Osteogenesis imperfecta due to mutations in non-collagenous genes: lessons in the biology of bone formation.

PURPOSE OF REVIEW: Osteogenesis imperfecta or 'brittle bone disease' has mainly been considered a bone disorder caused by collagen mutations. Within the last decade, however, a surge of genetic discoveries has created a new paradigm for osteogenesis imperfecta as a collagen-related disorder, where most cases are due to autosomal dominant type I collagen defects, while rare, mostly recessive, forms are due to defects in genes whose protein products interact with collagen protein. This review is both timely and relevant in outlining the genesis, development, and future of this paradigm shift in the understanding of osteogenesis imperfecta. RECENT FINDINGS: Bone-restricted interferon-induced transmembrane (IFITM)-like protein (BRIL) and pigment epithelium-derived factor (PEDF) defects cause types V and VI osteogenesis imperfecta via defective bone mineralization, while defects in cartilage-associated protein (CRTAP), prolyl 3-hydroxylase 1 (P3H1), and cyclophilin B (CYPB) cause types VII-IX osteogenesis imperfecta via defective collagen post-translational modification. Heat shock protein 47 (HSP47) and FK506-binding protein-65 (FKBP65) defects cause types X and XI osteogenesis imperfecta via aberrant collagen crosslinking, folding, and chaperoning, while defects in SP7 transcription factor, wingless-type MMTV integration site family member 1 (WNT1), trimeric intracellular cation channel type b (TRIC-B), and old astrocyte specifically induced substance (OASIS) disrupt osteoblast development. Finally, absence of the type I collagen C-propeptidase bone morphogenetic protein 1 (BMP1) causes type XII osteogenesis imperfecta due to altered collagen maturation/processing. SUMMARY: Identification of these multiple causative defects has provided crucial information for accurate genetic counseling, inspired a recently proposed functional grouping of osteogenesis imperfecta types by shared mechanism to simplify current nosology, and has prodded investigations into common pathways in osteogenesis imperfecta. Such investigations could yield critical information on cellular and bone tissue mechanisms and translate to new mechanistic insight into clinical therapies for patients.

Exploring the Experiences and Impacts of Research Role-Emerging Placements in Physiotherapy.

Purpose: Research role-emerging placements (RREPs) have been integrated into placement offerings in Canadian physiotherapy programmes. The purpose of the present study is to describe the experiences and impacts of RREPs completed by graduates of Canadian physiotherapy programmes. Methods: Participants were recruited by purposive sampling and completed semi-structured interviews to explore their RREP experiences. Themes were identified using thematic analysis and collaboratively analyzed using the DEPICT model. Results: Eleven participants who completed RREPs during their Canadian physiotherapy programmes (three men, eight women; aged 26.9 [SD 2.7] years) took part in this study. The participants expressed the RREP was a valuable experience. Four themes emerged from the data: (1) Motivators for selecting an RREP included interest in research or a medical injury, (2) The RREP experience involved benefits and challenges, (3) Impacts of completing an RREP, and (4) RREP participant suggestions. Conclusions: RREPs are valuable placement opportunities for learners in Canadian physiotherapy programmes facilitating the development of essential competencies in a non-traditional setting. RREPs could be considered as a placement opportunity for other allied health programmes, as the skills gained are beneficial for all health care professionals.

Objectif: les stages de recherche dans un rôle émergent (SRRÉ) sont intégrés aux offres de stage des programmes de physiothérapie canadiens. La présente étude visait à décrire les expériences et les effets des SRRÉ effectués par les diplômés des programmes de physiothérapie canadiens. Méthodologie: les chercheurs ont recruté les participants par échantillonnage dirigé et ont effectué des entrevues semi-structurées pour explorer leurs expériences de SRRÉ. Ils ont extrait les thèmes au moyen d'une analyse thématique et en ont fait une analyse coopérative à l'aide du modèle DEPICT. Résultats: onze participants qui ont effectué des SRRÉ pendant leur programme de physiothérapie au Canada (trois hommes, huit femmes; 26,9 ± 2,7 ans) ont participé à l'étude. Ils ont trouvé que leur SRRÉ avait été une expérience précieuse. Ils ont tiré quatre thèmes des données : 1) les motivations pour sélectionner un SRRÉ incluaient l'intérêt pour la recherche ou une lésion médicale, 2) l'expérience du SRRÉ comportait des avantages et des difficultés, 3) les répercussions d'avoir effectué un SRRÉ et 4) les suggestions des participants aux SRRÉ. Conclusions: les SRRÉ sont de précieuses occasions de stage pour les apprenants des programmes de physiothérapie canadiens, ce qui a facilité l'acquisition de compétences essentielles dans un milieu non traditionnel. Les SRRÉ pourraient être considérés comme des occasions de stage dans des programmes de santé connexes, car les compétences acquises sont bénéfiques pour tous les professionnels de la santé.

