Positive and Negative Social Consequences of Participating in a Sexual-Network Study.

Assessment of risks and benefits of study participation is standard practice preceding the initiation of human subjects research. Although tracking adverse events during research participation is routine, collecting information from participants about what they perceive as benefits is less common. We longitudinally tracked social risks and benefits of participation among a cohort of 241 men who have sex with men participating in a sexual health study to improve participants' experiences and enhance understanding of participant motivations to enroll and attend follow-up. Of the participants who returned for at least one follow-up visit (n = 217, 90%), most (n = 185, 85%) reported positive consequences resulting from participation. Reporting of negative social consequences was rare, and all concerned a stigmatized reaction from someone learning about the participant's involvement in a sexual health study. Better identification of both positive and negative consequences resulting from research participation may improve how researchers design, recruit, and conduct research.

The impact of fentanyl on state- and county-level psychostimulant and cocaine overdose death rates by race in Ohio from 2010 to 2020: a time series and spatiotemporal analysis.

BACKGROUND: Over the past decade in the USA, increases in overdose rates of cocaine and psychostimulants with opioids were highest among Black, compared to White, populations. Whether fentanyl has contributed to the rise in cocaine and psychostimulant overdoses in Ohio is unknown. We sought to measure the impact of fentanyl on cocaine and psychostimulant overdose death rates by race in Ohio. METHODS: We conducted time series and spatiotemporal analyses using data from the Ohio Public Health Information Warehouse. Primary outcomes were state- and county-level overdose death rates from 2010 to 2020 for Black and White populations. Measures of interest were overdoses consisting of four drug involvement classes: (1) all cocaine overdoses, (2) cocaine overdoses not involving fentanyl, (3) all psychostimulant overdoses, and (4) psychostimulant overdoses not involving fentanyl. We fit a time series model of log standardized mortality ratios (SMRs) using a Bayesian generalized linear mixed model to estimate posterior median rate ratios (RR). We conducted a spatiotemporal analysis by modeling the SMR for each drug class at the county level to characterize county-level variation over time. RESULTS: In 2020, the greatest overdose rates involved cocaine among Black (24.8 deaths/100,000 people) and psychostimulants among White (10.1 deaths/100,000 people) populations. Annual mortality rate ratios were highest for psychostimulant-involved overdoses among Black (aRR = 1.71; 95% CI (1.43, 2.02)) and White (aRR = 1.60, 95% CI (1.39, 1.80)) populations. For cocaine not involving fentanyl, annual mortality rate ratios were similar among Black (aRR = 1.04; 95% CI (0.96,1.16)) and White (aRR = 1.02; 95% CI (0.87, 1.20)) populations. Within each drug category, change over time was similar for both racial groups. The spatial models highlighted county-level variation for all drug categories. CONCLUSIONS: Without the involvement of fentanyl, cocaine overdoses remained constant while psychostimulant overdoses increased. Tailored harm reduction approaches, such as distribution of fentanyl test strips and the removal of punitive laws that influence decisions to contact emergency services, are the first steps to reduce cocaine overdose rates involving fentanyl among urban populations in Ohio. In parallel, harm reduction policies to address the increase in psychostimulant overdoses are warranted.

Associations Between Childhood Sexual Abuse, Intimate Partner Violence Trauma Exposure, Mental Health, and Social Gender Affirmation Among Black Transgender Women.

Introduction: The purpose of this study was to examine associations between social gender affirmation and mental health outcomes. The resulting relationships were explored within the context of childhood sexual abuse (CSA) and intimate partner violence (IPV) trauma history. Materials and Methods: A community sample of 138 Black trans women completed structured interviews assessing gender affirmation, mental health, and trauma history. Bivariate associations between gender affirmation scale and mental health measures were assessed using Pearson coefficients. Multiple linear regression models were used to generate adjusted estimates of association. Results: Childhood sexual victimization and IPV were common. Depressive symptoms, anxiety, quality of life, and body image satisfaction were significantly associated with social gender affirmation. Recent IPV dampened this association to not significant. Gender affirmation and anxiety/panic and quality-of-life outcomes did not retain significance in models adjusted for lifetime IPV. CSA did not weaken the association. Conclusion: Incorporating trauma-informed and gender-affirmative frameworks into medical care and evidence-based interventions is a crucial structural step toward protection of the mental health of Black trans women.

