Prevalence and predictors of obesity among women in the fire service.

OBJECTIVES: Firefighter health has received a great deal of increased attention over the past decade, but most work has been specific to men in the fire service due to small numbers of women, likely due to challenges with recruitment and retention of women in the fire service. While findings suggest men in the fire service struggle with high rates of overweight and obesity due to a number of occupational challenges, limited data are available on large samples of women firefighters. METHODS: Using snowball sampling techniques, we conducted an online survey of both career (N=2,398) and volunteer (N=781) women firefighters. RESULTS: Rates of obesity for both career (15.4%) and volunteer (31.6%) women firefighters were not only lower than men in the fire service (33.5% career and 43.2% volunteer), but also lower than the general population (41.1%). Women career and volunteer firefighters who engaged in heavy physical activity were less likely to be obese. Being a racial or ethnic minority firefighter was associated with being obese, as was serving more than 20 years in the fire service. CONCLUSION: Findings highlight that women firefighters have been successful in overcoming the occupational risks, such as a challenging nutrition environment, inconsistent schedules, limited time for fitness, and the metabolic impact of shift work, that put firefighters at increased risk for obesity.

Occupational factors and miscarriages in the US fire service: a cross-sectional analysis of women firefighters.

BACKGROUND: Evidence from previous studies suggests that women firefighters have greater risk of some adverse reproductive outcomes. The purpose of this study was to investigate whether women firefighters had greater risk of miscarriage compared to non-firefighters and whether there were occupational factors associated with risk of miscarriage among firefighters. METHODS: We studied pregnancies in the United States fire service using data from the Health and Wellness of Women Firefighters Study (n = 3181). We compared the prevalence of miscarriage among firefighters to published rates among non-firefighters using age-standardized prevalence ratios. We used generalized estimating equations to estimate relative risks (RRs) and 95% confidence intervals (CIs) between occupational factors (employment (career/volunteer), wildland firefighter status (wildland or wildland-urban-interface/structural), shift schedule, fire/rescue calls at pregnancy start) and risk of miscarriage, adjusted for age at pregnancy, education, gravidity, BMI, and smoking. We evaluated if associations varied by age at pregnancy or employment. RESULTS: Among 1074 firefighters and 1864 total pregnancies, 404 pregnancies resulted in miscarriages (22%). Among most recent pregnancies, 138 resulted in miscarriage (13%). Compared to a study of US nurses, firefighters had 2.33 times greater age-standardized prevalence of miscarriage (95% CI 1.96-2.75). Overall, we observed that volunteer firefighters had an increased risk of miscarriage which varied by wildland status (interaction p-value< 0.01). Among structural firefighters, volunteer firefighters had 1.42 times the risk of miscarriage (95% CI 1.11-1.80) compared to career firefighters. Among wildland/wildland-urban-interface firefighters, volunteer firefighters had 2.53 times the risk of miscarriage (95% CI 1.35-4.78) compared to career firefighters. CONCLUSIONS: Age-standardized miscarriage prevalence among firefighters may be greater than non-firefighters and there may be variation in risk of miscarriage by fire service role. Further research is needed to clarify these associations to inform policy and decision-making.

Maternal and Child Health Among Female Firefighters in the U.S.

Objectives Despite increasing attention to the occupational impact of firefighting, little is known specific to the health of women firefighters. In particular, quantitative data is lacking on the impact firefighting has on maternal and child health for women who become pregnant while working as firefighters. Methods A total of 1821 women firefighters responded to requests to complete a self-report survey of questions about pregnancy. Women answered questions about their departments' policies and practices and their own experiences of pregnancy. Those participants who reported a pregnancy while serving as a firefighter were asked detailed questions about their pregnancy and outcomes. Results Female firefighters reported that nearly a quarter of their first pregnancies while in the fire service ended in miscarriage and that increased to a third of pregnancies by the fourth. Rates of pre-term delivery also were high among this population. Conclusions Findings have important implications for policy and practice among women who become pregnant while actively serving in the fire service.

