tested for differences by location (rural vs. nonrural). Results. Compared to nonrural stores, rural-county stores were 2.1 (95% confidence interval [CI; 1.2, 3.6]) times more likely to sell chewing tobacco and 2.5 (95% CI [1.4, 4.2]) times more likely to sell roll-your-own. Rural-county stores sold larger packs of cigarillos for less than $1 (coefficient = 0.22, 95% CI [0.05, 0.39]) and charged less for the cheapest cigarette pack regardless of brand (estimated mean difference = $-0.21, 95% CI [-0.39, -0.03]). Contrary to expectation, a popular brand of chewing tobacco cost more in rural-county stores. A tract-level definition of rural reclassified only 1 in 10 stores, and did not substantially alter the results. Overall, 32.9% of stores advertised discounts on chewing tobacco, but this was more common in rural than nonrural census tracts (adjusted odds ratio = 1.81, 95% CI [1.14, 2.88]). Discussion. Evidence that $1 buys more cigarillos in rural-county stores than elsewhere adds to health equity concerns that the prevalence of cheap, flavored tobacco is not limited to neighborhoods characterized by socioeconomic disadvantage, higher proportions of African Americans, and higher proportions of school-age youth. Policies that focus on the retail environment for tobacco are needed to make tobacco less attractive and more costly everywhere, including rural areas.

The Price of Natural American Spirit Relative to Other Cigarette Brands.

INTRODUCTION: American Spirit cigarettes feature American Indian/Alaska Native (AI/AN) imagery in the branding and are marketed as environmentally friendly, without additives, and four varieties contain organic tobacco. This study is the first to examine retail price of American Spirit relative to other cigarette brands and to assess how its price varies by neighborhood demography. METHODS: In a random sample of licensed tobacco retailers (n = 1277), trained data collectors recorded availability and price of American Spirit, Pall Mall, Newport, Marlboro, and the cheapest cigarettes regardless of brand. Data were collected in January-March 2017 in California, the state with the largest AI/AN population. Paired t tests assessed prices (before sales tax) of American Spirit relative to others. Ordinary least squares regressions modeled prices as a function of neighborhood demography, adjusting for store type. RESULTS: American Spirit was sold in 77% of stores at an average price of $7.03 (SD = 0.66), which was $0.75-$1.78 (12.0%-34.4%) higher than Pall Mall, Newport, and Marlboro in the same stores. American Spirit costs significantly less in neighborhoods with a higher proportion of school-age residents; however, this pattern was not unique to that brand. Contrary to expectation, American Spirit did not cost less in neighborhoods with a higher proportion of AI/ANs. CONCLUSION: This study is the first to document lower prices for American Spirit in neighborhoods with a higher proportion of school-age youth. Future research should consider whether the ultra-premium price of American Spirit contributes to misperceptions that the brand is organic and less harmful than other cigarettes. IMPLICATIONS: In a large random sample of licensed tobacco retailers in California, American Spirit costs significantly more than other brands, 12.0%-34.4% more than Pall Mall, Newport, and Marlboro in the same stores. After controlling for store type, American Spirit price was significantly lower in neighborhoods with a higher proportion of school-age residents. Research about how an ultra-premium price contributes to misperceptions that all American Spirit varieties are organic and the brand is less harmful and less addictive than other cigarette brands would be informative for ongoing litigation and product regulation.

Marijuana as a 'concept' flavour for cigar products: availability and price near California schools.

OBJECTIVES: To assess the retail availability of cigar products that refer to marijuana and the largest package size of cigarillos available for ≤$1. METHODS: Trained data collectors conducted marketing surveillance in a random sample of licensed tobacco retailers that sold little cigars/cigarillos (LCCs) (n=530) near a statewide sample of middle and high schools (n=132) in California. Multilevel models examined the presence of marijuana co-marketing and cigarillo pack size as a function of school/neighbourhood characteristics and adjusted for store type. RESULTS: Of stores that sold LCCs, approximately 62% contained at least one form of marijuana co-marketing: 53.2% sold cigar wraps marketed as blunt wraps, 27.2% sold cigarillos marketed as blunts and 26.0% sold at least one LCC with a marijuana-related 'concept' flavour. Controlling for store type, marijuana co-marketing was more prevalent in school neighbourhoods with a higher proportion of young residents (ages 5-17 years) and with lower median household income. Nearly all stores that sold LCCs (87.9%) offered the products for ≤$1. However, significantly larger packs at similarly low prices were available near schools in lower-income neighbourhoods and with a lower percentage of Hispanic students. CONCLUSIONS: Understanding how the tobacco industry manipulates cigar products and marketing to capitalise on the appeal of marijuana to youth and other priority populations is important to inform regulation, particularly for flavoured tobacco products. In addition, the retail availability of five and six packs of LCCs for ≤$1 near California schools underscores policy recommendations to establish minimum prices for multipacks.

