Clinician perspectives on adolescent cannabis-related beliefs and behaviors following recreational cannabis legalization.

BACKGROUND: As more states legalize cannabis, studies are needed to understand the potential impacts of recreational cannabis legalization (RCL) on adolescents from the perspective of clinicians who care for them. METHODS: This qualitative study characterized clinician perspectives on whether cannabis legalization is associated with changes in adolescents' cannabis use beliefs, behaviors, and consequences. Semi-structured qualitative interviews were conducted with 32 clinicians in a large healthcare organization from 9/6/2022-12/21/2022. Video-recorded interviews were transcribed and analyzed using thematic analysis. RESULTS: The 32 participants (56.3 % female, mean [SD] age, 45.9 [7.6] years; 65.3 % non-Hispanic White) were from Addiction Medicine (n = 13), Psychiatry/Mental Health (n = 7), Pediatrics (n = 5), and the Emergency Department (n = 7). Clinicians described post-RCL increases in adolescent cannabis use, use of non-combustible modes and high-potency products, and younger age of first use. Clinicians reported social, physical, and policy changes, including changes in social norms, appealing advertisements, marketing, and easier access. Many noted fewer perceived harms among adolescents and greater self-medication post-RCL. They described how RCL contributed to increased parental cannabis use and permissiveness around adolescent use. Finally, many described post-RCL increases in cannabis hyperemesis syndrome, and several noted increased cannabis-related psychosis and acute intoxication, and decreased court-mandated treatment. CONCLUSIONS: Clinicians from diverse specialties described post-RCL increases in adolescent cannabis use and cannabis-related consequences, alongside changes in social norms, access, marketing and advertisements, and decreased perceptions of harms. Findings can inform strategies to support adolescents in the context of increased cannabis availability and acceptability post-legalization and support the development of hypotheses for broader-scale quantitative work.

Countering online marketing and user endorsements with enhanced cannabis warning labels: An online experiment among at-risk youth and young adults.

As cannabis legalization expands and online marketing intensifies, this study examines whether online social cues can amplify youth-targeted cannabis advertising and whether cannabis warning labels (CWLs) can counteract these influences. A U.S. online sample of 970 adolescents and 1776 young adults susceptible to cannabis use were recruited from Qualtrics in summer 2022. Each participant was randomly assigned to one of the 3 (CWLs: none vs. textual vs. pictorial) by 3 (comments: none vs. anti-cannabis vs. pro-cannabis) conditions in an online experiment. Participants were exposed to three online marketing posts promoting marijuana edibles (randomly selected from a large pool, N = 1260), each with either no warning label, a textual warning, or a pictorial warning (text and picture), and with either five comments (pro- or anti-cannabis in valence) or none. Results showed that among adolescents, pro-cannabis comments increased product appeal (vs. anti-cannabis comments: b = 0.18, p = .025; vs. no comments: b = 0.21, p = .021), and did so more than young adults. For adolescents, only pictorial warnings reduced product appeal (b = -0.20, p = .028). For young adults, both pictorial (b = -0.18, p = .002) and textual warnings (b = -0.12, p = .029) reduced product appeal. Furthermore, both textual (adolescents: b = -0.20, p = .004; young adults: b = -0.15, p = .005) and pictorial (adolescents: b = -0.30, p < .001; young adults: b = -0.18, p = .001) warnings reduced cannabis use intentions. Findings support requiring enhanced CWLs accompany online marketing ads.

Neonatal outcomes associated with in utero cannabis exposure: a population-based retrospective cohort study.