Measurement of Adolescent Dating Violence in Sexual Minority Youth: A Scoping Review.

Effectively addressing adolescent dating violence rests on the quality of its measurement, as that has substantial implications for our understanding of prevalence, correlates, outcomes. Although dating violence is highly prevalent among sexual minority youth, the state of measurement in this population has scarcely been explored. This scoping review presents information on the measurement of adolescent dating violence in exiting studies conducted with sexual minority youth. Three databases were searched, and the ancestry approach was used to identify relevant literature published in the United States between 1992-2022 that included sexual minority adolescents aged 19 years or younger. Twenty-one articles were identified. Five enrolled entirely sexual minority samples. Sexual minority distribution ranged from 2.1%-100%. All studies operationalized sexual identity as an orientation (not sexual behavior, attraction). Nineteen studies focused on measuring dating violence behavior. Twelve reported on female and male victimization, 4 on female and male perpetration and victimization, 2 on female perpetration and victimization, and 2 on female victimization-only. Most commonly used items were from the Youth Risk Behavior Survey (11 studies) and the Conflict in Adolescent Dating Relationships Inventory (3 studies). Two studies assessed knowledge of and attitudes toward dating violence. Domains explored included rape myth acceptance, victim empathy, bystander opportunity, and dating abuse knowledge. Only two scales had undergone previous systematic psychometric evaluation. There was no evidence of cross-cultural validation in sexual minority populations. Rigorous research on adolescent dating violence measurement among sexual minority youth is greatly needed and should be given priority among researchers.

Sexual minorities are not a homogeneous population: health disparity differences based on residence in rural versus urban settings.

INTRODUCTION: Past research has demonstrated that, separately, sexual minorities (SMs) and rural-dwelling populations are each at elevated risk for chronic diseases relative to heterosexuals and urban-dwelling populations, respectively. Little research, however, has assessed whether rural SM populations may experience even further chronic disease risk. METHODS: Data come from the US National Survey on Drug Use and Health, 2015-2019. Survey-weighted logistic regression analyses were used to assess the relationship between sexual identity and various health-associated outcomes, stratified by rural/urban status and adjusted for demographic and other risk factors. RESULTS: Urban bisexual and rural lesbian females had significantly decreased odds of having any health insurance and increased odds of asthma, chronic obstructive pulmonary disease, hepatitis, any heart disease, and STIs relative to their heterosexual counterparts, with disparities affecting bisexual women living in rural areas being largest. Urban gay males had increased odds of having health insurance relative to urban heterosexuals. Both urban gay and bisexual males also experienced increased odds for several chronic diseases, however, among rural residents increased risk was only observed for bisexual males with regards to high blood pressure. CONCLUSION: Rural-dwelling bisexual women experience elevated likelihood for physical health conditions compared to urban-dwelling bisexual women, but few other rural populations experience elevated risk. Urban gay men, meanwhile, are more likely to possess insurance but simultaneously experience worse health outcomes across several domains of diseases, suggesting lower utilization of healthcare services. Future research should strive to avoid pooling all SMs into a single risk group as we have clearly demonstrated that strong differences exist based on both sex and rural/urban status.

PrEP use and stigma among a sample of older adults in Columbus, Ohio.

INTRODUCTION: Despite older adults (age ≥50 years) continuing to account for 1 in 6 new HIV diagnoses, the majority of research has focused on young adults. Assessing PrEP use and stigma among this understudied population is key to achieving the U.S.'s goals of Ending the HIV Epidemic, a federal initiative focusing on reducing new HIV infections by at least 90% by 2030. METHODS: Data for this analysis came from the Columbus Health Aging Project (N = 794). This study was designed to assess several domains of health among adults aged 50 years and older in Columbus, Ohio. Multiple logistic and linear regression models were used to examine the associations between sociodemographic factors and past 6-month PrEP use, PrEP stigma, and concurrent use of PrEP and other prevention methods, adjusting for known confounders. RESULTS: Overall, 93 (11.7%) participants reported past 6-month PrEP use. Transgender women (aOR = 6.90; 95% CI: 2.19, 21.72), cisgender gay men (aOR = 5.58; 95% CI: 2.49, 12.50), cisgender lesbians (aOR = 2.24; 95% CI: 1.05, 4.80), and those living with family members or roommates (aOR = 6.59; 95% CI: 3.49, 12.45) were each more likely to report past 6-month PrEP use relative to cisgender women, heterosexuals, and those living with a spouse/partner, respectively. Relative to cisgender women, PrEP-related stigma was lower among transgender women (ß = -5.05; 95% CI: -8.44, -1.66) and higher among cisgender men (ß = 1.96; 95% CI: 0.46, 3.46). CONCLUSION: Future research should aim to continue developing a firm understanding of PrEP use and stigma among older adults to reduce HIV risk among this population and to understand unique needs of sub-populations of older adults.