Negative affect, message reactance and perceived risk: how do pictorial cigarette pack warnings change quit intentions?

OBJECTIVE: Pictorial warnings on cigarette packs increase motivation to quit smoking. We sought to examine the potential mediating role of negative affect, message reactance (ie, an oppositional reaction to a message) and perceived risk in shaping quit intentions. METHODS: In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings applied to their cigarette packs for 4 weeks. Analyses used structural equation modelling with bootstrapped SEs to test our theorised mediational model. FINDINGS: Pictorial warnings increased negative affect, message reactance and quit intentions (all P<0.001), but not perceived risk (ie, perceived likelihood and severity of harms of smoking). Negative affect mediated the impact of pictorial warnings on quit intentions (mediated effect=0.16, P<0.001). Message reactance weakened the impact of pictorial warnings on quit intentions, although the effect was small (mediated effect=-0.04, P<0.001). Although pictorial warnings did not directly influence perceived risk, the model showed additional small mediation effects on quit intentions through negative affect and its positive association with perceived risk (mediated effect=0.02, P<0.001), as well as reactance and its negative association with perceived risk (mediated effect=-0.01, P<0.001). CONCLUSIONS: Pictorial cigarette pack warnings increased quit intentions by increasing negative affect. Message reactance partially attenuated this increase in intentions. The opposing associations of negative affect and reactance on perceived risk may explain why pictorial warnings did not lead to observable changes in perceived risk.

Neighborhood Variation in the Price of Cheap Tobacco Products in California: Results From Healthy Stores for a Healthy Community.

BACKGROUND: Retail marketing surveillance research highlights concerns about lower priced cigarettes in neighborhoods with a higher proportion of racial/ethnic minorities but focuses almost exclusively on premium brands. To remedy this gap in the literature, the current study examines neighborhood variation in prices for the cheapest cigarettes and a popular brand of cigarillos in a large statewide sample of licensed tobacco retailers in a low-tax state. METHODS: All 61 local health departments in California trained data collectors to conduct observations in a census of eligible licensed tobacco retailers in randomly selected zip codes (n = 7393 stores, completion rate=91%). Data were collected in 2013, when California had a low and stagnant tobacco tax. Two prices were requested: the cheapest cigarette pack regardless of brand and a single, flavored Swisher Sweets cigarillo. Multilevel models (stores clustered in tracts) examined prices (before sales tax) as a function of neighborhood race/ethnicity and proportion of school-age youth (aged 5-17). Models adjusted for store type and median household income. RESULTS: Approximately 84% of stores sold cigarettes for less than $5 and a Swisher Sweets cigarillo was available for less than $1 in 74% of stores that sold the brand. The cheapest cigarettes cost even less in neighborhoods with a higher proportion of school-age residents and Asian/Pacific Islanders. CONCLUSIONS: Neighborhood disparities in the price of the cheapest combustible tobacco products are a public health threat. Policy changes that make all tobacco products, especially combustible products, less available and more costly may reduce disparities in their use and protect public health. IMPLICATIONS: Much of what is known about neighborhood variation in the price of combustible tobacco products focuses on premium brand cigarettes. The current study extends this literature in two ways, by studying prices for the cheapest cigarette pack regardless of brand and a popular brand of flavored cigarillos and by reporting data from the largest statewide sample of licensed tobacco retailers. Significantly lower prices in neighborhoods with a higher proportion of youth and of racial/ethnic groups with higher smoking prevalence are a cause of concern. The study results underscore the need for policies that reduce availability and increase price of combustible tobacco products, particularly in states with low, stagnant tobacco taxes.