BACKGROUND: The full spectrum of associations between in utero cannabis exposure and adverse neonatal outcomes is still unclear. OBJECTIVE: This study aimed to evaluate the associations between in utero cannabis exposure and neonatal outcomes. STUDY DESIGN: This population-based retrospective cohort study of singleton births among Kaiser Permanente Northern California members (January 1, 2011-July 31, 2020) included parent-infant dyads in which the pregnant parent was screened for cannabis use as part of standard prenatal care, generally upon entrance into care. Data were ascertained from electronic health records. Generalized estimating equation models were adjusted for sociodemographic characteristics, other non-cannabis prenatal substance use, medical and mental health comorbidities, and adequacy of prenatal care. In utero cannabis exposure was defined as self-reported use since becoming pregnant and/or a positive urine toxicology test for cannabis at any time during pregnancy (yes/no; primary exposure). Frequency of use was self-reported and categorized as daily, weekly, monthly or less, never, or unknown (secondary exposure). Neonatal outcomes included low birthweight, small for gestational age, preterm birth, neonatal intensive care unit admission, and infant respiratory support. RESULTS: Of 364,924 infants, 22,624 (6.2%) were exposed to cannabis in utero. After adjustment for potential confounders, including in utero exposure to other substances, in utero exposure to cannabis was associated with greater odds of low birthweight (adjusted odds ratio, 1.20; 95% confidence interval, 1.12-1.28), small for gestational age (adjusted odds ratio, 1.24; 95% confidence interval, 1.18-1.30), preterm birth (<37 weeks; adjusted odds ratio, 1.06; 95% confidence interval, 1.00-1.13), and neonatal intensive care unit admission (adjusted odds ratio, 1.06; 95% confidence interval, 1.01-1.11). There was a suggestive association with early preterm birth (<34 weeks; adjusted odds ratio, 1.11; 95% confidence interval, 1.00-1.23; P=.055), but no significant association with respiratory support (adjusted odds ratio, 1.07; 95% confidence interval, 0.97-1.18). Dose-response analysis found an increasing likelihood of low birthweight and small for gestational age with increasing frequency of prenatal cannabis use by the pregnant individual. Sensitivity analyses further supported an increased likelihood of low birthweight and small for gestational age, although associations with other outcomes did not reach statistical significance. CONCLUSION: In utero cannabis exposure was associated with increased likelihood of low birthweight, small for gestational age, preterm birth, and neonatal intensive care unit admission. Clinicians should counsel individuals who are pregnant or considering pregnancy about the potential adverse neonatal health outcomes associated with prenatal cannabis use.

Cannabis Vape Product Sales in California Following CDC's Initial Advisory About Lung Injuries.

Introduction: The 2019 outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) is believed to have been caused by vitamin E acetate, an additive used in some cannabis vaporizer products. Previous studies have primarily focused on changes in sales of electronic nicotine delivery systems following the initial advisory issued by the Centers for Disease Control (CDC) on August 17, 2019. The present study is intended to examine variation by age groups in sales of regulated cannabis vape products in the state of California before, during, and after the outbreak. Methods: Weekly sales revenue of cannabis vape products (from January 1, 2018, to December 31, 2020) was obtained from a sample of recreational cannabis retailers licensed in California. An interrupted time series analysis, using AutoRegressive, Integrated, Moving Average methods, was employed to estimate changes in the sales and market share of cannabis vape products in the weeks following the CDC advisory. Results: The total volume of regulated cannabis vape product sales increased substantially over the 3-year study period (2018-2020). Sales and market share of cannabis vape products, however, declined in both young and older adults immediately following the advisory, rebounding to pre-EVALI levels only for the young adults. For sales, the potential EVALI effect following the CDC's advisory equates to an 8.0% and 2.2% decline below expected levels in the older and young adults, respectively. Conclusions: The differential age effect on sales may reflect concerns regarding health effects of cannabis vaping products and greater awareness of the outbreak among older adults. Findings highlight the importance of informing consumers about health risks associated with using cannabis vape products acquired from regulated versus illicit sources.

Changes in sugar-sweetened beverage consumption in the first two years (2018 - 2020) of San Francisco's tax: A prospective longitudinal study.

