Compliance with North Dakota's smoke-free law among vape and tobacco specialty shops.

OBJECTIVE: To determine compliance with North Dakota's smoke-free law in vape shops and other tobacco specialty shops selling electronic nicotine delivery systems (ENDS) or e-liquids. DESIGN: In this 2019 descriptive study, shops (n = 35) were assessed for compliance with the smoke-free law by observation of indoor and outdoor areas for smoking or vaping, or evidence of such activity in prohibited areas, and the presence of required no-smoking signs. RESULTS: Only two shops (5.7%) were fully compliant with the smoke-free law. Full compliance for indoor and outdoor environments was 8.5% and 42.8%, respectively. Vaping occurred inside five shops (14.3%), and smoking occurred outdoors within required smoke-free areas in two (5.7%) shops. Four (11.4%) and 17 (48.6%) shops complied with indoor and outdoor signage requirements, respectively. CONCLUSIONS: Overall compliance remained low, although much of the noncompliance was related to signage. Use or evidence of ENDS use occurred both indoors and outdoors where prohibited by law. Classifying ENDS as tobacco products would require tobacco licensure of shops selling ENDS and e-liquids, aiding in identification of the shops for education and enforcement efforts to ensure compliance with the law and to improve public health protection.

Electronic Cigarette Refill Liquids: Nicotine Content, Presence of Child-Resistant Packaging, and in-Shop Compounding.

PURPOSE: To expand on our 2015 study of the nicotine content accuracy of e-liquids, including salts, and the presence of child-resistant packaging. We also describe compounding in shop (CIS). DESIGN AND METHODS: We analyzed samples from 35 shops. CIS processing was observed. Descriptive statistics summarized the data, and inference was performed. RESULTS: Actual nicotine content was significantly less than the identified content, on average, with a mean percent deviation 34.0% below the identified content. Only 3.8% of the samples' actual nicotine content was within 10% of the identified content; the maximum deviation was 213.2%. Of eight uniquely packaged samples, including designs resembling pop cans, ice cream cones, etc., the mean percent deviation was -39.6%; none were within 10% of the identified content. Eight shops compounded samples. After removing outlier values, significant differences were found in the percent deviations between the CIS and non-CIS free-base samples. A significantly higher percentage of CIS samples had nicotine content > 10% above the identified content, and none were within 10%. One shop visually estimated the nicotine quantities to add, e-liquids were not always relabeled to reflect new nicotine levels, and protective materials were not always worn during compounding. Child-resistant packaging was not present for one third of the samples. CONCLUSIONS: Labeling of nicotine content in e-liquids remains inaccurate, child-resistant packaging is inconsistent, and CIS is problematic. Effective e-liquid regulation is needed to protect public health. PRACTICE IMPLICATIONS: Nurses should educate families about the serious health risks of e-liquids and advocate for increased e-liquid regulations.

A systematic review of refillable e-liquid nicotine content accuracy.

OBJECTIVES: The use of e-cigarettes is becoming more common in the United States. E-cigarettes are often refilled with nicotine-containing solutions of various concentrations purchased in local shops or on the Internet. There is evidence that the nicotine content in these solutions is often mislabeled; thus, we reviewed the available literature on this topic. DATA SOURCES: We conducted a systematic review of peer-reviewed articles published worldwide on e-liquid nicotine content accuracy using the databases CAB Direct, Cochrane Central Register of Controlled Trials, PubMed, and SPORTDiscus (EBSCO). STUDY SELECTION: Initial screening of titles and abstracts was conducted to determine relevancy for inclusion. Full-article reviews of studies involving the purchase and chemical analysis of nicotine content in refillable e-liquids were conducted for final inclusion. DATA EXTRACTION: Data extraction included e-liquid sample size, whether the samples were labeled to contain nicotine, whether the samples were purchased in retail shops or online, and the number and percentage of samples where the analyzed nicotine content fell outside 10% of the labeled nicotine content. RESULTS: Twenty articles described cross-sectional studies of purchased samples containing nicotine. The number of nicotine-containing e-liquid samples obtained in each study varied from 2 to 71. The percentage of samples with an analyzed nicotine concentration of more than 10% above or below the labeled nicotine concentration ranged from 0% to 100% (277/574 or 48.3%; median 46.85%). A large percentage of the samples deviated by 10% from the labeled nicotine concentrations in both U.S. and non-U.S. samples, with U.S. samples having a higher percentage. CONCLUSION: Our review shows that actual nicotine concentrations in e-liquids may vary considerably from labeled concentrations. Pharmacists should warn patients to be wary of the contents of e-cigarettes, and explain the dangers of using these products.

Disparities in Rural Tobacco Use, Smoke-Free Policies, and Tobacco Taxes.