Regulation of collagen fibril nucleation and initial fibril assembly involves coordinate interactions with collagens V and XI in developing tendon.

Collagens V and XI comprise a single regulatory type of fibril-forming collagen with multiple isoforms. Both co-assemble with collagen I or II to form heterotypic fibrils and have been implicated in regulation of fibril assembly. The objective of this study was to determine the roles of collagens V and XI in the regulation of tendon fibrillogenesis. Flexor digitorum longus tendons from a haplo-insufficient collagen V mouse model of classic Ehlers Danlos syndrome (EDS) had decreased biomechanical stiffness compared with controls consistent with joint laxity in EDS patients. However, fibril structure was relatively normal, an unexpected finding given the altered fibrils observed in dermis and cornea from this model. This suggested roles for other related molecules, i.e. collagen XI, and compound Col5a1(+/-),Col11a1(+/-) tendons had altered fibril structures, supporting a role for collagen XI. To further evaluate this, transcript expression was analyzed in wild type tendons. During development (E18-P10) both collagen V and XI were comparably expressed; however, collagen V predominated in mature (P30) tendons. The collagens had a similar expression pattern. Tendons with altered collagen V and/or XI expression (Col5a1(+/-); Col11a1(+/-); Col5a1(+/-),Col11a1(+/-); Col11a1(-/-); Col5a1(+/-),Col11a1(-/-)) were analyzed at E18. All genotypes demonstrated a reduced fibril number and altered structure. This phenotype was more severe with a reduction in collagen XI. However, the absence of collagen XI with a reduction in collagen V was associated with the most severe fibril phenotype. The data demonstrate coordinate roles for collagens V and XI in the regulation of fibril nucleation and assembly during tendon development.

Pericellular proteins of the developing mouse tendon: a proteomic analysis.

Tendon fibroblasts synthesize and assemble collagen fibrils, the basic structural unit of tendons. Regulation of fibrillogenesis is essential for tendon development and function. Fibril assembly begins within extracellular micro-domains associated with the fibroblast surface. We hypothesize that molecules crucial to the regulation of fibril assembly are membrane associated and/or within the pericellular micro-environment. This report defines proteins in the surfaceome, that is, plasma membrane and pericellular matrix, from mouse flexor digitorum longus tendons. Proteomic analysis identified a set of surfaceome molecules including collagens, fibronectin, integrins, proteoglycans, and receptors in extracts from mouse tendons at postnatal day 1, a developmental stage when collagen protofibril nucleation and initial steps in fibril assembly predominate. The proteomic results were validated for molecules identified with a small number of unique peptides and/or low sequence coverage. For these analyses, proteins were selected based on their potential roles in fibril nucleation, that is, collagen V; organization of fibrillogenesis, that is, integrins and fibronectin; and known localization to the plasma membrane with potential to impact matrix assembly, that is, CD44, syndecan-1, epidermal growth factor receptor, and matrix metalloproteinase 25. These molecules were all detected in extracts of the developing tendon, demonstrating that the surfaceome included molecules hypothesized to regulate fibrillogenesis as well as many with no known function in this capacity. This report, therefore, generates an unbiased set of cell surface-associated molecules, providing a resource to identify novel or unexpected regulatory molecules involved in collagen fibril and matrix assembly.

Cutaneous Sensitivity Across Regions of the Foot Sole and Dorsum are Influenced by Foot Posture.

