Asking the Right Questions About Secondhand Smoke.

INTRODUCTION: Despite knowledge about major health effects of secondhand tobacco smoke (SHS) exposure, systematic incorporation of SHS screening and counseling in clinical settings has not occurred. METHODS: A three-round modified Delphi Panel of tobacco control experts was convened to build consensus on the screening questions that should be asked and identify opportunities and barriers to SHS exposure screening and counseling. The panel considered four questions: (1) what questions should be asked about SHS exposure; (2) what are the top priorities to advance the goal of ensuring that these questions are asked; (3) what are the barriers to achieving these goals; and (4) how might these barriers be overcome. Each panel member submitted answers to the questions. Responses were summarized and successive rounds were reviewed by panel members for consolidation and prioritization. RESULTS: Panelists agreed that both adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from any tobacco products in their usual environment. The panel found that consistent clinician training, quality measurement or other accountability, and policy and electronic health records interventions were needed to successfully implement consistent screening. CONCLUSIONS: The panel successfully generated screening questions and identified priorities to improve SHS exposure screening. Policy interventions and stakeholder engagement are needed to overcome barriers to implementing effective SHS screening. IMPLICATIONS: In a modified Delphi panel, tobacco control and clinical prevention experts agreed that all adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from tobacco products. Consistent training, accountability, and policy and electronic health records interventions are needed to implement consistent screening. Increasing SHS screening will have a significant impact on public health and costs.

Estimating cigarette tax avoidance and evasion: evidence from a national sample of littered packs.

INTRODUCTION: A number of recent studies document the proportion of all cigarette packs that are 'contraband' using discarded packs to measure tax avoidance and evasion, which we call tax non-compliance. To date, academic studies using discarded packs focused on relatively small geographical areas such as a city or a neighbourhood. METHODS: We visited 160 communities across 38 US states in 2012 and collected data from littered cigarette packs as part of the State and Community Tobacco Control (SCTC) Research Initiative and the Bridging the Gap Community Obesity Measures Project (BTG-COMP). Data collectors were trained in a previously tested littered pack data collection protocol. RESULTS: Field teams collected 2116 packs with cellophane across 132 communities. We estimate a national tax non-compliance rate of 18.5% with considerable variation across regions. Suburban areas had lower non-compliance than urban areas as well as areas with high and low median household income areas compared with middle income areas. DISCUSSION: We present the first academic national study of tax non-compliance using littered cigarette packs. We demonstrate the feasibility of meaningful large-scale data collection using this methodology and document considerable variation in tax non-compliance across areas, suggesting that both policy differences and geography may be important in control of illicit tobacco use. Given the geography of open borders among countries with varying tax rates, this simple methodology may be appropriate to estimate tax non-compliance in countries that use tax stamps or other pack markings, such as health warnings.

Advocacy for Global Tobacco Control and Child Health.

Tobacco and secondhand smoke remain leading threats to public health. Evidence since the 1950s has shown that the tobacco industry has acted in bad faith to deceive the public about the health effects of smoking. They have specifically targeted vulnerable populations including children and adolescents with various-and often misleading-marketing efforts and promotions. The increased popularity and weak regulation of electronic cigarettes have created a new generation of smokers who mistakenly believe they are "safer" from harm. Continued research, advocacy, and government action are needed to protect public health. Public health advocates must know the evidence, build coalitions, and prepare for industry countermeasures. Persistence is key, but public health efforts have successfully decreased tobacco-related deaths.

Receipt of Private Time Among Adolescents and Young Adults With and Without Special Healthcare Needs.

PURPOSE: Private time is an opportunity for the adolescent patient to speak directly to a healthcare provider and a marker of quality preventive health care. Little is known about whether adolescents and young adults (AYAs) with special healthcare needs (SHCNs) are afforded private discussions with their primary care clinicians. METHODS: We surveyed a nationally representative sample of 1,209 adolescents (13-18 years) and 709 young adults (19-26 years) about whether they had SHCNs and whether they had ever had private, one-on-one time with their healthcare providers. RESULTS: SHCNs were reported by 20.3% of adolescents and 15.6% of young adults. Among adolescents, older age was associated with more SHCNs. Among young adults, women and blacks were more likely to report SHCNs than men and those reporting other race categories. For both AYAs, those with SHCNs more often received private time than those without SHCNs: 54.2% of adolescents and 88.1% of young adults with SHCNs reported ever having received private time, compared with 29.6% of adolescents and 62.1% of young adults without SHCNs. CONCLUSIONS: Lack of private time continues to impact quality primary care for AYAs; however, AYAs with SHCNs are more likely to have received private time than AYAs who do not have SHCNs. Further research is needed to understand whether increased number of clinical visits, clinician-related factors, or other factors lead to more opportunities for young people with SHCNs to receive private time from their clinicians.

Smoking cessation counseling for parents during child hospitalization: a national survey of pediatric nurses.

