Do cigarette prices near secondary schools vary by area-level socioeconomic status? Findings from a field study in Ontario and Québec, Canada.

OBJECTIVES: To examine, in the context of youth smoking, whether cigarette prices near secondary schools varied by area-level socioeconomic status in Southwestern and Central Ontario, and the greater Montréal region. METHODS: We collected cigarette prices four times between 2016 and 2019 from stores near secondary schools and used mixed-effects and ordinary least squares regressions. RESULTS: We found consistent evidence that cigarette prices near secondary schools were lower in neighbourhoods with lower area-level household income, and that differences were large enough to be meaningful. In Ontario and Québec, our results indicate a Can$0.26 [0.04, 0.47] to Can$0.51 [0.33, 0.69] and Can$0.10 [-0.04, 0.24] to Can$0.37 [0.22, 0.52] difference in prices for a pack of 25 cigarettes between neighbourhoods with a median household income standard deviation below/above the provincial median, respectively. CONCLUSION: Policy changes that limit area-level cigarette price differences without lowering cigarette prices may reduce inequities in youth smoking.

Prices, taxes and alcohol use: a systematic umbrella review.

AIM: To measure the impact of taxes and prices on alcohol use with particular attention to the different context of rising alcohol consumption in low- and middle-income countries. METHODS: Systematic review: we searched MEDLINE, Embase, EconLit and LILACS, grey literature, hand-searched five specialty journals and examined references of relevant studies. We considered all reviews that included studies that quantitatively examined the relationship between alcohol prices or taxes and alcohol use. At least two reviewers independently screened the articles and extracted the characteristics, methods and main results and assessed the quality of each included study. We identified 30 reviews. RESULTS: There was overwhelming evidence that higher alcohol prices and taxes were associated with lower total alcohol consumption and that price responsiveness varied by beverage type. Total own-price elasticities of alcohol demand were consistently negative and substantial enough to be policy meaningful; total own-price elasticities for beer, wine and spirits were found to be approximately -0.3, -0.6 and -0.65. Reviews generally concluded that higher taxes and prices were associated with lower heavy episodic drinking and heavy drinking, although the magnitude of these associations was generally unclear. Reviews provided no evidence that alcohol price responsiveness differed by socioeconomic status, mixed and contradictory evidence with respect to age and sex and limited evidence that price responsiveness in low- and middle-income countries was approximately the same as in high-income countries. CONCLUSIONS: Taxes are effective in reducing alcohol use. Moreover, increasing the price of alcohol by increasing taxes can also be expected to increase tax revenue, because the demand for alcohol is most certainly inelastic.

An experimental study on perceptions of energy drink ads among youth and young adults in Canada.

Current regulations in Canada prohibit the marketing of caffeinated energy drinks (CEDs) for use during sports, with alcohol, and by children. The study examined perceptions of CED ads in association with sports and alcohol use, as well as target age groups. An online survey was conducted in 2015 with youth and young adults aged 12-24 years (n = 2010). Participants completed three experiments in which they were randomized to view CED advertisements: 1) sports/party-themed ads, 2) sports-themed ad, and 3) party-themed ad, vs. control 'product information' ads. For each ad, participants were asked about perceived target age group, and if the ad promoted using CEDs during sports and with alcohol. Logistic regression models were fitted to test differences in outcomes between conditions. The majority of respondents reported that the ads, across all themes, targeted people their age. In experiment 1, both sports/party-themed ads were more likely to be perceived as promoting use of CEDs during sports (AOR = 13.32; 95% CI 9.90, 17.91, and AOR = 9.73; 95% CI 7.38, 12.81, respectively), and with alcohol (AOR = 8.55; 95% CI 6.37, 11.48, and AOR = 2.81; 95% CI 2.08, 3.78, respectively), compared to the control ad. In experiment 2, the sports-themed ad was more likely to be perceived as promoting use of CEDs during sports (AOR = 15.02; 95% CI 11.83, 19.08), but not with alcohol, compared to the control ad. In experiment 3, the party-themed ad was more likely to be perceived as promoting use of CEDs with alcohol (AOR = 13.79; 95% CI 10.69, 17.78), but not during sports, compared to the control ad. Ads from leading energy drink brands are perceived as targeting young people and encouraging energy drink use during sports and with alcohol, despite Canadian regulations prohibiting these marketing practices.

Comparison of Developers' and End-Users' Perspectives About Smoking Cessation Support Through the Crush the Crave App.