Understanding the processing of tactile information is crucial for the development of biofeedback interventions that target cutaneous mechanoreceptors. Mechanics of the skin have been shown to influence cutaneous tactile sensitivity. It has been established that foot skin mechanics are altered due to foot posture, but whether these changes affect cutaneous sensitivity are unknown. The purpose of this study was to investigate the potential effect of posture-mediated skin deformation about the ankle joint on perceptual measures of foot skin sensitivity. Participants (N = 20) underwent perceptual skin sensitivity testing on either the foot sole (N = 10) or dorsum (N = 10) with the foot positioned in maximal dorsiflexion/toe extension, maximal plantarflexion/toe flexion, and a neutral foot posture. Perceptual tests included touch sensitivity, stretch sensitivity, and spatial acuity. Regional differences in touch sensitivity were found across the foot sole (p < 0.001) and dorsum (p < 0.001). Touch sensitivity also significantly increased in postures where the skin was compressed (p = 0.001). Regional differences in spatial acuity were found on the foot sole (p = 0.002) but not dorsum (p = 0.666). Spatial acuity was not significantly altered by posture across the foot sole and dorsum, other than an increase in sensitivity at the medial arch in the dorsiflexion posture (p = 0.006). Posture*site interactions were found for stretch sensitivity on the foot sole and dorsum in both the transverse and longitudinal directions (p < 0.005). Stretch sensitivity increased in postures where the skin was pre-stretched on both the foot sole and dorsum. Changes in sensitivity across locations and postures were believed to occur due to concurrent changes in skin mechanics, such as skin hardness and thickness, which follows our previous findings. Future cutaneous biofeedback interventions should be applied with an awareness of these changes in skin sensitivity, to maximize their effectiveness for foot sole and dorsum input.

Availability of Services and Caregiver Burden: Supporting Individuals With Neurogenetic Conditions During the COVID-19 Pandemic.

Because of the COVID-19 pandemic, in-person services for individuals with neurodevelopmental disabilities were disrupted globally, resulting in a transition to remote delivery of services and therapies. For individuals with neurogenetic conditions, reliance on nonclinical caregivers to facilitate all therapies and care was unprecedented. The study aimed to (1) describe caregivers' reported impact on their dependent's services, therapies, medical needs, and impact on themselves as a result of the COVID-19 pandemic and (2) assess the relationship between the extent of disruption of services and the degree of self-reported caregiver burden. Two online questionnaires were completed by caregivers participating in Simons Searchlight in April and May 2020. Surveys were completed by caregivers of children or dependent adults with neurodevelopmental genetic conditions in Simons Searchlight. Caregivers reported that the impact of the COVID-19 pandemic moderately or severely disrupted services, therapies, or medical supports. The majority of caregivers were responsible for providing some aspect of therapy. Caregivers reported "feeling stressed but able to deal with problems as they arise," and reported lower anxiety at follow-up. Caregivers reported that telehealth services were not meeting the needs of those with complex medical needs. Future surveys will assess if and how medical systems, educational programs, therapists, and caregivers adapt to the challenges arising during the COVID-19 pandemic.

Foot sole cutaneous stimulation mitigates neuromuscular fatigue during a sustained plantar flexor isometric task.

Neuromuscular fatigue impairs motor coordination, movement stability, and proprioception, which further decreases performance. A neuromechanical coupling exists between foot sole cutaneous mechanoreceptors and motoneurons of the lower limb, however, the contribution of skin sensory input on muscle fatigue remains unclear. The purpose of this study was to determine if the presence of cutaneous stimulation could mitigate the effect of fatigue of the plantar flexor muscles during a sustained isometric task at 30% maximal voluntary contraction (MVC). Participants (N = 16, age 24.1 ± 2.6 yr) underwent a 30% isometric plantar flexor fatiguing task in a seated position with hip, knee, and ankle angle at 80°, 100°, and 90°, respectively, with intermittent MVCs until task failure. Failure was defined as when the participant could no longer maintain 30% MVC for a minimum of two seconds. Throughout the protocol, electrical stimulation was applied to either the right heel, right metatarsals, or no stimulation. A subset of participants (N = 6) underwent an additional condition with electrical stimulation applied to the left arm. MVCs were also conducted intermittently throughout recovery for 30 min. Foot sole cutaneous stimulation mitigated fatigue, as demonstrated by an ~15% increased time to task failure (TTF) compared with the control condition. When normalized to TTF, MVC torque amplitude was not different at each time epoch, which indicated that each %MVC was maintained longer into the fatigue task during the heel and metatarsal stimulation conditions However, there was no significant effect of cutaneous stimulation on recovery. The results indicate that cutaneous stimulation may serve as a feasible means to mitigate fatigue.NEW & NOTEWORTHY Cutaneous coupling with lower limb motor neurons has long been known. We set out to establish whether this pathway could serve a purpose other than muscular modulation during standing and walking. We found that during a submaximal contraction of the plantar flexor muscles, the addition of intermittent cutaneous stimulation to the skin of the foot sole resulted in an increase in time to task failure by 15%, which was over a minute longer in duration. We conclude that skin stimulation may serve as a mechanism to mitigate fatigue.

