The special sauce of the Cancer Prevention and Control Research Network: 20 years of lessons learned in developing the evidence base, building community capacity, and translating research into practice.

PURPOSE: The Cancer Prevention and Control Research Network (CPCRN) is a national network focused on accelerating the translation of cancer prevention and control research evidence into practice through collaborative, multicenter projects in partnership with diverse communities. From 2003 to 2022, the CPCRN included 613 members. METHODS: We: (1) characterize the extent and nature of collaborations through a bibliometric analysis of 20 years of Network publications; and (2) describe key features and functions of the CPCRN as related to organizational structure, productivity, impact, and focus on health equity, partnership development, and capacity building through analysis of 22 in-depth interviews and review of Network documentation. RESULTS: Searching Scopus for multicenter publications among the CPCRN members from their time of Network engagement yielded 1,074 collaborative publications involving two or more members. Both the overall number and content breadth of multicenter publications increased over time as the Network matured. Since 2004, members submitted 123 multicenter grant applications, of which 72 were funded (59%), totaling more than $77 million secured. Thematic analysis of interviews revealed that the CPCRN's success-in terms of publication and grant productivity, as well as the breadth and depth of partnerships, subject matter expertise, and content area foci-is attributable to: (1) its people-the inclusion of members representing diverse content-area interests, multidisciplinary perspectives, and geographic contexts; (2) dedicated centralized structures and processes to enable and evaluate collaboration; and (3) focused attention to strategically adapting to change. CONCLUSION: CPCRN's history highlights organizational, strategic, and practical lessons learned over two decades to optimize Network collaboration for enhanced collective impact in cancer prevention and control. These insights may be useful to others seeking to leverage collaborative networks to address public health problems.

Syndromes associated with frontotemporal lobar degeneration change response patterns on visual analogue scales.

Self-report scales are widely used in cognitive neuroscience and psychology. However, they rest on the central assumption that respondents engage meaningfully. We hypothesise that this assumption does not hold for many patients, especially those with syndromes associated with frontotemporal lobar degeneration. In this study we investigated differences in response patterns on a visual analogue scale between people with frontotemporal degeneration and controls. We found that people with syndromes associated with frontotemporal lobar degeneration respond with more invariance and less internal consistency than controls, with Bayes Factors = 15.2 and 14.5 respectively indicating strong evidence for a group difference. There was also evidence that patient responses feature lower entropy. These results have important implications for the interpretation of self-report data in clinical populations. Meta-response markers related to response patterns, rather than the values reported on individual items, may be an informative addition to future research and clinical practise.

Smoking and cessation behaviors in patients at federally funded health centers - United States, 2014.

BACKGROUND: Federally funded health centers (HCs) provide care to the most vulnerable populations in the U.S., including populations with disproportionately higher smoking prevalence such as those with lower incomes. METHODS: This study compared characteristics of adult HC patients, by cigarette smoking status, and assessed smoking cessation-related behaviors using 2014 Health Center Patient Survey data; analysis was restricted to adults with data on cigarette smoking status (n = 5583). Chi-square and logistic regression analyses were conducted. RESULTS: Overall, 28.1 % were current smokers and 19.2 % were former smokers. Current smokers were more likely to report fair/poor health (48.2 %) and a high burden of behavioral health conditions (e.g., severe psychological distress 23.9 %) versus former and never smokers. Most current smokers reported wanting to quit in the past 12 months (79.0 %) and receiving advice to quit from a healthcare professional (78.7 %). In a multivariable model, age <45, non-white race, COPD diagnosis, and past 3-month marijuana use were significantly associated with desire to quit. Few former smokers (15.2 %) reported using cessation treatment, though use was higher among those who quit within the previous year (30.6 %). CONCLUSIONS: Although most current smokers reported a desire to quit, low uptake of evidence-based treatment may reduce the number who attempt to quit and succeed. Given the burden of tobacco use, future efforts could focus on identifying and overcoming unique personal, healthcare professional, or health system barriers to connecting them with cessation treatments. Increasing access to cessation treatments within HCs could reduce smoking-related disparities and improve population health.