The Effects of 4'-Esterified Resveratrol Derivatives on Calcium Dynamics in Breast Cancer Cells.

Triple-negative breast cancer is a highly aggressive subtype of breast cancer. Frequently, breast cancer cells modulate their calcium signaling pathways to optimize growth. Unique calcium pathways in breast cancer cells could serve as a way to target tumorigenic cells without affecting normal tissue. Resveratrol has previously been shown to activate calcium signaling pathways. We use cell viability, single-cell calcium microscopy, and RT-PCR assays to determine the activity and mechanism of three different 4'-esterified resveratrol derivatives. We demonstrate that two of the derivatives reduce cell viability more effectively than resveratrol in MDA-MB-231 human breast cancer cells. The derivatives also activate similar pro-apoptotic calcium signaling pathways. In particular, the pivalated and butyrated resveratrol derivatives are intriguing putative chemotherapeutics because they are more effective at decreasing cell viability in vitro and inhibiting the plasma membrane Ca2+-ATPase, a protein that is often modulated in breast cancer.

Tobacco outlet density near home and school: Associations with smoking and norms among US teens.

This study examined whether living or going to school in neighborhoods with higher tobacco outlet density is associated with higher odds of cigarette smoking among teens, and with perceptions of greater smoking prevalence and peer approval. Using an Internet panel that is representative of US households, we matched data from teen-parent pairs (n=2771, surveyed June 2011-December 2012) with environmental data about home and school neighborhoods. Density was measured as the number of tobacco outlets per square mile for a ½-mile roadway service area around each participant's home and school. Logistic regressions tested relationships between tobacco outlet density near home and schools with ever smoking. Linear regressions tested relationships between density, perceived prevalence and peer approval. Models were adjusted for teen, parent/household and neighborhood characteristics. In total, 41.0% of US teens (ages 13-16) lived within ½ mile of a tobacco outlet, and 44.4% attended school within 1000ft of a tobacco outlet. Higher tobacco outlet density near home was associated with higher odds of ever smoking, although the relationship was small, OR=1.01, 95% CI (1.00, 1.02). Higher tobacco outlet density near home was also associated with perceptions that more adults smoked, coef.=0.09, 95% CI (0.01, 0.17). Higher tobacco outlet density near schools was not associated with any outcomes. Living in neighborhoods with higher tobacco outlet density may contribute to teen smoking by increasing access to tobacco products and by cultivating perceptions that smoking is more prevalent. Policy interventions to restrict tobacco outlet density should not be limited to school environments.

How to Conduct Store Observations of Tobacco Marketing and Products.

As tobacco companies continue to heavily market their products at the point of sale, tobacco control groups seek strategies to combat the negative effects of this marketing. Store observations, which have been widely used by researchers and practitioners alike, are an excellent surveillance tool. This article provides a guide for public health practitioners interested in working in the tobacco retail environment by detailing the steps involved in conducting store observations of tobacco marketing and products including 1) obtaining tobacco product retailer lists, 2) creating measures, 3) selecting a mode of data collection, 4) training data collectors, and 5) analyzing data. We also highlight issues that may arise while in the field and provide information on disseminating results of store observations, including the potential policy implications.

Endothelial Kruppel-like factor 4 regulates angiogenesis and the Notch signaling pathway.

Regulation of endothelial cell biology by the Notch signaling pathway (Notch) is essential to vascular development, homeostasis, and sprouting angiogenesis. Although Notch determines cell fate and differentiation in a wide variety of cells, the molecular basis of upstream regulation of Notch remains poorly understood. Our group and others have implicated the Krüppel-like factor family of transcription factors as critical regulators of endothelial function. Here, we show that Krüppel-like factor 4 (KLF4) is a central regulator of sprouting angiogenesis via regulating Notch. Using a murine model in which KLF4 is overexpressed exclusively in the endothelium, we found that sustained expression of KLF4 promotes ineffective angiogenesis leading to diminished tumor growth independent of endothelial cell proliferation or cell cycling effects. These tumors feature increased vessel density yet are hypoperfused, leading to tumor hypoxia. Mechanistically, we show that KLF4 differentially regulates expression of Notch receptors, ligands, and target genes. We also demonstrate that KLF4 limits cleavage-mediated activation of Notch1. Finally, we rescue Notch target gene expression and the KLF4 sprouting angiogenesis phenotype by supplementation of DLL4 recombinant protein. Identification of this hitherto undiscovered role of KLF4 implicates this transcription factor as a critical regulator of Notch, tumor angiogenesis, and sprouting angiogenesis.