OBJECTIVE: Given the central role played by pediatric nurses in intake assessment, discharge planning, and education for families of hospitalized pediatric patients, a child's hospitalization may provide a unique opportunity for counseling parents about smoking. We sought to determine if hospital policies can support nurses in effectively counseling parents about smoking. DESIGN AND SAMPLE: We conducted a national survey of pediatric staff nurses and administrators/educators who were members of the Society of Pediatric Nurses in 2008 (n=888) to explore counseling practices for tobacco control. MEASURES: Questionnaires included data on demographics, personal and work environment characteristics, hospital policy characteristics, work attitudes and barriers and the main outcome--5As for smoking cessation counseling--Ask, Advise, Assess, Assist, and Arrange. RESULTS: Overall, routine screening for household smokers was most common (43%), followed by advice to quit (25%), assessing willingness to quit (19%), assisting with a quit plan (6%), and arranging follow-up contact (3%). Nurses working in hospitals with admission assessments specifically asking about household members who smoke were 7 times more likely than those without such assessments to routinely ask about smoking (OR: 7.2, 95% CI: 4.9-10.5). CONCLUSION: Future research should test the efficacy of developing comprehensive hospital-wide policies to deliver smoking cessation for parents during a child's hospitalization.

Enacting legislation to restrict youth access to tanning beds: a survey of advocates and sponsoring legislators.

BACKGROUND: Passing tanning bed legislation restricting underage use has remained challenging. OBJECTIVE: We sought to determine the resources required to pass tanning bed legislation restricting use to children and identify key barriers to its passage. METHODS: A total of 15 states sought to pass tanning bed legislation in 2006; in-depth surveys were completed with advocates in 10 states and legislators in 5 states. RESULTS: Advocates sought advice from the sponsoring legislator or legislators (n = 9), held discussions with other organizations (n = 8), and used a lobbyist (n = 5). The 3 major barriers were strong lobbying efforts by the tanning bed industry (n = 10), proceedings after the bill was filed (n = 5), and obtaining support from other organizations (n = 4). For legislators, the most significant barrier was making colleagues aware of the health effects of tanning bed use. LIMITATIONS: Five of 10 legislators and 10 of 15 advocates responded to the survey. CONCLUSION: Barriers to passage of tanning bed legislation can potentially be surmounted with advice to advocates and coordinated efforts by multiple organizations.

Delivery and Impact of a Motivational Intervention for Smoking Cessation: A PROS Study.

OBJECTIVES: We tested a Public Health Service 5As-based clinician-delivered smoking cessation counseling intervention with adolescent smokers in pediatric primary care practice. METHODS: We enrolled clinicians from 120 practices and recruited youth (age ≥14) from the American Academy of Pediatrics Pediatric Research in Office Settings practice-based research network. Practices were randomly assigned to training in smoking cessation (intervention) or social media counseling (attentional control). Youth recruited during clinical visits completed confidential screening forms. All self-reported smokers and a random sample of nonsmokers were offered enrollment and interviewed by phone at 4 to 6 weeks, 6 months, and 12 months after visits. Measures included adolescents' report of clinicians' delivery of screening and counseling, current tobacco use, and cessation behaviors and intentions. Analysis assessed receipt of screening and counseling, predictors of receiving 5As counseling, and effects of interventions on smoking behaviors and cessation at 6 and 12 months. RESULTS: Clinicians trained in the 5As intervention delivered more screening (ß = 1.0605, P < .0001) and counseling (ß = 0.4354, P < .0001). In both arms, clinicians more often screened smokers than nonsmokers. At 6 months, study arm was not significantly associated with successful cessation; however, smokers in the 5As group were more likely to have quit at 12 months. Addicted smokers more often were counseled, regardless of study arm, but were less likely to successfully quit smoking. CONCLUSIONS: Adolescent smokers whose clinicians were trained in 5As were more likely to receive smoking screening and counseling than controls, but the ability of this intervention to help adolescents quit smoking was limited.

Development and Reliability Testing of a Fast-Food Restaurant Observation Form.

PURPOSE: To develop a reliable observational data collection instrument to measure characteristics of the fast-food restaurant environment likely to influence consumer behaviors, including product availability, pricing, and promotion. DESIGN: The study used observational data collection. SETTING: Restaurants were in the Chicago Metropolitan Statistical Area. SUBJECTS: A total of 131 chain fast-food restaurant outlets were included. MEASURES: Interrater reliability was measured for product availability, pricing, and promotion measures on a fast-food restaurant observational data collection instrument. ANALYSIS: Analysis was done with Cohen's κ coefficient and proportion of overall agreement for categorical variables and intraclass correlation coefficient (ICC) for continuous variables. RESULTS: Interrater reliability, as measured by average κ coefficient, was .79 for menu characteristics, .84 for kids' menu characteristics, .92 for food availability and sizes, .85 for beverage availability and sizes, .78 for measures on the availability of nutrition information,.75 for characteristics of exterior advertisements, and .62 and .90 for exterior and interior characteristics measures, respectively. For continuous measures, average ICC was .88 for food pricing measures, .83 for beverage prices, and .65 for counts of exterior advertisements. CONCLUSION: Over 85% of measures demonstrated substantial or almost perfect agreement. Although some measures required revision or protocol clarification, results from this study suggest that the instrument may be used to reliably measure the fast-food restaurant environment.