Age Verification and Online Sales of Little Cigars and Cigarillos to Minors.

OBJECTIVES: In our cross-sectional study, we aimed to determine age verification and sales of little cigars and cigarillos (LCCs) online to underage teens. METHODS: We selected 100 popular Internet Little Cigar and Cigarillo Vendors (ILVs) for order attempts. From August to December 2015, we supervised 14 teens 14-17 years old making order attempts for LCCs. RESULTS: Of the 91 valid orders attempted, we received 89. For the valid orders attempted, 9.9% of ILVs used no age verification strategies at all, 84.6% used less effective forms of age verification, and 50.5% used more effective ones. Only one order was blocked during the order attempt and only one attempt was made to verify age at delivery. Most (79.8%) deliveries were left at the door and only 2 order attempts were rejected because of age verification strategies, resulting in a successful or valid buy rate of 97.8%. CONCLUSIONS: Our study demonstrated that ILVs selling LCCs were not making adequate efforts to verify the age of their customers, at the point-of-sale or point-of-delivery, facilitating easy access by minors. Few ILVs utilized age verification strategies that prevented online sales of LCCs to underage teens.

The internet market for Kratom, an opioid alternative and variably legal recreational drug.

BACKGROUND: Amidst the opioid crisis, many people are turning to plant-based kratom for self-treatment of pain, opioid addiction, and for recreational use. Its legality is variable and its safety and medicinal effects are not agreed upon. It is broadly available from Internet Kratom Vendors (IKVs). METHODS: An examination of the online marketplace for kratom was conducted to provide context to the market amidst regulatory attempts by the Food and Drug Administration (FDA) and state legislatures. A complex search strategy identified 663 English-language IKVs selling kratom for home delivery. The 100 most popular were selected for in-depth content analysis. IKVs were visited once for content analysis data collection in December, 2017 and revisited in April 2018 to assess responses to FDA action. IKV website and social media profiles were coded for topics including location, payment and shipping options, age verification, health warnings and disclaimers, and grassroots advocacy regarding upcoming state/federal regulations. RESULTS: Forty-seven percent of IKVs claimed that kratom provides pain relief, 25% claimed it provides relief from opioid withdrawal, 81% featured a disclaimer that kratom is addictive, 54% stated that kratom is not FDA approved, and 66% featured disclaimers that it was not intended for consumption. Only 5% of vendors advertised effective age verification (such as verifying age at delivery). Compliance on the vendor's part with state and local bans varied by ban location, with only 27% prohibiting sales to Rhode Island while 65% did not ship to Indiana. CONCLUSIONS: IKVs provide easy access to a wide variety of unregulated intoxicating products with poor age verification and low adherence to US state- and local-level restrictions. There is a high prevalence of vendors featuring health claims forbidden by the Food and Drug Administration. Lessons learned from regulating the Internet cigarette sales industry could be effectively applied to IKVs with future efforts.

Steps Toward Scalability: Illustrations From a Smoke-Free Homes Program.

Scalable interventions remain effective across a range of real-world settings and can be modified to fit organizational and community context. "Smoke-Free Homes: Some Things are Better Outside" has been effective in promoting smoke-free home rules in low-income households in efficacy, effectiveness, generalizability, and dissemination studies. Using data from a dissemination study in collaboration with five 2-1-1 call centers in Ohio, Florida, Oklahoma, and Alabama (n = 2,345 households), this article examines key dimensions of scalability, including effectiveness by subpopulation, secondary outcomes, identification of core elements driving effectiveness, and cost-effectiveness. Evaluated by 2-1-1 staff using a pre-post design with self-reported outcomes at 2 months postbaseline, the program was equally effective for men and women, across education levels, with varying number of smokers in the home, and whether children were present in the home or not. It was more effective for nonsmokers, those who smoked fewer cigarettes per day, and African Americans. Creating a smoke-free home was associated with a new smoke-free vehicle rule (odds ratio [OR] = 3.38, confidence interval [CI 2.58, 4.42]), decreased exposure to secondhand smoke among nonsmokers (b = -2.33, p < .0001), and increased cessation among smokers (OR = 5.8, CI [3.81, 8.81]). Use of each program component was significantly associated with success in creating a smoke-free home. Using an intent-to-treat effect size of 40.1%, program benefits from 5 years of health care savings exceed program costs yielding a net savings of $9,633 for delivery to 100 households. Cost effectiveness, subpopulation analyses, and identification of core elements can help in assessing the scalability potential of research-tested interventions such as this smoke-free homes program.