Tobacco use and exposure to secondhand smoke (SHS) remain leading causes of preventable disease, disability, and mortality in the United States. Rural populations are among those being left behind in the recent declining smoking rates and have become a focus of discussions on tobacco-related disparities. This article describes tobacco-related disparities in rural populations including tobacco use, exposure to SHS, smoke-free policies, and tobacco taxes. Nurses, as social justice and tobacco control policy advocates, are needed especially at the local level, where much of the policy work occurs and where nursing's voice is respected and can be powerful.

Systems change to improve tobacco use identification and referral in the chiropractic setting: a pilot study.

Background: Tobacco use remains a leading cause of death and disability in the United States. Health professionals need to address the use of tobacco products by their patients, but chiropractic clinical systems often remain unsupported and underappreciated in their role to facilitate tobacco use cessation. Methods: This pilot study tested an intervention to assist a chiropractic community to implement sustainable health systems changes for tobacco use based on U.S. Public Health Service guidelines. Chiropractors were educated on the Ask, Advise, Refer (AAR) approach, provided with ongoing guidance, and followed for six months to assess systems change. The study was conducted from March 2016 to July 2017. Results: Evidence of a systematic process in place to conduct AAR was present in all clinics by the end of the fourth month of the intervention period. Although no clinic had sustained health system change for full AAR, all six of the clinics made progress in the individual AAR components. Furthermore, five clinics achieved sustained system change for the Ask component, as after systems change was achieved, the rate of tobacco user identifications did not drop below 50%. For the Advise component, five clinics succeeded in having individual months of ≥50% of tobacco users being advised, and three clinics achieved the formal definition of systems change. For the Refer component, no clinic achieved system change, although four had individual months of ≥50% of tobacco users being referred. The patient quit rate was 13.3% (n = 15) for the 30-day follow-up and 16.7% (n = 6) for the three-month follow-up. Conclusions: This study demonstrates the feasibility of implementing a health systems change in the chiropractic setting to identify tobacco users, to advise them to quit, and to refer users for cessation services.

Place and Policy: Secondhand Smoke Exposure in Bars and Restaurants.

BACKGROUND: Rural populations have been identified as having tobacco use disparities, with contributing factors including less demand for policy change than in urban areas, resulting in higher age-adjusted death rates related to tobacco use. In 2012, the rural state of North Dakota enacted a statewide comprehensive law requiring all bars and restaurants to be smoke-free. OBJECTIVES: The purpose of this longitudinal study, performed in three phases, was to assess the continued effects of a statewide comprehensive smoke-free law in a primarily rural state, using a stratified random sample. METHODS: Particulate matter and compliance indicators were assessed in restaurants and bars 21 months after enactment of the comprehensive law. Results were compared with the findings from the Phase 1 and Phase 2 samples, in which venues were assessed before passage of the law and approximately 3 months after enactment, respectively. RESULTS: The comprehensive, statewide, smoke-free law led to immediate, sustained, and substantial reductions in secondhand smoke and eliminated previous significant disparities in secondhand smoke exposure in rural communities. Although indoor smoke-free compliance with the law was generally high, compliance in required outdoor smoke-free areas was low. Compliance with signage requirements, both indoors and outdoors, was low. DISCUSSION: The comprehensive statewide smoke-free law created a just distribution of smoke-free laws statewide, resulting in increased protection of rural populations from secondhand smoke. Targeted public health interventions to address compliance may reduce secondhand smoke levels in outlier venues that continue to have high levels of secondhand smoke.

An observational study of compliance with North Dakota's smoke-free law among retail stores that sell electronic smoking devices.

OBJECTIVE: To determine whether retail stores selling electronic smoking devices or liquid nicotine were compliant with North Dakota's smoke-free law. METHODS: During June 2015, retail stores selling electronic smoking devices or liquid nicotine (n=16), but not legally required to be licensed to sell tobacco products, were assessed for compliance with North Dakota's smoke-free law by observing for smoking or e-smoking, or evidence of such, in prohibited areas and for the presence of required no-smoking signs. RESULTS: Use of e-cigarettes, or evidence of use, was observed inside 8 (50%) stores required to be smoke-free. On the basis of all indicators of compliance assessed, compliance with the state's smoke-free law was low, with only 6% and 44% of stores compliant with all indoor and outdoor requirements, respectively. CONCLUSIONS: To the best of our knowledge, this is the first U.S. study assessing retail stores selling electronic smoking devices or liquid nicotine for compliance with the smoke-free law. The use of e-cigarettes, or evidence of use, occurred in the stores where it is prohibited by law. Overall compliance with the smoke-free law was low. These stores should be licensed by the state, as are other tobacco retailers, because this may assist in education, enforcement and compliance with the law and increase public health protection.

Tobacco Smoke Pollution in Hospitality Venues Before and After Passage of Statewide Smoke-Free Legislation.