BACKGROUND: Sugar sweetened beverage (SSB) taxes are a promising strategy to decrease SSB consumption, and their inequitable health impacts, while raising revenue to meet social objectives. In 2016, San Francisco passed a one cent per ounce tax on SSBs. This study compared SSB consumption in San Francisco to that in San José, before and after tax implementation in 2018. METHODS & FINDINGS: A longitudinal panel of adults (n = 1,443) was surveyed from zip codes in San Francisco and San José, CA with higher densities of Black and Latino residents, racial/ethnic groups with higher SSB consumption in California. SSB consumption was measured at baseline (11/17-1/18), one- (11/18-1/19), and two-years (11/19-1/20) after the SSB tax was implemented in January 2018. Average daily SSB consumption (in ounces) was ascertained using the BevQ-15 instrument and modeled as both continuous and binary (high consumption: ≥6 oz (178 ml) versus low consumption: <6 oz) daily beverage intake measures. Weighted generalized linear models (GLMs) estimated difference-in-differences of SSB consumption between cities by including variables for year, city, and their interaction, adjusting for demographics and sampling source. In San Francisco, average SSB consumption in the sample declined by 34.1% (-3.68 oz, p = 0.004) from baseline to 2 years post-tax, versus San José which declined 16.5% by 2 years post-tax (-1.29 oz, p = 0.157), a non-significant difference-in-differences (-17.6%, adjusted AMR = 0.79, p = 0.224). The probability of high SSB intake in San Francisco declined significantly more than in San José from baseline to 2-years post-tax (AOR[interaction] = 0.49, p = 0.031). The difference-in-differences of odds of high consumption, examining the interaction between cities, time and poverty, was far greater (AOR[city*year 2*federal poverty level] = 0.12, p = 0.010) among those living below 200% of the federal poverty level 2-years post-tax. CONCLUSIONS: Average SSB intake declined significantly in San Francisco post-tax, but the difference in differences between cities over time did not vary significantly. Likelihood of high SSB intake declined significantly more in San Francisco by year 2 and more so among low-income respondents.

Geographic Accessibility of Retail Cannabis in Northern California and Prenatal Cannabis Use During the COVID-19 Pandemic.

Importance: Prenatal cannabis use is associated with health risks for mothers and their children. Prior research suggests that rates of prenatal cannabis use in Northern California increased during the COVID-19 pandemic, but it is unknown whether increases varied with the local cannabis retail and policy environment. Objective: To test whether pandemic-related increases in prenatal cannabis use were greater among pregnant individuals with greater retail availability of cannabis around their homes or among those living in jurisdictions that allowed storefront retailers. Design, Setting, and Participants: A cross-sectional, population-based time series study used data from pregnancies in the Kaiser Permanente Northern California health care system screened for cannabis use before (January 1, 2019, to March 31, 2020) and during (April 1 to December 31, 2020) the early COVID-19 pandemic. Proximity to the nearest retailer and number of retailers within a 15-minute drive from one's home and local cannabis storefront retailer policy (banned vs permitted) were calculated. Interrupted time series models were fit using multiplicative and additive Poisson regression, adjusting for age and race and ethnicity. Exposures: The COVID-19 pandemic. Main Outcomes and Measures: Prenatal cannabis use based on universal urine toxicology tests conducted during early pregnancy at entrance to prenatal care. Results: The sample (n = 99 127 pregnancies) included 26.2% Asian or Pacific Islander, 6.8% Black, 27.6% Hispanic, 34.4% non-Hispanic White, and 4.9% other, unknown, or multiracial individuals, with a mean (SD) age of 30.8 (5.3) years. Prenatal cannabis use before (6.8%) and during (8.2%) the pandemic was associated with closer proximity to a retailer, greater retailer density, and residing in a jurisdiction that permitted vs banned retailers. There was a greater absolute increase in cannabis use from before to during the pandemic among those within a 10-minute drive (<10 minutes: adjusted rate difference [aRD], 0.93 cases/100 patients; 95% CI, 0.56-1.29 cases/100 patients; ≥10 minutes: aRD, 0.40 cases/100 patients; 95% CI, 0.12-0.68 cases/100 patients; interaction P = .02). Otherwise, relative and absolute rates increased similarly across categories of cannabis retailer proximity/density and local policy (interaction P > .05). Conclusions and Relevance: Prenatal cannabis use was more common among individuals living in areas with greater retail availability of cannabis. Although relative rates increased similarly during the pandemic regardless of local cannabis retail and policy environment, there was a larger absolute increase associated with living closer to a storefront cannabis retailer. Continued monitoring of local cannabis policy, the retail environment, and prenatal cannabis use is needed.