BACKGROUND: High smoking rates among end-users, combined with their high rates of app use, render this age group as a particularly captive audience for quit smoking apps. There is emerging evidence that apps are an effective way to support smoking cessation among end-users. How the expectations behind the design of apps align with the needs and preferences of end-users, and if this differs by gender, is poorly understood, limiting the ability to evaluate and scale these interventions. OBJECTIVE: The objective of this qualitative case study was to detail how the overall design approach of Crush the Crave (CTC), a quit smoking app that targets end-users, compares with young adult women's and men's perspectives and experiences, with consideration for the influence of gender. METHODS: Semistructured interviews were conducted with 15 developers involved in the development of CTC and 31 young adult CTC users. Data were analyzed inductively to derive thematic findings of the perceived pros and cons of CTC by both developers and end-users. Findings were grouped under 4 categories (1) technology and platforms utilized for the app, (2) foundation of app content, (3) underlying focus of the app, and (4) look, feel and functionality of the app. RESULTS: Under the category, technology and platforms utilized for the app, it was found that both developers and end-users agreed that apps aligned with the needs and preferences of young adult smokers. Major limitations with the technology identified by end-users were the frequent "glitches" and requirement for internet or data. For the category, foundation of app content,developers agreed that the strength of CTC was in its strong evidence-base. What mattered to end-users, however, was that the content was packaged positively, focusing on the benefits of quitting versus the consequences of smoking. It was found under the category, underlying focus of the app, that the individually-led focus of the app resonated with both developers and end-users, especially young men. Under the final category, look, feel and functionality of the app, it was found that developers were very positive about the app's aesthetics but end-users thought that the aesthetics incited a negative effect. Also, while end-users found it easy to use, they did not find the app intuitive. Finally, end-users thought that, because the app functions were largely based on a user's quit date versus their ongoing efforts, this often lent to unmeaningful data. CONCLUSIONS: The current study findings highlight the importance of understanding multiple perspectives of stakeholders involved in a mobile-based intervention. By gathering the viewpoints of developers and end-users, both problematic and effective approaches that underlie development goals were revealed as a means of informing the development, implementation, and evaluation of future electronic health (eHealth) interventions.

Exposure to Caffeinated Energy Drink Marketing and Educational Messages among Youth and Young Adults in Canada.

The objective of the current study was to evaluate young Canadians' exposure to caffeinated energy drink marketing and educational messages that warn about the potential health risks of energy drinks. An online survey was conducted in 2015 with youth and young adults aged 12⁻24 years recruited from a national online panel (n = 2023). Respondents were asked about their exposure to energy drink marketing and educational messages that warn about the potential health risks of energy drinks. Regression models were fitted to examine correlates of exposure to marketing and to educational messages. Over 80% of respondents reported ever seeing energy drink marketing through at least one channel, most commonly television (58.8%), posters or signs in a convenience or grocery store (48.5%), and online ads (45.7%). The mean number of marketing channels selected was 3.4 (SD = 2.9) out of ten. Respondents aged 18⁻19 (vs. 12⁻14 and 15⁻17) and 20⁻24 (vs. 12⁻14 and 15⁻17) reported significantly more channels of exposure to marketing. Overall, 32% of respondents reporting ever seeing an educational message about energy drinks. The most frequently reported sources of exposure were at school (16.2%), online (15.0%), and on television (12.6%). Respondents aged 18⁻19 (vs. 12⁻14, 15⁻17 and 20⁻24) and 20⁻24 (vs. 15⁻17) were significantly more likely to report having seen an educational message. Exposure to energy drink marketing was common among youth and young adults and was significantly more prevalent than exposure to educational messages that warn about the potential health risks of energy drinks. A comprehensive policy approach, including enforcing responsible marketing and increasing education surrounding the risks of consuming energy drinks, may be an effective approach in promoting lower-risk consumption of CEDs.

Tobacco use cessation interventions for lesbian, gay, bisexual, transgender and queer youth and young adults: A scoping review.