Strategies to Reduce Illicit Trade of Regular Nicotine Tobacco Products After Introduction of a Low-Nicotine Tobacco Product Standard.

The US Food and Drug Administration is considering mandating a substantial reduction in the nicotine level of cigarettes and possibly other combusted tobacco products to render them minimially addictive. This would likely result in several public health benefits, including increased cessation, decreased progression to dependence, and reduced consumption of combusted tobacco products. However, findings from clinical trials of reduced-nicotine cigarettes suggest that many smokers consuming low nicotine-content cigarettes sought out regular nicotine-content cigarettes, even when they were asked to only smoke free low-nicotine cigarettes. If this policy were implemented without ensuring that cessation treatments and appealing alternative products (e.g., e-cigarettes) were readily available, some consumers would be likely to seek banned regular nicotine-content combusted tobacco products from illicit sources: retail, online, and individuals. Left unchecked, this illicit market could undermine the public health benefits of the policy. We describe supply and demand factors in an illicit market. Informed by the literature on controlling Internet tobacco sales and reducing illicit trade in low-cost cigarettes when there are price differentials, we recommend tracking and tracing products and greater surveillance and enforcement efforts to minimize illicit trade in normal nicotine products under a low-nicotine tobacco product standard.

Moderators of Establishing a Smoke-Free Home: Pooled Data from Three Randomized Controlled Trials of a Brief Intervention.

Interventions to create smoke-free homes typically focus on parents, involve multiple counseling sessions and blend cessation and smoke-free home messages. Smoke-Free Homes: Some Things are Better Outside is a minimal intervention focused on smokers and nonsmokers who allow smoking in the home, and emphasizes creation of a smoke-free home over cessation. The purpose of this study is to conduct moderator analyses using pooled data from three randomized controlled trials of the intervention conducted in collaboration with 2-1-1 contact centers in Atlanta, North Carolina and Houston. 2-1-1 is a strategic partner for tobacco control as it connects over 15 million clients, largely socio-economically disadvantaged, to social and health resources each year. A total of 1506 2-1-1 callers participated across the three intervention trials. Outcomes from 6 months intent-to-treat analyses were used to examine whether sociodemographic variables and smoking-related characteristics moderated effectiveness of the intervention in establishing full home smoking bans. Intervention effectiveness was not moderated by race/ethnicity, education, income, children in the home or number of smokers in the home. Smoking status of the participant, however, did moderate program effectiveness, as did time to first cigarette. Number of cigarettes per day and daily versus nondaily smoking did not moderate intervention effectiveness. Overall, the intervention was effective across socio-demographic groups and was effective without respect to daily versus nondaily smoking or number of cigarettes smoked per day, although smoking status and level of nicotine dependence did influence effectiveness.

Implementing an Evidence-based Tobacco Control Program at Five 2-1-1 Call Centers: An Evaluation Using the Consolidated Framework for Implementation Research.