OBJECTIVE: In 2012, North Dakota enacted a comprehensive statewide law prohibiting smoking in enclosed public places. Disparities in tobacco control exist in rural areas. This study's objective was to determine the extent to which the passage of a comprehensive, statewide, smoke-free law in a predominantly rural state influenced tobacco smoke pollution in rural and nonrural venues. DESIGN AND SAMPLE: A longitudinal cohort design study comparing the levels of tobacco smoke pollution before and after passage of the statewide smoke-free law was conducted in 64 restaurants and bars statewide in North Dakota. MEASURES: Particulate matter with a median aerodynamic diameter of <2.5 µm (a valid atmospheric marker of tobacco smoke pollution) was assessed. RESULTS: A significant 83% reduction in tobacco smoke pollution levels occurred after passage of the law. Significant reductions in tobacco smoke pollution levels occurred in each of the rural categories; however, no difference by rurality was noted in the analysis after passage of the law, in contrast to the study before passage. CONCLUSIONS: To our knowledge, this was the largest, single, rural postlaw study globally. A comprehensive statewide smoke-free law implemented in North Dakota dramatically decreased the level of tobacco smoke pollution in bars and restaurants.

Electronic Cigarette Refill Liquids: Child-Resistant Packaging, Nicotine Content, and Sales to Minors.

UNLABELLED: To determine the accuracy of the labeled quantity of the nicotine content of the e-liquids sold in unlicensed vape stores, whether the packaging of e-liquids sold within the vape stores was child-resistant, whether minors were present within vape stores, and whether sales to minors occurred. This study was conducted across North Dakota prior to implementation of a new e-cigarette state law and provided a baseline assessment before enactment of the new legal requirements. DESIGN AND METHODS: We tested samples of e-liquids and performed observations in 16 stores that were selling e-cigarettes but were not legally required to be licensed for tobacco retail. The e-liquids were analyzed for nicotine content using a validated high-performance liquid chromatography method for nicotine analysis. RESULTS: Of the 70 collected e-liquid samples that claimed to contain nicotine, 17% contained more than the labeled quantity and 34% contained less than the labeled quantity by 10% or more, with one sample containing 172% more than the labeled quantity. Of the 94 e-liquid containers sampled, only 35% were determined to be child-resistant. Minors were present in stores, although no sales to minors occurred. CONCLUSIONS: Mislabeling of nicotine in e-liquids is common and exposes the user to the harmful effects of nicotine. The lack of child-resistant packaging for this potentially toxic substance is a serious public health problem. E-cigarettes should be included in the legal definition of tobacco products, child-resistant packaging and nicotine labeling laws should be enacted and strictly enforced, and vape stores should be licensed by states.

Tobacco smoke exposure and impact of smoking legislation on rural and non-rural hospitality venues in North Dakota.

The purpose of this cross-sectional study in a stratified random sample of 135 bars and restaurants in North Dakota was to describe factors that influenced tobacco smoke pollution levels in the venues; to compare the quantity of tobacco smoke pollution by rurality and by presence of local ordinances; and to assess compliance with state and local laws. In data collection in 2012, we measured the indoor air quality indicator of particulate matter (2.5 microns aerodynamic diameter or smaller), calculated average smoking density and occupant density, and determined compliance with state and local smoking ordinances using observational methods. As rurality increased, tobacco smoke pollution in bars increased. A significant association was found between stringency of local laws and level of tobacco smoke pollution, but the strength of the association varied by venue type. Compliance was significantly lower in venues in communities without local ordinances. Controlling for venue type, 69.2% of smoke-free policy's impact on tobacco smoke pollution levels was mediated by observed smoking. This study advances scientific knowledge on the factors influencing tobacco smoke pollution and informs public health advocates and decision makers on policy needs, especially in rural areas.

Social justice: a concept analysis.

AIM: This article is a report of an analysis of the concept of social justice. BACKGROUND: Nursing's involvement in social justice has waned in the recent past. A resurgence of interest in nurses' roles about social justice requires a clear understanding of the concept. DATA SOURCES: Literature for this concept analysis included English language articles from CINAHL, PubMed, and broad multidisciplinary literature databases, within and outside of health-related literature, for the years 1968-2010. Two books and appropriate websites were also reviewed. The reference lists of the identified sources were reviewed for additional sources. REVIEW METHODS: The authors used Wilsonian methods of concept analysis as a guide. RESULTS: An efficient, synthesized definition of social justice was developed, based on the identification of its attributes, antecedents and consequences that provides clarification of the concept. Social justice was defined as full participation in society and the balancing of benefits and burdens by all citizens, resulting in equitable living and a just ordering of society. Its attributes included: (1) fairness; (2) equity in the distribution of power, resources, and processes that affect the sufficiency of the social determinants of health; (3) just institutions, systems, structures, policies, and processes; (4) equity in human development, rights, and sustainability; and (5) sufficiency of well-being. CONCLUSION: Nurses can have an important influence on the health of people globally by reinvesting in social justice. Implications for research, education, practice and policy, such as development of a social justice framework and educational competencies are presented.