Hepcidin and iron: novel findings for elite female rugby Sevens players.

BACKGROUND: Iron deficiency is a common deficiency disease worldwide with athletes at increased risk. METHODS: A proposed new mechanism of exercise-induced iron deficiency in athletes involves the iron-regulatory hormone hepcidin, however, there is limited information on this amongst elite athletes. This study describes iron status in elite female rugby Sevens players. RESULTS: Blood samples were collected at the start and mid-season and analyzed for serum iron, serum ferritin (SF), soluble transferring receptor (sTfR), high sensitivity C-reactive Protein (hsCRP) and hepcidin. Of the 17 players 18% were iron deficient (SF<30 µg/L) with 29-35% of players with sub-optimal iron stores at some point during the study (SF<45 µg/L). Serum hepcidin was strongly correlated with SF (r=0.61, P=0.0001). CONCLUSIONS: Some elite female rugby Sevens players have sub-optimal iron stores over the course of a season.

Water pipe tobacco smoking among middle and high school students.

OBJECTIVES: We examined prevalence rates of water pipe tobacco smoking among young people as a first step in assessing the health implications of this form of tobacco use. METHODS: We examined water pipe use with data from the 2007 Florida Youth Tobacco Survey, which assessed tobacco-related beliefs, attitudes, and behaviors among the state's middle and high school students. RESULTS: Four percent of middle school students and 11% of high school students reported ever having used a water pipe. Adolescent boys were significantly more likely than adolescent girls to use water pipes, and African American adolescents were significantly less likely than adolescents from other racial/ethnic backgrounds to do so. Those who indicated ever having tried cigarettes and those who reported positive attitudes toward the social nature of cigarette use were more likely to have tried water pipes. CONCLUSIONS: Water pipe use appears to be widespread among middle and high school students. Further research is needed to assess the health risks associated with water pipe tobacco smoking as well as young people's attitudes toward this form of tobacco use.

Effects of foot position on skin structural deformation.

As the largest and most superficial organ, the skin is well positioned for receiving sensory information from the environment. It is conceivable that changes in posture could result in deformations of the skin and subsequent changes in skin material properties. Specifically, the ankle and metatarsophalangeal joints have the capability to undergo large postural alterations with the potential to induce large structural deformations in the skin of the foot. The purpose of this study was to determine the extent to which alterations in foot posture may influence measures of foot sole and dorsum skin stretch, hardness, and thickness in vivo. Ten young and healthy individuals were tested while three static foot postures (plantar flexion, neutral and dorsiflexion) were maintained passively. Skin stretch deformation was quantified across each posture using an 11 × 4 point matrix of 3D kinematic markers affixed to the skin of the foot sole and dorsum. Skin hardness was assessed across each posture at specific locations of the foot sole (1st metatarsal, 5th metatarsal, medial arch, lateral arch and heel) and foot dorsum (proximal, middle and distal) using a handheld Shore durometer. Skin (epidermal + dermal) thickness was measured in each posture from the same test locations using ultrasound images obtained for the foot sole and dorsum. In the plantar flexion ankle posture, the foot sole skin was observed to relax/retract on average (± standard errorr of the mean (SEM) by 9 ± 2% to become both 20 ± 6% softer and 10 ± 6% thicker. In this posture, the foot dorsum skin stretched on average by 7 ± 2% resulting in 84 ± 8% harder and 5 ± 4% thinner skin. In the dorsiflexion ankle posture, the skin of the foot sole was observed to stretch on average by 5 ± 1% to become both 20 ± 8% harder and 4 ± 7% thinner. In this posture, the skin of the foot dorsum relaxed/retracted on average by 9 ± 1% resulting in the skin becoming 27 ± 12% softer and 7 ± 5% thicker. Notably, all of the sites responded with movement in a similar direction, but each site responded to a variable extent. Importantly, it was clear that the majority of skin structural deformation of the foot sole occurred within the 1st metatarsal, 5th metatarsal, and medial arch regions, while deformation was more evenly distributed across regions of the foot dorsum. The results suggest there is location specificity in the retraction and stretch characteristics of the foot skin. While not tested directly, this may suggest that local stretch distributions could be in part due to the underlying dermal and hypodermal structures in these foot regions. With these observed changes in the mechanical structure of the foot sole and dorsum skin tissue matrix, it is possible that corresponding posture-dependent changes in cutaneous mechanoreceptor activation may be present.