Prevalence and Correlates of Late Initiation of Smokeless Tobacco in US Firefighters.

INTRODUCTION: Prevalence rates of smokeless tobacco (SLT) use and late initiation among firefighters (ie, starting use as an adult after joining the fire service) are remarkably high, 10.5% and 26.0%, respectively. The purpose of this study is to examine characteristics associated with late SLT initiation in a sample comprised of male career firefighters from two large cohort studies. METHODS: We examined correlates of late SLT initiation in a secondary analysis of data combining the baseline evaluations of two published firefighter health studies with 1474 male career firefighters in the United States. RESULTS: Fourteen percent of participants were current SLT users. Among this group, the unadjusted rate of firefighters who initiated SLT use after joining the fire service was 15.9%, while the age-standardized rate was 38.2%; this is substantially higher than the national adjusted late initiation rate among adult males (0.8%). In addition, firefighters demonstrated higher rates of late SLT initiation (15.9% unadjusted; 18.4% age-standardized) when compared to males in the military overall (13.8%). CONCLUSIONS: The exceptionally high prevalence of SLT use overall and late initiation in the fire service suggest that joining the fire service in the United States is a risk factor for SLT use. There is a need to develop interventions aimed at reducing SLT use in the fire service that are specifically tailored for this occupational group. IMPLICATIONS: The high prevalence of late SLT initiation (ie, starting use as an adult after joining the fire service) among firefighters should be addressed by both researchers and fire service organizations given the significant health risks associated with SLT and its impact on occupational readiness. There is a need for developing intervention programs aimed at reducing SLT use in the fire service. Interventions would need to be specifically tailored for this occupational group and their unique culture, given that joining the fire service appears to be a risk factor for SLT initiation among firefighters who did not use tobacco prior to joining the fire service.

Perspectives of US military commanders on tobacco use and tobacco control policy.

BACKGROUND: Tobacco use among members of the US military service is unacceptably high, resulting in substantial healthcare and personnel costs. Support of military command is critical to the success of tobacco control policies because line commanders are responsible for implementation and enforcement. This study is the first to examine US military line commanders' perspectives about current tobacco control policies and the impact of tobacco on readiness. METHODS: We conducted key-informant interviews with 20 officers at the US Army's Command and General Staff College about military tobacco use and tobacco control policy. RESULTS: Participants identified the long-term impact of tobacco use on military members, but were unaware of proximal effects on health and readiness other than lost productivity due to smoke breaks. Officers also discussed nicotine addiction and the logistics of ensuring that an addicted population had access to tobacco. Regarding policy, most knew about regulations governing smoke-free areas and were open to stronger restrictions, but were unaware of current policies governing prevention, intervention and product sales. CONCLUSIONS: Findings suggest that strong policy that takes advantage of the hierarchical and disciplined nature of the military, supported by senior line and civilian leadership up to and including the secretaries of the services and the Secretary of Defense, will be critical to substantially diminishing tobacco use by military personnel.

Cigarette prices and community price comparisons in US military retail stores.

BACKGROUND: Tobacco pricing impacts use, yet military retailers sell discounted cigarettes. No systematic research has examined how military retail stores use internal community comparisons to set prices. We analysed data obtained through a Freedom of Information Act request on community price comparisons used by military retail to set cigarette prices. METHODS: Data on cigarette prices were obtained directly from military retailers (exchanges) from January 2013 to March 2014. Complete pricing data were obtained from exchanges on 114 military installations. RESULTS: The average price for a pack of Marlboro cigarettes in military exchanges was US$5.51, which was similar to the average lowest community price (US$5.45; mean difference=-0.06; p=0.104) and almost a US$1.00 lower than the average highest price (US$6.44). Military retail prices were 2.1%, 6.2% and 13.7% higher than the lowest, average and highest community comparisons, respectively, and 18.2% of exchange prices violated pricing instructions. There was a negative correlation (r=-0.21, p=0.02) between the number of community stores surveyed and exchange cigarette prices. CONCLUSIONS: There was no significant difference between prices for cigarettes on military installations and the lowest average community comparison, and in some locations, the prices violated Department of Defense (DoD) policy. US Marine Corps exchanges had the lowest prices, which is of concern given that the Marines also have the highest rates of tobacco use in the DoD. Given the relationship between tobacco product prices and demand, a common minimum (or floor) shelf price for tobacco products should be set for all exchanges and discount coupon redemptions should be prohibited.