Smoking prevalence among LGBTQ + youth and young adults is alarmingly high compared to their non-LGBTQ + peers. The purpose of the scoping review was to assess the current state of smoking prevention and cessation intervention research for LGBTQ + youth and young adults, identify and describe these interventions and their effectiveness, and identify gaps in both practice and research. A search for published literature was conducted in PubMed, Scopus, CINAHL, PsychInfo, and LGBT Life, as well as an in-depth search of the grey literature. All English articles published or written between January 2000 and February 2016 were extracted. The search identified 24 records, of which 21 were included; 11 from peer reviewed sources and 10 from the grey literature. Of these 21, only one study targeted young adults and only one study had smoking prevention as an objective. Records were extracted into evidence tables using a modified PICO framework and a narrative synthesis was conducted. The evidence to date is drawn from methodologically weak studies; however, group cessation counselling demonstrates high quit rates and community-based programs have been implemented, although very little evidence of outcomes exist. Better-controlled research studies are needed and limited evidence exists to guide implementation of interventions for LGBTQ + youth and young adults. This scoping review identified a large research gap in the area of prevention and cessation interventions for LGBTQ youth and young adults. There is a need for effective, community-informed, and engaged interventions specific to LGBTQ + youth and young adults for the prevention and cessation of tobacco.

Perceptions Toward a Smoking Cessation App Targeting LGBTQ+ Youth and Young Adults: A Qualitative Framework Analysis of Focus Groups.

BACKGROUND: The prevalence of smoking among lesbian, gay, bisexual, trans, queer, and other sexual minority (LGBTQ+) youth and young adults (YYA) is significantly higher compared with that among non-LGBTQ+ persons. However, in the past, interventions were primarily group cessation classes that targeted LGBTQ+ persons of all ages. mHealth interventions offer an alternate and modern intervention platform for this subpopulation and may be of particular interest for young LGBTQ+ persons. OBJECTIVE: This study explored LGBTQ+ YYA (the potential users') perceptions of a culturally tailored mobile app for smoking cessation. Specifically, we sought to understand what LGBTQ+ YYA like and dislike about this potential cessation tool, along with how such interventions could be improved. METHODS: We conducted 24 focus groups with 204 LGBTQ+ YYA (aged 16-29 years) in Toronto and Ottawa, Canada. Participants reflected on how an app might support LGBTQ+ persons with smoking cessation. Participants indicated their feelings, likes and dislikes, concerns, and additional ideas for culturally tailored smoking cessation apps. Framework analysis was used to code transcripts and identify the overarching themes. RESULTS: Study findings suggested that LGBTQ+ YYA were eager about using culturally tailored mobile apps for smoking cessation. Accessibility, monitoring and tracking, connecting with community members, tailoring, connecting with social networks, and personalization were key reasons that were valued for a mobile app cessation program. However, concerns were raised about individual privacy and that not all individuals had access to a mobile phone, users might lose interest quickly, an app would need to be marketed effectively, and app users might cheat and lie about progress to themselves. Participants highlighted that the addition of distractions, rewards, notifications, and Web-based and print versions of the app would be extremely useful to mitigate some of their concerns. CONCLUSIONS: This study provided insight into the perspectives of LGBTQ+ YYA on a smoking cessation intervention delivered through a mobile app. The findings suggested a number of components of a mobile app that were valued and those that were concerning, as well as suggestions on how to make a mobile app cessation program successful. App development for this subpopulation should take into consideration the opinions of the intended users and involve them in the development and evaluation of mobile-based smoking cessation programs.

Impact of Canadian tobacco packaging policy on use of a toll-free quit-smoking line: an interrupted time-series analysis.

BACKGROUND: A policy for new pictorial health warning labels on tobacco packaging was introduced by Health Canada in 2012. The labels included, for the first time, a prominently displayed toll-free number for a quit-smoking line. We used data from the Ontario provincial quitline to investigate the call volume and number of new callers receiving treatment in the months before and after the new policy was introduced. METHODS: We used an interrupted time-series analysis to examine trends in the overall call volume and number of new callers receiving treatment (≥ 1 telephone counselling session) through Ontario's quitline (Smokers' Helpline) between January 2010 and December 2013. We analyzed data using Box-Jenkins autoregressive integrated moving-average models; we adjusted the models for a major campaign promoting the quitline, a seasonality (January) effect and tobacco pricing. RESULTS: We found a relative increase of 160% in the average monthly call volume during the 7 months after the introduction of the new labels (870 calls per month at baseline and 1391 additional calls per month on average after the policy change; standard error [SE] 108.94, p < 0.001), and a sustained increase of 43% in subsequent months. We observed a relative increase of 174% in the number of new callers receiving treatment (153 new callers per month at baseline and 267 additional new callers per month after the policy change; SE 40.03, p < 0.001) and a sustained increase of 80% in subsequent months. The effect was significant even after controlling for a major promotion campaign and the January effect. INTERPRETATION: We found a significant increase in the monthly overall call volume and number of new callers receiving treatment per month after the introduction of the new tobacco health warning labels, with a sustained increase in overall calls and new callers beyond the first 7 months. Our findings add to the body of evidence on the benefit of including a toll-free quitline number on tobacco packaging.