Textual and pictorial enhancement of cannabis warning labels: An Online experiment among at-risk U.S. young adults.

BACKGROUND: This study experimentally examines whether enhanced cannabis warning labels (CWLs) outperform those currently required in the U.S. in improving recall of health risks, emotional responses, and perceived message effectiveness among at-risk young adults. METHOD: We conducted an online national survey-based experiment in October 2020. Young adults aged 18-26 years old and at-risk for cannabis use (N = 523) were randomly assigned in an online experiment, to view either currently required CWLs in California with small font and a composite health risk statement, or enhanced single-theme CWLs with varying textual and pictorial components. We performed linear regression analyses to compare the enhanced with existing CWLs on information recall, negative emotions, and perceived message effectiveness. Furthermore, information recall and negative emotions were examined as parallel mediators to better understand the mechanisms underlying effective textual and pictorial enhancement of CWLs. RESULTS: Compared with currently required CWLs in California, both textually (b = 0.30, p = .011) and pictorially (b = 0.59, p < .001) enhanced CWLs increased recall accuracy. Pictorially enhanced CWLs outperformed their text-only counterparts (b = 0.28, p = .019) in improving information recall. Only pictorially enhanced CWLs improved perceived message effectiveness (b = 0.31, p = .008), which was mediated by negative emotions but not by information recall. CONCLUSIONS: Given rapid expansion of the cannabis industry and declining perception of harm, currently required CWLs in the U.S. such as California's, would benefit from redesign to improve public understanding of health risks and to prevent youth use.

Local Laws Regulating Cannabis in California Two Years Post Legalization: Assessing Incorporation of Lessons from Tobacco Control.

Introduction: As cannabis legalization continues to spread, best regulatory practice remains ill-defined and elusive, exposing the population to potential harms. Methods: We conducted an annual, statewide, cross- sectional survey to assess cannabis-related laws in effect by January 1, 2020, in local California jurisdictions and at the state level and measured adoption of potential best practices. Results: The current laws of all 539 jurisdictions were located; 276 jurisdictions allowed any retail sales (storefront or delivery) covering 58% of the population, an increase of 20 jurisdictions (8%) from year 1 of legalization (2018). Half allowed sales of medical cannabis, whereas slightly fewer jurisdictions (n = 225) allowed adult-use sales. Only 9 jurisdictions imposed any restrictions on products stricter than state regulations. Cannabis temporary special events were allowed in 22 jurisdictions, up from 14 in the year prior. Thirty-three jurisdictions required additional health warnings for consumers. Just over half of legalizing jurisdictions taxed cannabis locally and little revenue was captured for prevention. No new jurisdictions established a potency-linked tax. Of jurisdictions allowing storefront retailers (n = 162), 114 capped outlet licenses, and 49 increased the state-specified buffers between storefronts and schools. Thirty-six allowed on-site consumption, up from 29. As of January 2020, the state had not updated its regulations of key provisions addressed in this paper. Conclusions: In year 2 of legalized adult-use cannabis sales in California, the state remained split between retail bans and legal sale. Local policy continued to vary widely on protective measures, and State policy remained misaligned with protection of youth and public health.

Impact of California's tobacco and cannabis policies on the retail availability of little cigars/cigarillos and blunt wraps.