Development and reliability testing of a food store observation form.

OBJECTIVE: To develop a reliable food store observational data collection instrument to be used for measuring product availability, pricing, and promotion. DESIGN: Observational data collection. SETTING: A total of 120 food stores (26 supermarkets, 34 grocery stores, 54 gas/convenience stores, and 6 mass merchandise stores) in the Chicago metropolitan statistical area. MAIN OUTCOME MEASURES: Inter-rater reliability for product availability, pricing, and promotion measures on a food store observational data collection instrument. ANALYSIS: Cohen's kappa coefficient and proportion of overall agreement for dichotomous variables and intra-class correlation coefficient for continuous variables. RESULTS: Inter-rater reliability, as measured by average kappa coefficient, was 0.84 for food and beverage product availability measures, 0.80 for interior store characteristics, and 0.70 for exterior store characteristics. For continuous measures, average intra-class correlation coefficient was 0.82 for product pricing measures; 0.90 for counts of fresh, frozen, and canned fruit and vegetable options; and 0.85 for counts of advertisements on the store exterior and property. CONCLUSIONS AND IMPLICATIONS: The vast majority of measures demonstrated substantial or almost perfect agreement. Although some items may require revision, results suggest that the instrument may be used to reliably measure the food store environment.

Field validation of secondary commercial data sources on the retail food outlet environment in the U.S.

This study used direct field observations with interior assessments of outlets to validate food store and restaurant data from two commercial business lists conditional on classification of outlet type, including supermarkets, grocery stores, convenience stores, full-service restaurants and fast food restaurants. The study used a stratified random sample that included 274 urban census tracts across 9 counties from the Chicago Metropolitan Statistical Area (MSA) and 46 suburban and 61 rural census tracts across 13 counties from a 50-mile buffer surrounding the MSA. Results showed that agreement between the field observations and the commercial business lists for the food store and restaurant outlets was generally moderate (ranging from fair to good). However, when the listed data were validated based on an exact classification match, agreement was only fair (ranging from poor to moderate) and, in particular, poor for fast food restaurants. The study also found that agreement levels for some outlet types differed by tract characteristics. Commercial databases must be used with caution as substitutes for on the ground data collection.

The CHEER study to reduce BMI in Elementary School students: a school-based, parent-directed study in Framingham, Massachusetts.

Childhood obesity may be lessened by parent-focused interventions. A pilot parent-directed trial with 46 parents of overweight and obese elementary school students was conducted at two ethnically diverse public schools in Framingham, Massachusetts. Parents were randomly assigned to either the Materials Group, which received mailed educational materials, or the Materials plus Personal Encounters Group, which received educational materials through interactions with community health workers (CHWs). Parents completed baseline and post-intervention surveys; children's body mass index (BMI) percentiles were measured at baseline and post-intervention. There were no differences in the reduction of children's BMI between groups. However, the mean BMI percentile for all children dropped from 94.1 to 90.6 (p = .005), while there was no change in BMI among a nonrandomized contemporaneous control group. Findings are limited by the lack of a true control group and small sample size. Results from this school nurse and CHW outreach program to parents are encouraging.

A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home.

OBJECTIVE: Good hand hygiene may reduce the spread of infections in families with children who are in out-of-home child care. Alcohol-based hand sanitizers rapidly kill viruses that are commonly associated with respiratory and gastrointestinal (GI) infections. The objective of this study was to determine whether a multifactorial campaign centered on increasing alcohol-based hand sanitizer use and hand-hygiene education reduces illness transmission in the home. METHODS: A cluster randomized, controlled trial was conducted of homes of 292 families with children who were enrolled in out-of-home child care in 26 child care centers. Eligible families had > or =1 child who was 6 months to 5 years of age and in child care for > or =10 hours/week. Intervention families received a supply of hand sanitizer and biweekly hand-hygiene educational materials for 5 months; control families received only materials promoting good nutrition. Primary caregivers were phoned biweekly and reported respiratory and GI illnesses in family members. Respiratory and GI-illness-transmission rates (measured as secondary illnesses per susceptible person-month) were compared between groups, adjusting for demographic variables, hand-hygiene practices, and previous experience using hand sanitizers. RESULTS: Baseline demographics were similar in the 2 groups. A total of 1802 respiratory illnesses occurred during the study; 443 (25%) were secondary illnesses. A total of 252 GI illnesses occurred during the study; 28 (11%) were secondary illnesses. The secondary GI-illness rate was significantly lower in intervention families compared with control families (incidence rate ratio [IRR]: 0.41; 95% confidence interval [CI]: 0.19-0.90). The overall rate of secondary respiratory illness was not significantly different between groups (IRR: 0.97; 95% CI: 0.72-1.30). However, families with higher sanitizer usage had a marginally lower secondary respiratory illness rate than those with less usage (IRR: 0.81; 95% CI: 0.65-1.09). CONCLUSIONS: A multifactorial intervention emphasizing alcohol-based hand sanitizer use in the home reduced transmission of GI illnesses within families with children in child care. Hand sanitizers and multifaceted educational messages may have a role in improving hand-hygiene practices within the home setting.