Changes in Sexual Behavior Over the COVID-19 Pandemic Among a Community-Based Cohort of Men Who Have Sex With Men in Columbus, Ohio.

BACKGROUND: The purpose was to assess COVID-19 beliefs and attitudes and examine COVID-19-related changes in sexual behavior of men who have sex with men during 3 time periods: April-July 2020 (T1), August-December 2020 (T2), January-May 2021 (T3). METHODS: Data were analyzed from 157 men who have sex with men in Ohio recruited to participate in a longitudinal multisite network study of syphilis epidemiology in 3 US cities: Columbus, Ohio; Baltimore, Maryland; and Chicago, Illinois. In April 2020, a COVID-19 module was appended to existing baseline and follow-up surveys to assess beliefs, attitudes, and changes in sexual behavior. Sample characteristics were summarized. Correlations between demographic variables (age, racial identity) and COVID-19 outcomes were examined. RESULTS: In response to COVID-19 social distancing restrictions and self-reported anxiety, some men limited sexual activity at T1, but the majority (n = 105 [67%]) continued to engage in sex. The number of men engaging in sex increased over time (T2: n = 124 [79%]; T3: n = 121 [77%]). At T1, men not in a relationship more frequently reported having less sex compared with prepandemic (n = 39 [57%]). By T3, men in a relationship more frequently reported less sex (n = 32 [54%]). Increased anxiety about sex and condom use was positively correlated with identifying as a man of color (P < 0.001). Most of the sample reported either starting or increasing online sexual activity during each time period. CONCLUSIONS: Future efforts to target sexual health during a pandemic or other health emergencies should prioritize men of color and address the unique perspective of both single and partnered men.

A Systematic Literature Review of Community-Based Participatory Health Research with Sexual and Gender Minority Communities.

Purpose: The objective was to review sexual and gender minority (SGM) health research studies to gain an understanding of how the community-based participatory research (CBPR) framework has been operationalized. Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct a review of all SGM health research studies published in the past 10 years that cited a CBPR approach (PROSPERO Registration No. CRD42016036608). CINAHL, PubMed, and PsycINFO databases were systematically searched in October 2020. Dimensions of community involvement (e.g., shared decision-making; flexibility to community needs and priorities) and the strength of evidence for each dimension were rated using guidance from the Agency of Healthcare Research and Quality. Results: The 48 eligible articles identified reported a range of 0-11 (out of 13) community elements. Seven studies reported zero elements. Qualitative studies (n=28; 58.3%) had an average quality score of 2.32 (range: 1.43-2.5). The 15 (31.3%) cross-sectional studies had an average quality score of 2.08 (range: 1.64-2.27). Conclusion: Adhering to the CBPR framework is challenging. The benefits of striving toward its principles, however, can move us toward transformative and sustainable social change within SGM communities.

A home-practice intervention for increasing condom use among university undergraduates.

The consistently high rate of sexually transmitted infections among people 18-24 years old warrants novel strategies promoting condom use among large segments of this population. Ample opportunity exits to employ such strategies in university settings. This study evaluated a sex-positive, home-practice intervention designed to promote condom use among university undergraduates engaging in penile-vaginal intercourse (PVI). A sample of 29 opposite-sex undergraduate couples, engaging in PVI, was recruited from a large university. After teaching couples about condom use, a health educator helped couples select condoms/lubricants from options comprising various sizes, fits, shapes, textures, and other features. A 30-day 'homework assignment' was made to use these products while reducing condom use errors/problems and enhancing sexual pleasure. A repeated measures design, with a six-month observation period, was used to evaluate the program. Over the six-month period, the mean frequency of condomless PVI decreased from 26.4 to 3.9 times (P < .001). Significant and favorable changes were also found relative to attitudes toward condom use (P = .027) and in condom use self-efficacy (P < .001). Most students completing the follow-up assessment indicated the intervention would favorably impact their future condom use. Findings suggest this intervention program may be important to promoting condom use among university couples engaging in PVI.