Introduction: The Smoke-Free Homes (SFH) Program is an evidence-based intervention offered within 2-1-1 information and referral call centers to promote smoke-free homes in low-income populations. We used the Consolidated Framework for Implementation Research to conduct a mixed-methods analysis of facilitators and barriers to scaling up SFH to five 2-1-1 sites in the United States. Methods: Data were collected from staff in 2015-2016 via online surveys administered before (N = 120) and after SFH training (N = 101) and after SFH implementation (N = 79). Semi-structured telephone interviews were conducted in 2016 with 25 staff to examine attitudes towards SFH, ways local context affected implementation, and unintended benefits and consequences of implementing SFH. Results: Post-implementation, 79% of respondents reported that SFH was consistent with their 2-1-1's mission, 70% thought it led to more smoke-free homes in their population, 62% thought it was easy to adapt, and 56% thought participants were satisfied. Composite measures of perceived appropriateness of SFH for 2-1-1 callers and staff positivity toward SFH were significantly lower post-implementation than pre-implementation. In interviews, staff said SFH fit with their 2-1-1's mission but expressed concerns about intervention sustainability, time and resources needed for delivery, and how SFH fit into their workflow. Conclusions: Sites' SFH implementation experiences were affected both by demands of intervention delivery and by SFH's perceived effectiveness and fit with organizational mission. Future implementation of SFH and other tobacco control programs should address identified barriers by securing ongoing funding, providing dedicated staff time, and ensuring programs fit with staff workflow. Implications: Smoke-free home policies reduce exposure to secondhand smoke. Partnering with social service agencies offers a promising way to scale up evidence-based smoke-free home interventions among low-income populations. We found that the SFH intervention was acceptable and feasible among multiple 2-1-1 delivery sites. There were also significant challenges to implementation, including site workflow, desire to adapt the intervention, time needed for intervention delivery, and financial sustainability. Addressing such challenges will aid future efforts to scale up evidence-based tobacco control interventions to social service agencies such as 2-1-1.

Assessing Levels and Correlates of Implementation of Evidence-Based Approaches for Colorectal Cancer Screening: A Cross-Sectional Study With Federally Qualified Health Centers.

Multiple evidence-based approaches (EBAs) exist to improve colorectal cancer screening in health clinics. The success of these approaches is tied to effective implementation. Therefore, the purpose of this study was to assess the implementation of EBAs for colorectal cancer screening and clinic-level correlates of implementation in federally qualified health centers (FQHCs). We conducted descriptive and cross-sectional analyses using data collected from FQHC clinics across seven states ( n = 51). A clinic representative completed electronic surveys about clinic characteristics (e.g., size, patient characteristics, and medical record system characteristics) and the implementation of Community Guide recommended EBAs (e.g., client reminders, small media, and provider assessment and feedback). We used bivariate Spearman correlations to assess clinic-level correlates with implementation outcomes. Most clinics were planning to implement, in the early implementation stages, or inconsistently implementing EBAs. No EBA was fully implemented by more than nine (17.6%) clinics. Clinic size variables were inversely related to implementation levels of one-on-one education; medical record variables were directly related to implementation levels of client and provider reminders as well as provider assessment and feedback; and rapid and timely feedback from clinic leaders was directly associated with implementation levels of four out of six EBAs. Given the varying levels of implementation, clinics need to assess current use of implementation strategies and improve effective program delivery to increase colorectal cancer screening among their patients. In addition, clinics should also consider how their characteristics may support or serve as a barrier to implementation in their respective settings.

Developing measures to assess constructs from the Inner Setting domain of the Consolidated Framework for Implementation Research.