Tobacco use pattern among a national firefighter cohort.

INTRODUCTION: To date, there have been no large-scale, national epidemiological studies of tobacco use patterns among firefighters, particularly with a focus on smokeless tobacco (SLT) and dual use with cigarettes. While rates of firefighters' smoking are relatively low compared to the general population, SLT use typically is substantially higher than the populations they protect. In the current study, we systemically examine tobacco use, including SLT and dual use, and the health-related profiles of various tobacco use groups in a national sample of career firefighters. METHODS: Data are from a national cohort study of career departments (N = 20) comprised of 947 male firefighters. RESULTS: Among 947 participants, 197 (21%) were tobacco users, of which, 34.5% used cigarettes, 53.2% used SLT, and 12.2% used both cigarettes and SLT. Adjusted rates of smoking, SLT use, and dual use were 13.2%, 10.5%, and 12.2%, respectively. Tobacco users of all types were significantly younger and had served fewer years in fire service and were significantly more likely to engage in heavy and binge drinking, as well as more likely to show signs of depressive symptoms compared to nontobacco users. CONCLUSIONS: Detailed information on tobacco use pattern will aid in better understanding what factors are contributing to the high rates of SLT and dual use among firefighters in order to guide and develop an appropriate treatment program for the fire service.

Meta-Analysis of Incidence and Mortality of Firefighter Cancer: An Update on Emerging Science.

BACKGROUND: Firefighters are faced with a broad range of toxic exposures during their work, including known and suspected carcinogens. The current study is an update to the previously published meta-analysis of cancer risk among firefighters by Soteriades and colleagues, and focuses on studies published from 2008 to 2020. METHODS: A comprehensive search of the literature was conducted, including electronic databases and bibliographies of recently published papers. Analyses include stratification of studies conducted in the United States (US) versus other countries. Cancer incidence and mortality rates were compared to the relevant general population. Random effects models were used to calculate summary risk estimates and their 95% confidence intervals. RESULTS: A total of 24 studies were included in the meta-analysis. Among the 42 cancer types covered, incidence was associated with firefighting in US samples for colon, kidney, large intestine, pleura, and prostate cancer, as well as malignant melanoma. There was an increased incidence of Hodgkin's Disease and malignant melanoma and a significantly lower risk of kidney cancer for non-US samples. Significant cancer mortality estimates for US samples included oral/buccal/mouth, other parts of the buccal cavity, pharynx, colon, esophagus, large intestine, lung, Non-Hodgkin's Lymphoma, pancreas, pleura, rectum, and soft tissue sarcoma. No cancer had a significantly higher rate of mortality among non-US samples. CONCLUSIONS: The findings underscore the global cancer burden among firefighters, and indicate that geographically stratifying studies afford a more nuanced risk perspective. Further research should investigate why US firefighters exhibit higher cancer mortality rates compared to international counterparts.

Injury among a population based sample of career firefighters in the central USA.