Heparan and chondroitin sulfate on growth plate perlecan mediate binding and delivery of FGF-2 to FGF receptors.

Fibroblast growth factor (FGF)-2 regulates chondrocyte proliferation in the growth plate. Heparan sulfate (HS) proteoglycans bind FGF-2. Perlecan, a heparan sulfate proteoglycan (HSPG) in the developing growth plate, however, contains both HS and chondroitin sulfate (CS) chains. The binding of FGF-2 to perlecan isolated from the growth plate was evaluated using cationic filtration (CAF) and immunoprecipitation (IP) assays. FGF-2 bound to perlecan in both the CAF and IP assays primarily via the HS chains on perlecan. A maximum of 123 molecules of FGF-2 was calculated to bind per molecule of perlecan. When digested with chondroitinase ABC to remove its CS chains, perlecan augmented binding of FGF-2 to the FGFR-1 and FGFR-3 receptors and also increased FGF-2 stimulation of [(3)H]-thymidine incorporation in BaF3 cells expressing these FGF receptors. These data show that growth plate perlecan binds to FGF-2 by its HS chains but can only deliver FGF-2 to FGF receptors when its CS chains are removed.

The core protein of growth plate perlecan binds FGF-18 and alters its mitogenic effect on chondrocytes.

Fibroblast growth factor-18 (FGF-18) has been shown to regulate the growth plate chondrocyte proliferation, hypertrophy and cartilage vascularization necessary for endochondral ossification. The heparan sulfate proteoglycan perlecan is also critical for growth plate chondrocyte proliferation. FGF-18 null mice exhibit a skeletal dwarfism similar to that of perlecan null mice. Growth plate perlecan contains chondroitin sulfate (CS) and heparan sulfate (HS) chains and FGF-18 is known to bind to heparin and to heparan sulfate from some sources. We used cationic filtration and immunoprecipitation assays to investigate the binding of FGF-18 to perlecan purified from the growth plate and to recombinant perlecan domains expressed in COS-7 cells. FGF-18 bound to perlecan with a K(d) of 145 nM. Near saturation, approximately 103 molecules of FGF-18 bound per molecule of perlecan. At the lower concentrations used, FGF-18 bound with a K(d) of 27.8 nM. This binding was not significantly altered by chondroitinase nor heparitinase digestion of perlecan, but was substantially and significantly reduced by reduction and alkylation of the perlecan core protein. This indicates that the perlecan core protein (and not the CS nor HS chains) is involved in FGF-18 binding. FGF-18 bound equally to full-length perlecan purified from the growth plate and to recombinant domains I-III and III of perlecan. These data indicate that low affinity binding sites for FGF-18 are present in cysteine-rich regions of domain III of perlecan. FGF-18 stimulated 3H-thymidine incorporation in growth plate chondrocyte cultures derived from the lower and upper proliferating zones by 9- and 14-fold, respectively. The addition of perlecan reversed this increased incorporation in the lower proliferating chondrocytes by 74% and in the upper proliferating cells by 37%. These results suggest that perlecan can bind FGF-18 and alter the mitogenic effect of FGF-18 on growth plate chondrocytes.

Spine Posture Influences Tactile Perceptual Sensitivity of the Trunk Dorsum.

The purpose of the current work was to quantify the influence of posture-mediated skin deformation on trunk dorsum tactile perceptual sensitivity. Twelve young and healthy individuals were assessed while adopting three different spine postures (extension, neutral and flexion). Tactile sensitivity threshold tests (T10 and L4 vertebral levels) included measures of touch sensitivity, spatial acuity and stretch sensitivity. The results demonstrate that tactile sensitivity can differ due to changes in body posture. The skin of the trunk dorsum had increased thresholds for touch sensitivity, longitudinal spatial acuity and transverse stretch sensitivity in spine flexion. Furthermore, spine flexion also resulted in a reduced sensory threshold to stretching stimuli in the longitudinal direction. The opposite trends occurred when participants adopted spine extension. It is suggested that posture-mediated skin deformation generates changes in the amount of strain experienced by individual skin mechanoreceptors, and the relative spacing between mechanoreceptors. Furthermore, it is suggested that "pre-stretch" of the skin brings mechanoreceptors closer to their stretch activation thresholds, thereby increasing an individual's sensitivity to skin stretch when in spine flexion.