BACKGROUND: Scientists and practitioners alike need reliable, valid measures of contextual factors that influence implementation. Yet, few existing measures demonstrate reliability or validity. To meet this need, we developed and assessed the psychometric properties of measures of several constructs within the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR). METHODS: We searched the literature for existing measures for the 7 Inner Setting domain constructs (Culture Overall, Culture Stress, Culture Effort, Implementation Climate, Learning Climate, Leadership Engagement, and Available Resources). We adapted items for the healthcare context, pilot-tested the adapted measures in 4 Federally Qualified Health Centers (FQHCs), and implemented the revised measures in 78 FQHCs in the 7 states (N = 327 respondents) with a focus on colorectal cancer (CRC) screening practices. To psychometrically assess our measures, we conducted confirmatory factor analysis models (CFA; structural validity), assessed inter-item consistency (reliability), computed scale correlations (discriminant validity), and calculated inter-rater reliability and agreement (organization-level construct reliability and validity). RESULTS: CFAs for most constructs exhibited good model fit (CFI > 0.90, TLI > 0.90, SRMR < 0.08, RMSEA < 0.08), with almost all factor loadings exceeding 0.40. Scale reliabilities ranged from good (0.7 ≤ α < 0.9) to excellent (α ≥ 0.9). Scale correlations fell below 0.90, indicating discriminant validity. Inter-rater reliability and agreement were sufficiently high to justify measuring constructs at the clinic-level. CONCLUSIONS: Our findings provide psychometric evidence in support of the CFIR Inner Setting measures. Our findings also suggest the Inner Setting measures from individuals can be aggregated to represent the clinic-level. Measurement of the Inner Setting constructs can be useful in better understanding and predicting implementation in FQHCs and can be used to identify targets of strategies to accelerate and enhance implementation efforts in FQHCs.

Internet little cigar and cigarillo vendors: Surveillance of sales and marketing practices via website content analysis.

INTRODUCTION: Cigar sales have nearly doubled as cigarette sales have dropped, and large cigars have been replaced by little cigars and cigarillos (LCCs). Many LCCs are flavored, are perceived as less harmful than cigarettes, and have become increasingly available from e-commerce sources. We conducted surveillance of the online retail environment in 2013 and 2014 for LCCs in order to describe characteristics of Internet tobacco vendors selling LCCs and their sales and marketing practices, youth access practices, and their practices in relation to cigarette and other tobacco product sales. METHODS: In 2013, we identified and manually screened 32,446 websites, yielding 500 unique Internet LCC vendors. In 2014, we identified 511 vendors selling LCCs from a list of 31,239 manually screened websites. We then selected 249 in 2013 and 263 in 2014 for content analysis focusing on six domains including demographics, youth access, payment and delivery, products for sale, promotions and claims, and prices. RESULTS: Just over half of vendors in both years were located solely in the U.S. with 70.1% of those selling flavored LCCs in 2013 and 76.1% in 2014. Nearly half only used proven ineffective age verification strategies and another 10% made no attempts to verify age at all. Most vendors accepted credit cards and advertised using the United States Postal Service. Half of vendors featured a variety of health warnings and most featured promotions. CONCLUSIONS: Federal bans on flavored cigarettes and restrictions on age verification, payment, and shipping for Internet tobacco sales should be extended to include LCCs.

Content analysis of age verification, purchase and delivery methods of internet e-cigarette vendors, 2013 and 2014.

OBJECTIVE: Identify the population of internet e-cigarette vendors (IEVs) and conduct content analyses of their age verification, purchase and delivery methods in 2013 and 2014. METHODS: We used multiple sources to identify IEV websites, primarily complex search algorithms scanning more than 180 million websites. In 2013, we manually screened 32 446 websites, identifying 980 IEVs, selecting the 281 most popular for content analysis. This methodology yielded 31 239 websites for screening in 2014, identifying 3096 IEVs, with 283 selected for content analysis. RESULTS: The proportion of vendors that sold online-only, with no retail store, dropped significantly from 2013 (74.7%) to 2014 (64.3%) (p<0.01), with a corresponding significant decrease in US-based vendors (71.9% in 2013 and 65% in 2014). Most vendors did little to prevent youth access in either year, with 67.6% in 2013 and 63.2% in 2014 employing no age verification or relying exclusively on strategies that cannot effectively verify age. Effective age verification strategies such as online age verification services (7.1% in 2013 and 8.5% in 2014), driving licences (1.8% in 2013 and 7.4% in 2014, p<0.01) or age verification at delivery (6.4% in 2013 and 8.1% in 2104) were rarely advertised on IEV websites. Nearly all vendors advertised accepting credit cards, and about ¾ shipping via United States Postal Service, similar to the internet cigarette industry prior to federal bans. CONCLUSIONS: The number of IEVs grew sharply from 2013 to 2014, with poor age verification practices. New and expanded regulations for online e-cigarette sales are needed, including strict age and identity verification requirements.