BACKGROUND: Rates of occupational injuries among firefighters are high because of the physically demanding and variable tasks required by their job. While descriptive data about injuries exist, few studies have explored individual risk factors and their relationship to occupational injury. METHODS: The current study presents data from a population-based sample of 462 career firefighters from 11 randomly-selected fire departments in the Missouri Valley region of the USA (Kansas, Missouri, Iowa, North Dakota, South Dakota, Colorado, Wyoming, Nebraska) who participated in a study evaluating risks for negative cardiovascular outcomes and injury. Relationships were examined between injury and demographic characteristics, body composition, fitness, and health behaviours. RESULTS: Participants were most likely to be injured during physical exercise and those who reported regular on-duty exercise had a fourfold increase in risk for exercise-related injury compared with those who did not exercise on duty (OR=4.06, 95% CI 1.73 to 12.24). However, those who exercised were half as likely to sustain non-exercise injuries (OR=0.53, 95% CI 0.32 to 0.85). CONCLUSIONS: Findings highlight the benefit of physical training for firefighters despite the risk of injury during exercise.

An examination of the benefits of health promotion programs for the national fire service.

BACKGROUND: Firefighters suffer from high prevalence of obesity, substandard fitness, and cardiovascular-related deaths. There have been a limited number of firefighter health promotion programs that have been developed and empirically-tested for this important occupational group. We evaluated the health of firefighters from departments with well-developed health promotion programs and compared them with those from departments not having such programs using a large national sample of career fire departments that varied in size and mission. We measured a broad array of important individual firefighter health outcomes (e.g., body composition, physical activity, and general and behavioral health) consistent with national fire service goals and addressed significant statistical limitations unaccounted for in previous studies. METHODS: Using the approach of purposive sampling of heterogeneous instances, we selected and conducted a national evaluation of 10 departments already implementing wellness and fitness programs (Wellness Approach; WA) with 10 departments that did not (Standard). Participants were 1,002 male firefighters (WA n = 522; Standard n = 480) who underwent assessments including body composition, fitness, and general/behavioral health (e.g., injury, depressive symptoms). RESULTS: Firefighters in WA departments were healthier than their Standard department counterparts. For example, they were less likely to be obese (adjusted [A]OR = 0.58; 95% CI = 0.41-0.82), more likely to meet endurance capacity standards for firefighting (AOR = 5.19; 95% CI = 2.49-10.83) and have higher estimated VO2max (40.7 ± 0.6 vs. 37.5 ± 1.3 for firefighters in Standard departments; p = 0.001). In addition, WA firefighter were substantially less likely to smoke (AOR = 0.30; 95% CI = 0.17-0.54) or ever have been diagnosed with an anxiety disorder (AOR = 0.27; 95% CI = 0.14-0.52) and they expressed higher job satisfaction across several domains. However, WA firefighters were somewhat more likely to have reported an injury to Workers' Compensation (AOR = 1.74; 95% CI = 1.05-2.90). It was notable that both groups evidenced high prevalence of smokeless tobacco use and binge drinking. CONCLUSIONS: Firefighters in departments selected based on having strong wellness programs (WA) were healthier along a number of dimensions important to firefighter wellness and operational readiness. However, several health areas require greater attention including problematic alcohol consumption and smokeless tobacco use, suggesting that more emphasis on these behavioral health issues is needed in the fire service.

Evaluation of the Implementation of the NFFF Stress First Aid Intervention in Career Fire Departments: A Cluster Randomized Controlled Trial.

Firefighting is inherently dangerous, though recently concerns have shifted from traditional fireground injuries (burns and asphyxiation) to a focus on mental and behavioral health. Although firefighters are remarkably resilient, research suggests many suffer negative psychological consequences from repeated exposures to trauma. While the Stress First Aid (SFA) model has gained increased attention and adoption among fire departments as a model for behavioral health training, it has not been formally evaluated. This cluster randomized controlled trial used a crossover design comparing the immediate SFA group to delayed SFA control to test the impact of the SFA on firefighters' mental and behavioral health changes after 10-12 months (n = 400; Mage = 37.6, 4.8% women). A convenience sample of 79 firefighters (Mage = 41.4; 8.7% women) provided evaluations on one or more of the training modules. Participants reported satisfaction with all training components (Peer team training 97.6%, Online SFA 94.9%, Curbside Manner 88.4%, After Action Review 89.4%) and reported success in changing personnel's perception of their department's ability to respond to behavioral health issues (SFA M = 3.93, Control 3.50; t = 2.52, p = 0.042). Future work should focus on additional resources and training to augment existing efforts to help departments continue their efforts.