Modulation of FGF-2 binding to chondrocytes from the developing growth plate by perlecan.

FGF-2 is a regulator of chondrocyte proliferation in the developing growth plate and has been shown to bind to perlecan, a heparan sulfate proteoglycan. We evaluated the effect of perlecan isolated from the growth plate on the binding of FGF-2 to its low and high affinity receptors on resting and proliferating chondrocytes. Chondrocytes were isolated by pronase/collagenase digestion of 1 mm thick slices from the resting and proliferating zones of fetal bovine ribs and were plated in serum-free DMEM. Chondrocytes maintained their zone-specific level of DNA and matrix synthesis over a two-day culture period. The collagen, aggrecan, and perlecan components of the matrix produced were associated with the cell layer and were secreted into the medium. Most of the perlecan made by the chondrocytes was secreted into the medium. Western blots showed medium perlecan to contain two high molecular weight core proteins and overlay assays showed only the large core protein bound FGF-2. Cell layer perlecan contained only the smaller core protein. Immunoprecipitation assays of media showed that the medium perlecan bound (125)I-FGF-2, that the bound FGF-2 was eluted from perlecan by 2 M NaCl at pH 7.4, and that this binding was eliminated by prior digestion with heparatinase. This indicates that the perlecan secreted into the medium is a low affinity receptor for FGF-2. (125)I-FGF-2 also bound to the chondrocytes in cell culture. Competition studies showed exogenous FGF-2 reduced (125)I-FGF-2 binding to high affinity receptor but not the low affinity receptor in the cell layer. Exogenous perlecan, however, reduced (125)I-FGF-2 binding to both the low and the high affinity receptors in the cell layer by approximately 60%. The results suggest that perlecan made by growth plate chondrocytes is a low affinity receptor for FGF-2 and acts to sequester FGF-2 away from the high affinity receptor.

Collagen V localizes to pericellular sites during tendon collagen fibrillogenesis.

During tendon development collagen fibrillogenesis occurs in extracellular micro-domains defined by the tenocytes. This permits cellular regulation of the extracellular steps involved in the tissue-specific matrix assembly required for function. The hypothesis tested here is that collagen V associates with the tenocyte surface where it functions in regulation of collagen assembly and cell-directed fibril deposition. The in vitro and in vivo data demonstrate that collagen V is a quantitatively minor component of the tendon. It is preferentially localized on the tenocyte surface as distinct foci in tendons and in cell culture. In vitro data indicate that this interaction with the tenocyte is not HSPG GAG-dependent. Collagen V is present as the mature, processed form, is absent from the media, and is a significant part of the detergent-insoluble cell layer, presumably as part of a membrane-associated complex. In contrast, procollagen I is not efficiently processed and is found predominantly in the culture media. Our data suggest that the regulatory role of collagen V requires collagen V to occupy a different cellular niche from the structural collagen I. In monolayer cultures, the conversion to the tissue form of collagen V and its deposition with the cell layer suggest efficient engagement of procollagen V with pericellular receptors and processing enzymes. The secretion of collagen I into the media and inefficient processing of procollagen I suggest reduced accessibility to these pericellular molecules due to disengagement from the cell surface. This all points to differential spatial localization of collagen V as a mechanism to optimize its regulatory roles during the cell-surface directed steps in tendon collagen fibril assembly.

Consumer and health literacy: The need to better design tobacco-cessation product packaging, labels, and inserts.