Content analysis of e-cigarette products, promotions, prices and claims on Internet tobacco vendor websites, 2013-2014.

OBJECTIVE: To identify the population of Internet e-cigarette vendors (IEVs) and conduct content analysis of products sold and IEVs' promotional, claims and pricing practices. METHODS: Multiple sources were used to identify IEV websites, primarily complex search algorithms scanning over 180 million websites. In 2013, 32 446 websites were manually screened, identifying 980 IEVs, with the 281 most popular selected for content analysis. This methodology yielded 31 239 websites for manual screening in 2014, identifying 3096 IEVs, with 283 selected for content analysis. RESULTS: While the majority of IEVs (71.9%) were US based in 2013, this dropped to 64.3% in 2014 (p<0.01), with IEVs located in at least 38 countries, and 12% providing location indicators reflecting two or more countries, complicating jurisdictional determinations.Reflecting the retail market, IEVs are transitioning from offering disposable and 'cigalike' e-cigarettes to larger tank and "mod" systems. Flavored e-cigarettes were available from 85.9% of IEVs in 2014, with fruit and candy flavors being most popular. Most vendors (76.5%) made health claims in 2013, dropping to 43.1% in 2014. Some IEVs featured conflicting claims about whether or not e-cigarettes aid in smoking cessation. There was wide variation in pricing, with e-cigarettes available as inexpensive as one dollar, well within the affordable range for adults and teens. CONCLUSIONS: The number of Internet e-cigarette vendors grew threefold from 2013 to 2014, far surpassing the number of Internet cigarette vendors (N=775) at the 2004 height of that industry. New and expanded regulations for online e-cigarette sales are needed, including restrictions on flavors and marketing claims.

What is included with your online e-cigarette order? An analysis of e-cigarette shipping, product and packaging features.

BACKGROUND: The electronic cigarette industry is growing, with youth using e-cigarettes at higher rates than they are using cigarettes, and retail and online sales projected to reach $10 billion in 2017. Minimal regulation of the production and marketing of e-cigarettes exists to date, which has allowed companies to promote unsupported claims. We assessed the shipping, product features and packaging of a wide variety of e-cigarettes purchased online by adults and youth. METHODS: The most popular internet e-cigarette vendors were identified from a larger study of internet tobacco vendors. Between August 2013 and June 2014, adults made 56 purchase attempts from online vendors, and youth made 98 attempts. Packages received were assessed for exterior and internal packaging features, including product information, health warnings and additional materials. RESULTS: We analysed a total of 125 orders featuring 86 unique brands of e-cigarettes. The contents were rarely indicated on package exteriors. Product information came with just 60% of orders and just 38.4% included an instruction manual. Only 44.6% of products included a health warning, and some had unsupported claims, such as lack of secondhand smoke exposure. Additionally, some products were leaking e-liquid and battery fluid on arrival. CONCLUSIONS: A large variety of e-cigarette products are manufactured and marketed to consumers. Many products do not include instructions for use, and unsupported claims are being presented to consumers. Effective federal regulation of the manufacturing, packaging, product information and health claims surrounding e-cigarettes is necessary to ensure consumers are presented with accurate e-cigarette use information.

Impact of the Cancer Prevention and Control Research Network: Accelerating the Translation of Research Into Practice.