A national qualitative study of tobacco use among career firefighters and department health personnel.

INTRODUCTION: Firefighters currently have substantially lower smoking rates than similar occupational groups and the general U.S. population. In contrast, firefighters have very high rates of smokeless tobacco (SLT). The reasons for this paradox have not been explored; thus, the current study examined firefighters' perspectives on tobacco use. METHODS: Key informant interviews and focus groups were conducted in a national, cross-sectional purposively sampled group of 332 career firefighters. RESULTS: Firefighters suggested several reasons for the decline in smoking in the fire service including changes in the fire service culture, concerns about the impact of smoking on their ability to perform their job, regulations aimed at reducing smoking in departments, and the costs of smoking. In contrast, they felt that the greater use of SLT was primarily due to increasing restrictions on smoking. CONCLUSIONS: The primary reasons cited for decreased smoking rates by firefighters in our study were policy implementation at the state and local levels that prohibit tobacco use as a condition of employment and related presumption laws. However, reasons beyond policy mandates such as witnessing the end results of tobacco use, fitness, greater education about the negative health effects of smoking, and awareness about increased risk of exposure to toxic products of combustions also were noted. The primary reason cited for increased SLT use was the greater restrictions on smoking.

The health of women in the US fire service.

BACKGROUND: Despite statements from national fire service organizations, including the International Association of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC), promoting a diverse work force related to gender within the fire service, rates of women firefighters remain very low. Thus, research into why this extensive gender disparity continues is a high priority. Recent years have seen a number of large scale studies on firefighter health and health risk behaviors however, none have focused on the health of women firefighters and nearly all have eliminated women from the sample due to small sample size. Data from the present report is drawn from all females in a large, randomly selected cohort of firefighters in an epidemiological study designed to assess health outcomes and health risk behaviors identified as most important to the fire service. METHODS: Data reported for the present study were collected as baseline data for the Firefighter Injury and Risk Evaluation (FIRE) Study, a longitudinal cohort study examining risk factors for injury in both career and volunteer firefighters in the IAFC Missouri Valley Region. Of the departments assessed, only 8 career and 6 volunteer departments had any women firefighters. All the women solicited for participation chose to enroll in the study. The number of women ranged from 1 to 7 in career departments and 1 to 6 in volunteer departments. RESULTS: Where possible, comparisons are made between female firefighters and published data on male firefighters as well as comparisons between female firefighters and military members. Compared to male firefighters, females had more favorable body composition among both career and volunteer firefighters. Tobacco use rates were generally higher among females than males and rates among female firefighters were similar to the rates of female military members. While rates of alcohol use were higher than the general population, only one of the participants evidenced responses in the range of concern on the CAGE screening. CONCLUSIONS: In general, the findings offer an interesting glimpse of the health of women in the fire service as a generally healthy occupational workforce with some unique health risk behavior challenges. They also highlight some of the similarities and differences between male and female firefighters and bolster the argument for studying female firefighters as a unique occupational sub-population.

Norms about Alcohol Use among US Firefighters.

Background: Problem drinking is a perennial concern in the US fire service. A large literature has documented the importance of addressing alcohol norms in intervention research. The purpose of this study was to explore alcohol norms in a national cohort of firefighters (FFs) to inform intervention development in this occupational group. Methods: Data were from a national online survey of career and volunteer FFs (N = 674). Participants were recruited through national fire service listservs and a database of FFs who had agreed to be contacted for research. Results: When asked about "acceptable" levels of alcohol consumption, FFs on average suggested levels which exceeded public health guidelines. Further, approximately half of career and volunteer FFs believed that, at least under some circumstances, drinking until intoxicated was normative. When asked how long should elapse between a FFs last drink and reporting for duty, the average suggested lag was 11.2 hours (sd = 4.6). However, among male volunteer FFs who reported heavy drinking, the average was 6.68 hours (sd = 4.77). Conclusions: Given the high prevalence of heavy and binge drinking in the fire service, it is not surprising that the alcohol norms found in this study were consistent with a culture of drinking. Participants' reports of alcohol use among their peers were consistent with the actual prevalence of problem drinking. Thus, education and prevention efforts in this occupation should focus on changing norms about alcohol use, including linking heavy drinking to other health and safety issues they face.