BACKGROUND: Recent changes in California's tobacco and cannabis policies could impact the retail availability of little cigars/cigarillos (LCCs) and blunt wraps that are used for blunt smoking. This study was intended to test whether tobacco flavor bans and minimum pack sizes of LCCs have reduced tobacco availability in California jurisdictions, whereas, permissive policies on sales and marketing of cannabis increased availability. METHODS: Measures of retail availability of LCCs and blunt wraps were obtained from the 2016-2019 longitudinal sample of licensed tobacco retailers (LTRs, n = 4062) from California's Healthy Stores for Healthy Communities campaign. Additional data sources included the California Cannabis Local Laws database and geographic location of 1063 cannabis retailers used for constructing a spatial index of accessibility to the LTRs. Two-level generalized structural equation models were developed to assess effects of store- and jurisdiction-level predictors of change in tobacco availability (+, -, no change). RESULTS: Neither permissive cannabis policies nor accessibility to cannabis retailers were associated with an increase in retail availability of the tobacco products. Enactment of a tobacco flavor ban, however, was associated with reduced availability of LCCs and blunt wraps, which was more pronounced in jurisdictions that had permissive cannabis policies (i.e. policy interaction). CONCLUSIONS: A tobacco flavor ban may be an effective strategy to reduce retail availability of LCCs, blunt wraps and possibly other tobacco in California jurisdictions. This finding is of particular relevance as the tobacco industry has successfully petitioned for a referendum vote on California's statewide flavor ban in the 2022 election.

Implementation of the First US Sugar-Sweetened Beverage Tax in Berkeley, CA, 2015-2019.

Objectives. To identify lessons learned from implementation of the nation's first sugar-sweetened beverage (SSB) excise tax in 2015 in Berkeley, California.Methods. We interviewed city stakeholders and SSB distributors and retailers (n = 48) from June 2015 to April 2017 and analyzed records through January 2019.Results. Lessons included the importance of thorough and timely communications with distributors and retailers, adequate lead time for implementation, advisory commissions for revenue allocations, and funding of staff, communications, and evaluation before tax collection begins. Early and robust outreach about the tax and programs funded can promote and sustain public support, reduce friction, and facilitate beverage price increases on SSBs only. No retailer reported raising food prices, indicating that Berkeley's SSB tax did not function as a "grocery tax," as industry claimed. Revenue allocations totaled more than $9 million for public health, nutrition, and health equity through 2021.Conclusions. The policy package, context, and implementation process facilitated translating policy into public health outcomes. Further research is needed to understand long-term facilitators and barriers to sustaining public health benefits of Berkeley's tax and how those differ from facilitators and barriers in jurisdictions facing significant industry-funded repeal efforts.

Assessment of Incorporation of Lessons From Tobacco Control in City and County Laws Regulating Legal Marijuana in California.