Tobacco-cessation product packaging and instruction materials may not be appropriate for some smokers and may contribute to the underuse and misuse of evidence-based treatments. The dual goals of this project are to analyze literacy levels of Food and Drug Administration (FDA)-approved and non-approved tobacco-cessation product packaging, directions, and claims, and to identify and categorize claims found on product packaging. The Campaign for Tobacco Free Kids (CTFK) maintains the Quitting and Reducing Tobacco Use Inventory of Products (QuiTIP) database, which catalogs products marketed and sold to consumers to reduce or quit use of tobacco products. It also includes all medications approved by the FDA for tobacco cessation as well as a sample of non-approved products such as homeopathic, herbal, nutritional, or dietary supplements commonly marketed as either cessation aids or alternative tobacco/nicotine products. This paper assesses the reading levels required to understand product packaging, labeling, and instructions using the Simple Measure of Gobbledygook (SMOG) and identifies claims on the product package labels using standard qualitative methods. Key findings show that the average reading levels needed to understand instructions for both FDA-approved and non-approved cessation products are above the reading levels recommended to ensure maximum comprehension. Improving the packaging and directions of evidence-based tobacco-cessation products so that they are preferably at or below a fifth-grade reading level, along with using consumer-based design principles to develop packaging, may help smokers take advantage of and correctly use products that will greatly increase their chances of successful quitting.

Waterpipe tobacco smoking on a U.S. College campus: prevalence and correlates.

PURPOSE: Waterpipe tobacco smoking is reported to be growing in popularity, particularly among college students. This study examined the prevalence of waterpipe tobacco smoking prevalence and perceptions in a university-based population. METHOD: This was a cross-sectional Internet-based survey of first-year university students, which examined waterpipe tobacco smoking and other tobacco use, risk perceptions, influences, and perceived social acceptability. RESULTS: Waterpipe tobacco smoking within the past 30 days was reported by 20% (151/744). Relative to never users, users were more likely to perceive waterpipe tobacco smoking as less harmful than cigarette use. CONCLUSIONS: Because waterpipe tobacco smoking is increasing in prevalence and because it can involve toxicant inhalation at even greater levels than with cigarette smoking, it represents a growing public health issue.

Waterpipe tobacco smoking: knowledge, attitudes, beliefs, and behavior in two U.S. samples.

Despite evidence of increasing waterpipe tobacco smoking prevalence among U.S. young adults, little is known about the knowledge, attitudes, beliefs, and smoking patterns of waterpipe users in this population. To address this lack of knowledge, two convenience samples of U.S. waterpipe users were surveyed--one from a Richmond, Virginia, waterpipe café (n=101), the other from an Internet forum called HookahForum.com (n=100). Sixty percent reported first-time waterpipe use at or before age 18. Daily waterpipe use was reported by 19%, weekly use by 41%, and monthly use by 29%. Waterpipe use was more common during the weekend (75%) than during weekdays (43%). Forty-four percent reported spending >or=60 min smoking tobacco during a waterpipe session. The majority of waterpipe users owned a waterpipe (57%) and purchased it on the Internet (71%). Many waterpipe users smoked the sweetened and flavored tobacco (i.e., maassel), and fruit flavors were the most popular (54%). Past month use of cigarettes, tobacco products other than cigarettes or waterpipe, and alcohol was 54%, 33%, and 80% respectively, and 36% reported past-month marijuana use. Most waterpipe users were confident about their ability to quit (96%), but only a minority (32%) intended to quit. Most waterpipe users believed waterpipe tobacco smoking was less harmful and addictive than cigarettes. These results are from small convenience samples; more detailed study of a larger group of randomly sampled U.S. waterpipe tobacco smokers will be valuable in understanding this behavior and developing effective strategies to prevent it.

Differing psychosocial risk profiles of college freshmen waterpipe, cigar, and cigarette smokers.

Few studies have examined the psychosocial aspects of tobacco smoking in young adults, particularly among alternative forms such as waterpipe. To address this gap, we examined the association of psychosocial characteristics (i.e., sociodemographics, risk perception, social norms, and pluralistic ignorance) with waterpipe, cigar, and cigarette smoking in college freshmen. Data are from a cross-sectional internet survey conducted during spring semester 2004 at Johns Hopkins University, N=411. Multinomial logistic regression was used to determine the association between psychosocial risk factors and waterpipe, cigar, and cigarette smoking. Results reveal that (1) psychosocial risk profiles of smokers differed by type of smoker and by type of tobacco product smoked, and (2) freshmen perceived the waterpipe as the most attractive product, out of the three products evaluated, to use among their peers. This study provides some of the first data on the association of psychosocial characteristics and various forms of tobacco smoking in young adults. This area of research is of increasing importance as a surge of waterpipe use among college students is becoming evident and interventions to reduce and prevent use are critically needed.