Comparisons of Baseline Obesity Prevalence and Its Association with Perceived Health and Physical Performance in Military Officers.

Increasing obesity rates among USA military members vary by age, pay grade, and measurement methods and threaten force fitness and readiness. Limited research has directly measured obesity among officers; those enrolled in graduate school at the Command and General Staff College (CGSC) face additional demands and increased obesity risk. This study compared obesity measurements and performance on the Army Physical Fitness test and self-rated health for a sample of mostly CGSC officers. Participants (n = 136, 75.7% male, 79.6% officers) completed body composition measures; BMI, body fat percentage (BF%), waist circumference (WC), and waist-to-height ratio (WHtR) estimated obesity rates and were compared for discordance. Army Physical Fitness Test pass/fail rates and self-reported perceived health were compared with each obesity classification. Obesity prevalence was 18.5-39.7%, differing by sex and measure. BMI, WC, and WHtR underestimated obesity compared to BF% at least 21% of the time. WHtR had the lowest discordance with BF%. Soldiers categorized as obese were significantly more likely to fail the fitness test and report lower self-rated health than non-obese soldiers. Overall, obesity rates among our primarily officer sample were higher than previous studies, particularly for women. Interventions to address obesity are necessary among military officers to optimize human performance.

Tobacco use among firefighters in the central United States.

BACKGROUND: This study provides a comprehensive, population-based examination of tobacco use among both career and volunteer firefighters. METHODS: Data are from a population-based cohort study of randomly selected career (N = 11) and volunteer (N = 13) departments comprised of 677 male firefighters. RESULTS: Unadjusted rates of smoking were 13.6% and 17.4% for career and volunteer firefighters, respectively. Smoking rates were less than a comparable occupational group (military personnel) and adult males in the states represented. Smokers were more likely to have been diagnosed with an anxiety disorder (OR = 5.8; P = 0.010), have an elevated CAGE alcohol problem score (OR = 2.9; P = 0.040), and more likely to report driving after drinking too much (OR = 4.5; P = 0.020) compared to never-smokers. Large percentages of career (18.4%) and volunteer (16.8%) firefighters used smokeless tobacco. CONCLUSIONS Smoking among firefighters is associated with other significant health and safety risks. High rates of smokeless tobacco use suggest that the fire service is an important target for intervention. Thus, despite strong statements against smoking by the fire service, the need to maintain high levels of health and fitness and relatively low smoking rates, a significant proportion of firefighters continue to use tobacco products.

Development and beta test of a smokeless tobacco cessation program for firefighters.

INTRODUCTION: The prevalence of smokeless tobacco (SLT) use among firefighters is substantially higher than the general population and similar occupational groups. Despite the significant health risks associated with SLT and its impact on occupational readiness, there are no occupationally-tailored SLT education or treatment programs for the fire service. The purpose of this study was to beta test QUIT SPIT!, a self-help SLT cessation program that is culturally tailored for the US fire service and firefighters who are interested in quitting. METHODS: After development and tailoring the QUIT SPIT! SLT cessation program for firefighters, the feasibility and acceptability of the program were evaluated in a sample of eleven SLT-using firefighters who wanted to quit. The primary outcome was a 7-day point prevalence of SLT abstinence measured at 4 and 12 weeks post-enrollment follow-up assessments. RESULTS: Four firefighters reported having quit SLT (7-days point prevalence) at follow-up at 12 weeks. Those who did not achieve SLT abstinence reported reductions in frequency and quantity in SLT use and demonstrated a decrease in nicotine dependence. Firefighters also reported being satisfied with the QUIT SPIT! cessation program. CONCLUSIONS: The results provide strong support for the feasibility and acceptability of the QUIT SPIT! in SLT-using firefighters interested in quitting. The findings provide critical information about the next steps for further development and evaluation of the QUIT SPIT! program.