Importance: As marijuana continues to be legalized in many states, little is known about best regulatory practice, exposing the population to significant potential harm. Objective: To assess the extent to which potential best practices, including those from tobacco control, were incorporated into state and local marijuana policies in California. Design and Setting: California legalized medical marijuana in 1996 and adult recreational use in 2016, effective in January 2018. A cross-sectional study with data collection and analysis from February 1 to November 30, 2019, measured the adoption of potential demand reduction and youth protection best practices, including restrictions on sales, products, marketing, warnings, and taxation. Laws in effect by January 31, 2019, were verified and all 539 California local jurisdictions were studied. Main Outcomes and Measures: Adoption of potential best practices in marijuana laws for demand reduction and youth protection. Results: The laws of 534 of California's 539 jurisdictions (99%) were successfully identified; 263 of these 534 jurisdictions (49%) allowed any retail sale of marijuana, covering 57% of the state's population. More than one-third of jurisdictions allow sales of marijuana for adult recreational use (203 of 534 [38%]); of those, 122 allow storefront dispensaries and 81 allow sales by delivery only. A total of 257 of 534 jurisdictions (48%) allow medical sales. Of 147 jurisdictions allowing medical or adult use dispensaries, 93 (63%) limited the number of licenses, with a mean of 1 store for every 19 058 residents (range, 154-355 143). The state imposed no limits on number of dispensaries or deliverers. Forty-two jurisdictions increased the state-specified distances required between dispensaries and schools. Only 8 jurisdictions allowing retail sales imposed restrictions on products exceeding state regulations; 1 prohibited sale of flavored products, 3 prohibited sale of marijuana-infused beverages, and 5 imposed additional restrictions on edible marijuana products. No jurisdictions limited potency of products sold, although 1 established a potency-linked tax. The state did not limit or tax potency, except for establishing a standard 10-mg dose of tetrahydrocannabinol for edible marijuana products, nor did they limit manufacturing or sale of flavored products. The state required only a health warning in 6-point font on packages. Twenty-seven jurisdictions required additional health warnings in stores or on packages, 27 allowed onsite consumption of marijuana products, and 13 allowed marijuana-related events. More than half of jurisdictions legalizing any cannabis commerce (154 of 289 [53%]) did not tax marijuana locally and little revenue was captured for prevention. Much of the state excise and cultivation taxes is slated for youth substance use prevention and treatment. Conclusions and Relevance: In implementing legalization of marijuana in California, local policies varied widely. Where marijuana was legalized, many lessons from tobacco control to reduce demand, limit harm, and prevent youth use were not adopted, potentially creating greater risk of harm.

Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study.

BACKGROUND: Taxes on sugar-sweetened beverages (SSBs) meant to improve health and raise revenue are being adopted, yet evaluation is scarce. This study examines the association of the first penny per ounce SSB excise tax in the United States, in Berkeley, California, with beverage prices, sales, store revenue/consumer spending, and usual beverage intake. METHODS AND FINDINGS: Methods included comparison of pre-taxation (before 1 January 2015) and first-year post-taxation (1 March 2015-29 February 2016) measures of (1) beverage prices at 26 Berkeley stores; (2) point-of-sale scanner data on 15.5 million checkouts for beverage prices, sales, and store revenue for two supermarket chains covering three Berkeley and six control non-Berkeley large supermarkets in adjacent cities; and (3) a representative telephone survey (17.4% cooperation rate) of 957 adult Berkeley residents. Key hypotheses were that (1) the tax would be passed through to the prices of taxed beverages among the chain stores in which Berkeley implemented the tax in 2015; (2) sales of taxed beverages would decline, and sales of untaxed beverages would rise, in Berkeley stores more than in comparison non-Berkeley stores; (3) consumer spending per transaction (checkout episode) would not increase in Berkeley stores; and (4) self-reported consumption of taxed beverages would decline. Main outcomes and measures included changes in inflation-adjusted prices (cents/ounce), beverage sales (ounces), consumers' spending measured as store revenue (inflation-adjusted dollars per transaction) in two large chains, and usual beverage intake (grams/day and kilocalories/day). Tax pass-through (changes in the price after imposition of the tax) for SSBs varied in degree and timing by store type and beverage type. Pass-through was complete in large chain supermarkets (+1.07¢/oz, p = 0.001) and small chain supermarkets and chain gas stations (1.31¢/oz, p = 0.004), partial in pharmacies (+0.45¢/oz, p = 0.03), and negative in independent corner stores and independent gas stations (-0.64¢/oz, p = 0.004). Sales-unweighted mean price change from scanner data was +0.67¢/oz (p = 0.00) (sales-weighted, +0.65¢/oz, p = 0.003), with +1.09¢/oz (p < 0.001) for sodas and energy drinks, but a lower change in other categories. Post-tax year 1 scanner data SSB sales (ounces/transaction) in Berkeley stores declined 9.6% (p < 0.001) compared to estimates if the tax were not in place, but rose 6.9% (p < 0.001) for non-Berkeley stores. Sales of untaxed beverages in Berkeley stores rose by 3.5% versus 0.5% (both p < 0.001) for non-Berkeley stores. Overall beverage sales also rose across stores. In Berkeley, sales of water rose by 15.6% (p < 0.001) (exceeding the decline in SSB sales in ounces); untaxed fruit, vegetable, and tea drinks, by 4.37% (p < 0.001); and plain milk, by 0.63% (p = 0.01). Scanner data mean store revenue/consumer spending (dollars per transaction) fell 18¢ less in Berkeley (-$0.36, p < 0.001) than in comparison stores (-$0.54, p < 0.001). Baseline and post-tax Berkeley SSB sales and usual dietary intake were markedly low compared to national levels (at baseline, National Health and Nutrition Examination Survey SSB intake nationally was 131 kcal/d and in Berkeley was 45 kcal/d). Reductions in self-reported mean daily SSB intake in grams (-19.8%, p = 0.49) and in mean per capita SSB caloric intake (-13.3%, p = 0.56) from baseline to post-tax were not statistically significant. Limitations of the study include inability to establish causal links due to observational design, and the absence of health outcomes. Analysis of consumption was limited by the small effect size in relation to high standard error and Berkeley's low baseline consumption. CONCLUSIONS: One year following implementation of the nation's first large SSB tax, prices of SSBs increased in many, but not all, settings, SSB sales declined, and sales of untaxed beverages (especially water) and overall study beverages rose in Berkeley; overall consumer spending per transaction in the stores studied did not rise. Price increases for SSBs in two distinct data sources, their timing, and the patterns of change in taxed and untaxed beverage sales suggest that the observed changes may be attributable to the tax. Post-tax self-reported SSB intake did not change significantly compared to baseline. Significant declines in SSB sales, even in this relatively affluent community, accompanied by revenue used for prevention suggest promise for this policy. Evaluation of taxation in jurisdictions with more typical SSB consumption, with controls, is needed to assess broader dietary and potential health impacts.