The Cancer Prevention and Control Research Network (CPCRN) is a thematic network dedicated to accelerating the adoption of evidence-based cancer prevention and control practices in communities by advancing dissemination and implementation science. Funded by the Centers for Disease Control and Prevention and National Cancer Institute, CPCRN has operated at two levels: Each participating network center conducts research projects with primarily local partners as well as multicenter collaborative research projects with state and national partners. Through multicenter collaboration, thematic networks leverage the expertise, resources, and partnerships of participating centers to conduct research projects collectively that might not be feasible individually. Although multicenter collaboration is often advocated, it is challenging to promote and assess. Using bibliometric network analysis and other graphical methods, this paper describes CPCRN's multicenter publication progression from 2004 to 2014. Searching PubMed, Scopus, and Web of Science in 2014 identified 249 peer-reviewed CPCRN publications involving two or more centers out of 6,534 total. The research and public health impact of these multicenter collaborative projects initiated by CPCRN during that 10-year period were then examined. CPCRN established numerous workgroups around topics such as: 2-1-1, training and technical assistance, colorectal cancer control, federally qualified health centers, cancer survivorship, and human papillomavirus. This paper discusses the challenges that arise in promoting multicenter collaboration and the strategies that CPCRN uses to address those challenges. The lessons learned should broadly interest those seeking to promote multisite collaboration to address public health problems, such as cancer prevention and control.

Cigarette sales to minors via the internet: how the story has changed in the wake of federal regulation.

OBJECTIVE: To assess how easily minors can purchase cigarettes online and online cigarette vendors' compliance with federal age/ID verification and shipping regulations, North Carolina's 2013 tobacco age verification law, and federal prohibitions on the sale of non-menthol flavoured cigarettes or those labelled or advertised as 'light'. METHODS: In early 2014, 10 minors aged 14-17 attempted to purchase cigarettes by credit card and electronic check from 68 popular internet vendors. RESULTS: Minors received cigarettes from 32.4% of purchase attempts, all delivered by the US Postal Service (USPS) from overseas sellers. None failed due to age/ID verification. All failures were due to payment processing problems. USPS left 63.6% of delivered orders at the door with the remainder handed to minors with no age verification. 70.6% of vendors advertised light cigarettes and 60.3% flavoured, with 23.5% and 11.8%, respectively, delivered to the teens. Study credit cards were exposed to an estimated $7000 of fraudulent charges. CONCLUSIONS: Despite years of regulations restricting internet cigarette sales, poor vendor compliance and lack of shipper and federal enforcement leaves minors still able to obtain cigarettes (including 'light' and flavoured) online. The internet cigarette marketplace has shifted overseas, exposing buyers to widespread credit card fraud. Federal agencies should rigorously enforce existing internet cigarette sales laws to prevent illegal shipments from reaching US consumers, shut down non-compliant and fraudulent websites, and stop the theft and fraudulent use of credit card information provided online. Future studies should assess whether these agencies begin adequately enforcing the existing laws.

A Minimal Intervention to Promote Smoke-Free Homes among 2-1-1 Callers: North Carolina Randomized Effectiveness Trial.

This study examined the extent to which delivery of the minimal Smoke-Free Homes intervention by trained 2-1-1 information and referral specialists had an effect on the adoption of home smoking bans in low-income households. A randomized controlled trial was conducted among 2-1-1 callers (n = 500) assigned to control or intervention conditions. 2-1-1 information and referral specialists collected baseline data and delivered the intervention consisting of 3 mailings and 1 coaching call; university-based data collectors conducted follow-up interviews at 3 and 6 months post-baseline. Data were collected from June 2013 through July 2014. Participants were mostly female (87.2%), African American (61.4%), and smokers (76.6%). Participants assigned to the intervention condition were more likely than controls to report a full ban on smoking in the home at both 3- (38.1% vs 19.3%, p = < .001) and 6-month follow-up (43.2% vs 33.2%, p = .02). The longitudinal intent-to-treat analysis showed a significant intervention effect over time (OR = 1.31, p = .001), i.e. OR = 1.72 at 6 months. This study replicates prior findings showing the effectiveness of the minimal intervention to promote smoke-free homes in low-income households, and extends those findings by demonstrating they can be achieved when 2-1-1 information and referral specialists deliver the intervention. Findings offer support for this intervention as a generalizable and scalable model for reducing secondhand smoke exposure in homes.

Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: a Texas generalisation trial.

BACKGROUND: Replication of intervention research is reported infrequently, limiting what we know about external validity and generalisability. The Smoke Free Homes Program, a minimal intervention, increased home smoking bans by United Way 2-1-1 callers in randomised controlled trials in Atlanta, Georgia and North Carolina. OBJECTIVE: Test the programme's generalisability-external validity in a different context. METHODS: A randomised controlled trial (n=508) of English-speaking callers from smoking-discordant households (≥1 smoker and ≥1 non-smoker). 2-1-1 Texas/United Way HELPLINE call specialists serving the Texas Gulf Coast recruited callers and delivered three mailings and one coaching call, supported by an online tracking system. Data collectors, blind to study assignment, conducted telephone interviews 3 and 6 months postbaseline. RESULTS: At 3 months, more intervention households reported a smoke-free home (46.6% vs 25.4%, p<0.0001; growth model intent-to-treat OR=1.48, 95% CI 1.241 to 1.772, p<0.0001). At 6 months, self-reported full bans were 62.9% for intervention participants and 38.4% for controls (OR=2.19). Texas trial participants were predominantly women (83%), single-smoker households (76%) and African-American (65%); half had incomes ≤US$10 000/year (50%). Texas recruitment was <50% of the other sites. Fewer callers reported having a smoker in the household. Almost twice the callers with a household smoker declined interest in the programme/study. CONCLUSIONS: Our findings in a region with lower smoking rates and more diverse callers, including English-speaking Latinos, support programme generalisability and convey evidence of external validity. Our recruitment experience indicates that site-specific adjustments might improve recruitment efficiency and reach. TRIAL REGISTRATION NUMBER: NCT02097914, Results.

Is the E-Liquid Industry Regulating Itself? A Look at E-Liquid Internet Vendors in the United States.

INTRODUCTION: The objective of this study was to assess whether the nascent, but rapidly growing e-liquid industry prohibits Internet sales to minors and employs safety measures to prevent accidental poisonings. METHODS: A stratified simple random sample (n = 120) was selected from the target population (N = 1107) of US online vendors of e-liquid in July 2015. The vendors were stratified and subsequently oversampled by trade association membership and vendor popularity. Three minors aged 16 to 17, who were supervised by adult research staff, attempted to purchase e-liquid from the 120 online vendors using debit cards issued in their names. Measures included vendors' use of age verification, warning labels on e-liquid bottles, and child-resistant packaging. RESULTS: Statistically significant differences were observed by vendor popularity, but not by membership in a trade association. The differences by vendor popularity, however, occurred for measures that were limited to an age warning and list of ingredients. The most striking finding was the scant vendors (n = 4) who successfully prevented the sale of e-liquid to the minors. In contrast, 87.5% and 53.9% of the bottles contained child-resistant packaging and a health warning label, respectively. CONCLUSIONS: Irrespective of trade association membership or vendor popularity, online vendors of e-liquids are not taking the proper precautions in preventing sales to minors. The FDA's upcoming deeming rules on e-cigarette products should include explicit requirements for offline and online e-liquid vendors, particularly the use of effective age verification, warning labels, and child-resistant packaging. IMPLICATIONS: This study demonstrates that, in the absence of any current FDA regulation of e-liquid products, self-regulation among vendors is not effective in preventing product acquisition by minors. Lax oversight of the e-liquid industry may draw consumers to bypass current tobacco control restrictions implemented in face-to-face sales settings. As a consequence, there may be an increase in online sales to minors. Further regulation of the industry may increase the already prevalent use of child-resistant packaging, leading to fewer cases of accidental nicotine poisoning.