Muscular Strength, Power, and Endurance Adaptations after Two Different University Fitness Classes.

Physical activity (PA) classes help college students add weekly PA, which can help improve health and maintain body weight. Traditional weight training (TWT) can improve strength and aerobic capacity. High-intensity functional training such as CrossFit® (CF) provides time-efficient workouts with both muscle strengthening and aerobic exercises. Limited research has compared these classes for college students. We examined changes in muscular strength, power, and endurance as well as body composition. Participants were 85 healthy college students enrolled in TWT (n = 36, age 22.6 ± 4.1 years, 72.2% male) or CF (n = 49, age 21.8 ± 3.2 years, 55.1% male) classes meeting twice/wk for 8 weeks between October 2017 and May 2018. Baseline and posttest measurements included a vertical jump, grip strength, a 2 min push-up test, a 1 min squat test, height, weight, and a bioelectrical impedance analysis. Although no significant group × time interactions were found, there was a significant main effect of time for push-ups and squats (both p < 0.001). Participants enjoyed the classes and most planned to continue. Both classes improved muscular endurance although no significant differences were found between them. Activity classes provide college students with an option for increasing their weekly PA and help maintain body composition. Future research should examine the benefits from longer or more frequent classes.

A qualitative study to assess perceptions, barriers, and motivators supporting smokeless tobacco cessation in the US fire service.

While firefighters currently have low smoking rates, rates of smokeless tobacco (SLT) use among this population are remarkably high and substantially greater than similar occupational groups, and the general population. This study explored determinants associated with SLT use, barriers to cessation, and motivators for SLT cessation in the fire service. Key informant interviews were conducted in 23 career firefighters who were current (n = 14) and former (n = 9) SLT users from across the U.S. Discussions were recorded and independently coded according to questions and themes. Major themes that developed among firefighters regarding SLT use determinants included positive perceptions of SLT products, social influences from their peers and family members, acceptability of SLT use in the fire service, and a coping resource for job stress. Firefighters discussed several barriers to SLT cessation, including intrapersonal barriers such as SLT use habits and its dependency, concerns about withdrawal symptoms; and social-environmental barriers including lack of support from health and other services providers, and lack of enforcement of existing tobacco policies regarding SLT use. Firefighters also mentioned both internal and external motivators for cessation. Internal motivators included self-motivation and their health concerns while external motivators included friends and family support, incentives or rewards, and price of SLT products. Findings provide unique perspectives from firefighters on factors that influence SLT use and barriers and motivators to SLT cessation. These are insufficiently assessed and considered by the fire service organizations and their health care providers. Thus, the organizations must understand these issues in order to mitigate barriers and motivate the personnel to quit using SLT. Information gained from firefighters who were current and former SLT users can be used to develop an effective, culturally-tailored intervention that is acceptable to fire service personnel.

The Census of Social Institutions (CSI): a public health direct observation measure of local land use.

This manuscript describes the development of the Census of Social Institutions (CSI), a reliable direct observation parcel-level built environment measure. The CSI was used to measure all non-residential parcels (n = 10,842) in 21 one-mile-radius neighborhoods centered around census block groups of varying income and ethnicity in a large metropolitan area. One year test-retest and inter-rater intra-class correlations showed high reliability for major use type and detail code observations. The CSI accurately captured the presence of about 9,500 uses, including 828 multiple major use and 431 mixed major use parcels that would have been missed in standard commercial databases. CSI data can be utilized to determine the health impacts of environmental settings.