Costs and effects of a telephonic diabetes self-management support intervention using health educators.

BACKGROUND: Self-management is crucial to successful glycemic control in patients with diabetes, yet it requires patients to initiate and sustain complicated behavioral changes. Support programs can improve glycemic control, but may be expensive to implement. We report here an analysis of the costs of a successful telephone-based self-management support program delivered by lay health educators utilizing a municipal health department A1c registry, and relate them to near-term effectiveness. METHODS: Costs of implementation were assessed by micro-costing of all resources used. Per-capita costs and cost-effectiveness ratios from the perspective of the service provider are estimated for net A1c reduction, and percentages of patients achieving A1c reductions of 0.5 and 1.0 percentage points. One-way sensitivity analyses of key cost elements, and a Monte Carlo sensitivity analysis are reported. RESULTS: The telephone intervention was provided to 443 people at a net cost of $187.61 each. Each percentage point of net A1c reduction was achieved at a cost of $464.41. Labor costs were the largest component of costs, and cost-effectiveness was most sensitive to the wages paid to the health educators. CONCLUSIONS: Effective telephone-based self-management support for people in poor diabetes control can be delivered by health educators at moderate cost relative to the gains achieved. The costs of doing so are most sensitive to the prevailing wage for the health educators.

Telephone Intervention to Improve Diabetes Control: A Randomized Trial in the New York City A1c Registry.