Impact of Canadian tobacco packaging policy on quitline reach and reach equity.

OBJECTIVE: To examine the impact of the new Canadian tobacco package warning labels with a quitline toll-free phone number for seven provincial quitlines, focusing on treatment reach and reach equity in selected vulnerable groups. METHODS: A quasi-experimental design assessed changes in new incoming caller characteristics, treatment reach for selected vulnerable sub-populations and the extent to which this reach is equitable, before and after the introduction of the labels in June, 2012. Administrative call data on smokers were collected at intake. Pre- and post-label treatment reach and reach equity differences were analysed by comparing the natural logarithms of the reach and reach equity statistics. RESULTS: During the six months following the introduction of the new warning labels, 86.4% of incoming new callers indicated seeing the quitline number on the labels. Treatment reach for the six-month period significantly improved compared to the same six-month period the year before from .042% to .114% (p<.0001) and reach equity significantly improved for young males (p<.0001) and those with high school education or less (p=.004). CONCLUSIONS: The introduction of the new tobacco warning labels with a quitline toll-free number in Canada was associated with an increase in treatment reach. The toll-free number on tobacco warning labels aided in reducing tobacco related inequalities, such as improved reach equity for young males and those with high school or less education.

The reach ratio--a new indicator for comparing quitline reach into smoking subgroups.

INTRODUCTION: There is growing concern about population disparities in tobacco-related morbidity and mortality. This paper introduces the reach ratio as a complementary measure to reach for monitoring whether quitline interventions are reaching high risk groups of smokers proportionate to their prevalence in the population. METHODS: Data on smokers were collected at intake by 7 Canadian provincial quitlines from 2007 to 2009 and grouped to identify 4 high risk subgroups: males, young adults, heavy smokers, and those with low education. Provincial data are from the Canadian Tobacco Use Monitoring Survey. Reach ratios (ReRas), defined as the proportion of quitline callers from a subgroup divided by the proportion of the smoking population in the subgroup, and 95% confidence intervals were calculated for the subgroups. A ReRa of 1.0 indicates proportionate representation. RESULTS: ReRas for male smokers and young adults are consistently less than 1.0 across all provinces, indicating that a lower proportion of these high-risk smokers were receiving evidence-based smoking cessation treatment from quitlines. Those with high levels of tobacco addiction and less than high school education have ReRas greater than 1.0, indicating that a greater proportion of these smokers were receiving cessation treatments. CONCLUSION: ReRas complement other measures of reach and provide a standardized estimate of the extent to which subgroups of interest are benefiting from available cessation interventions. This information can help quitline operators, funders, and policymakers determine the need for promotional strategies targeted to high risk subgroups, and allocate resources to meet program and policy objectives.

Systematic review and meta-analysis of practice facilitation within primary care settings.

PURPOSE: This study was a systematic review with a quantitative synthesis of the literature examining the overall effect size of practice facilitation and possible moderating factors. The primary outcome was the change in evidence-based practice behavior calculated as a standardized mean difference. METHODS: In this systematic review, we searched 4 electronic databases and the reference lists of published literature reviews to find practice facilitation studies that identified evidence-based guideline implementation within primary care practices as the outcome. We included randomized and nonrandomized controlled trials and prospective cohort studies published from 1966 to December 2010 in English language only peer-reviewed journals. Reviews of each study were conducted and assessed for quality; data were abstracted, and standardized mean difference estimates and 95% confidence intervals (CIs) were calculated using a random-effects model. Publication bias, influence, subgroup, and meta-regression analyses were also conducted. RESULTS: Twenty-three studies contributed to the analysis for a total of 1,398 participating practices: 697 practice facilitation intervention and 701 control group practices. The degree of variability between studies was consistent with what would be expected to occur by chance alone (I2 = 20%). An overall effect size of 0.56 (95% CI, 0.43-0.68) favored practice facilitation (z = 8.76; P <.001), and publication bias was evident. Primary care practices are 2.76 (95% CI, 2.18-3.43) times more likely to adopt evidence-based guidelines through practice facilitation. Meta-regression analysis indicated that tailoring (P = .05), the intensity of the intervention (P = .03), and the number of intervention practices per facilitator (P = .004) modified evidence-based guideline adoption. CONCLUSION: Practice facilitation has a moderately robust effect on evidence-based guideline adoption within primary care. Implementation fidelity factors, such as tailoring, the number of practices per facilitator, and the intensity of the intervention, have important resource implications.