Phase diagram of a three-dimensional antiferromagnet with random magnetic anisotropy.

Three-dimensional antiferromagnets with random magnetic anisotropy (RMA) that have been experimentally studied to date have competing two-dimensional and three-dimensional exchange interactions which can obscure the authentic effects of RMA. The magnetic phase diagram of Fe_{x}Ni_{1-x}F_{2} epitaxial thin films with true random single-ion anisotropy was deduced from magnetometry and neutron scattering measurements and analyzed using mean-field theory. Regions with uniaxial, oblique, and easy-plane anisotropies were identified. A RMA-induced glass region was discovered where a Griffiths-like breakdown of long-range spin order occurs.

Wall-mounted folding chairs to promote resident physician sitting at the hospital bedside.

BACKGROUND: Sitting at the bedside may improve patient-clinician communication; however, many clinicians do not regularly sit during inpatient encounters. OBJECTIVE: To determine the impact of adding wall-mounted folding chairs inside patient rooms, beyond any impact from a resident education campaign, on the patient-reported frequency of sitting at the bedside by internal medicine resident physicians. DESIGN, SETTING, AND PARTICIPANTS: Prospective, controlled pre-post trial between 2019 and 2022 (data collection paused 2020-2021 due to COVID-19) at an academic hospital in Baltimore, Maryland. Folding chairs were installed in two of four internal medicine units and educational activities were delivered equally across all units. MAIN OUTCOME AND MEASURES: Patient-reported frequency of sitting at bedside, assessed as means on Likert-type items with 1 being "never" and 5 being "every single time." We also examined the frequency of other patient-reported communication behaviors. RESULTS: Two hundred fifty six and 206 patients enrolled in the pre and post-intervention periods, respectively. The mean frequency of patient-reported sitting by resident physicians increased from 1.8 (SD 1.2) to 2.3 (1.2) on education-only units (absolute difference 0.48 [95% CI: 0.21-0.75]) and from 2.0 (1.3) to 3.2 (1.4) on units receiving chairs (1.16, [0.87-1.45]). Comparing differences between groups using ordered logistic regression adjusting for clustering within residents, units with added chairs had greater increases in sitting (odds ratio 2.05 [1.10-3.82]), spending enough time at the bedside (2.43 [1.32-4.49]), and checking for understanding (3.04 [1.44-6.39]). Improvements in sitting and other behaviors were sustained on both types of units. CONCLUSIONS: Adding wall-mounted folding chairs may help promote effective patient-clinician communication.

Underage sales signage in vape shops: Comparison of stores near and far from California colleges.

Objective: Two-thirds of U.S. colleges are near vape shops, where higher rates of underage sales exist. This study examined vape shop compliance with state-mandated age-of-sale signs, the presence of age-of-entry signs and the tobacco industry's "We Card" sign. Participants: Random sample of 614 California vape shops, stratified by distance to community colleges or 4-year universities/colleges; visited June-August, 2019. Methods: Logistic regressions examined whether signage varied by distance to colleges and whether stores sold other tobacco products (OTP). Results: Compliance with the state-mandated age-of-sale sign was 69.4%; vape-only stores were less compliant than vape + OTP (AOR = 0.39, 95% CI = 0.22,0.70). Age-of-entry signs were more common in vape-only (AOR = 1.87, 95% CI = 1.07,3.28) than vape + OTP stores. However, this difference was greater for vape-only stores near community colleges and attenuated for vape-only stores near 4-year universities/colleges. Conclusion: Improved enforcement and retailer education regarding age-of-sale signage are needed, particularly near colleges where greater potential for underage sales presumably exists.