INTRODUCTION: Scalable self-management interventions are necessary to address suboptimal diabetes control, especially among minority populations. The study tested the effectiveness of a telephone behavioral intervention in improving glycemic control among adults with diabetes in the New York City A1c Registry. DESIGN: RCT comparing a telephone intervention to print-only intervention in the context of the A1c Registry program. SETTING/PARTICIPANTS: Nine hundred forty-one adults with diabetes and hemoglobin A1c (A1c) >7% from a low-income, predominantly Latino population in the South Bronx were recruited from the A1c Registry. INTERVENTION: All study participants were mailed print diabetes self-management materials at baseline and modest lifestyle incentives quarterly. Only the telephone participants received four calls from health educators evenly spaced over 1 year if baseline A1c was >7%-9%, or eight calls if baseline A1c was >9%. Medication adherence was the main behavioral focus and, secondarily, nutrition and exercise. MAIN OUTCOME MEASURES: Primary outcome was difference between two study arms in change in A1c from baseline to 1 year. Secondary outcomes included diabetes self-care activities, including self-reported medication adherence. Data were collected in 2008-2012 and analyzed in 2012-2014. RESULTS: Participants were predominantly Latino (67.7%) or non-Latino black (28%), with 69.7% foreign-born and 55.1% Spanish-speaking. Among 694 (74%) participants with follow-up A1c, mean A1c decreased by 0.9 (SD=0.1) among the telephone group compared with 0.5 (SD=0.1) among the print-only group, a difference of 0.4 (95% CI=0.09, 0.74, p=0.01). The intervention had significant effect when baseline A1c was >9%. Both groups experienced similar improvements in self-care activities, medication adherence, and intensification. CONCLUSIONS: A telephone intervention delivered by health educators can be a clinically effective tool to improve diabetes control in diverse populations, specifically for those with worse metabolic control identified using a registry. This public health approach could be adopted by health systems supported by electronic record capabilities. CLINICALTRIALS. GOV REGISTRATION: NCT00797888.

Insights and implications for health departments from the evaluation of New York City's regulations on nutrition, physical activity, and screen time in child care centers.

In 2006, the New York City Department of Health and Mental Hygiene, seeking to address the epidemic of childhood obesity, issued new regulations on beverages, physical activity, and screen time in group child care centers. An evaluation was conducted to identify characteristics of New York City child care centers that have implemented these regulations and to examine how varying degrees of implementation affected children's behaviors. This article discusses results of this evaluation and how findings can be useful for other public health agencies. Knowing the characteristics of centers that are more likely to comply can help other jurisdictions identify centers that may need additional support and training. Results indicated that compliance may improve when rules established by governing agencies, national standards, and local regulatory bodies are complementary or additive. Therefore, the establishment of clear standards for obesity prevention for child care providers can be a significant public health achievement.

Rationale for New York City's regulations on nutrition, physical activity, and screen time in early child care centers.

Childhood obesity is associated with health risks in childhood, and it increases the risk of adult obesity, which is associated with many chronic diseases. Therefore, implementing policies that may prevent obesity at young ages is important. In 2007, the New York City Department of Health and Mental Hygiene implemented new regulations for early childhood centers to increase physical activity, limit screen time, and provide healthful beverage offerings (ie, restrict sugar-sweetened beverages for all children, restrict whole milk for those older than 2 years, restrict juice to beverages that are 100% juice and limit serving of juice to only 6 ounces per day, and make water available and accessible at all times). This article explains why these amendments to the Health Code were created, how information about these changes was disseminated, and what training programs were used to help ensure implementation, particularly in high-need neighborhoods.

Toward a healthier city: nutrition standards for New York City government.

Poor diet is a leading cause of disability, death, and rising health care costs. Government agencies can have a large impact on population nutrition by adopting healthy food purchasing policies. In 2007, New York City (NYC) began developing a nutrition policy for all foods purchased, served, or contracted for by City agencies. A Food Procurement Workgroup was created with representatives from all City agencies that engaged in food purchasing or service, and the NYC Health Department served as technical advisor. The NYC Standards for Meals/Snacks Purchased and Served (Standards) became a citywide policy in 2008. The first of its kind, the Standards apply to more than 3,000 programs run by 12 City agencies. This paper describes the development process and initial implementation of the Standards. With more than 260 million meals and snacks per year covered, the Standards increase demand for healthier products, model healthy eating, and may also affect clients' food choices beyond the institutional environment. Our experience suggests that implementation of nutrition standards across a wide range of diverse agencies is feasible, especially when high-level support is established and technical assistance is available. Healthy procurement policies can ensure that food purchased by a jurisdiction supports its public health efforts.