Access to single-visit IUD insertion at obstetrician-gynecology practices in Ohio: An audit study.

OBJECTIVE: Single-visit intrauterine device (IUD) insertion protocols are recommended. We assessed the availability of single-visit IUD insertions, and whether access to these services varies by age, race or parity. STUDY DESIGN: Using audit study methodology, we called a random sample of 396 obstetrician-gynecology practices in Ohio while posing as a potential client seeking an IUD insertion appointment. Callers used eight standardized scripts and noted justifications for protocols offered by clinic staff. Practices were randomized to follow a balanced 3×2 factorial design, whereby practices were assigned to one of two conditions: (1) age (18 vs. 30 years of age); (2) race (white vs. black); and (3) parity. Multivariable logistic regression was used to control for clinics rural vs. urban location while considering the effects of these variables on service provision. RESULTS: Almost all (95%) of the practices called offered IUD placement, of which 92% required multiple appointments for IUD insertion. Although access to single-visit IUD services did not vary by age or race, we found that parity was associated with clinics' willingness to schedule a single-visit insertion visit (OR = 3.84, 95% CI = 1.23, 12.04). The most frequent justification provided by clinic staff for their multiple-appointment protocol was the need to verify insurance coverage or order the device directly through the patient's insurance company. CONCLUSION: Ohio patients seeking IUD placement must typically make more than one clinic visit. IMPLICATIONS: Efforts are needed to reassure Ohio clinics that IUDs are routinely covered by insurers and to increase access to same-day IUD placement for women in Ohio, as the requirement to attend multiple clinics appointments to obtain a desired contraceptive may pose an insurmountable barrier to care for those with the fewest resources.

Relationship power and HIV risk among young Black men who have sex with men in the Southern United States.

Background The purpose of this study was to examine the impact of relationship power on HIV risk behaviour among young Black men who have sex with men (MSM) in the Southern US. METHODS: Data from 425 Black/African American males aged 18-29 years who reported recent anal intercourse with a male partner were analysed. Five selected measures of relationship power were tested for correlation and association with protected receptive anal intercourse using contingency tables and logistic regression analysis. RESULTS: Acts of 100% protected receptive anal intercourse were common (n=277, 65.2%). Men who reported low barriers to condom negotiation were significantly more likely to report protected acts (P<0.001). Men who reported 100% protected acts were less likely to report financial dependence on male sexual partners and serosorting behaviour (12.0% vs 20.7%, P=0.02; 31.5% vs 49.8%, P<0.001 respectively). CONCLUSION: Future efforts should further examine the role of relationship power in HIV risk among young Black MSM, including the intersection of individual, dyadic and social-structure risks.

Attitudes, social norms and perceived behavioral control factors influencing participation in a cooking skills program in rural Central Appalachia.

A focus group session, using the Theory of Planned Behavior to guide questions and discussion, was conducted at midpoint of a 12-month cooking skills program in a rural Appalachian food desert. The purpose of this qualitative study was to determine the attitudes, subjective norms and perceived behavioral control beliefs that influenced participation in these classes. Participants viewed the classes as opportunities for social interaction and to have new experiences. Subjective norms were influenced by family members and traditional cooking. Perceived behavioral control was influenced by the opportunity to try new foods without concern of food waste, acquisition of the knowledge to introduce healthy foods into family meals and enhanced food preparation skills. During the evaluation, a strong sense of participant appreciation of researcher presence was discovered. This unexpected positive component of the program will be promoted using motivational interviewing techniques to enhance adherence to healthy eating behaviors during and after cooking skills programs.

Correlates of sexual-risk behaviors among young black MSM: implications for clinic-based counseling programs.

This study applied an 8-item index of recent sexual-risk behaviors to young Black men who have sex with men (YBMSM) and evaluated the distribution for normality. The distribution was tested for associations with possible antecedents of sexual risk. YBMSM (N = 600), aged 16-29 years, were recruited from a sexually transmitted infection clinic, located in the southern US. Men completed an extensive audio computer-assisted self-interview. Thirteen possible antecedents of sexual risk, as assessed by the index, were selected for analyses. The 8-item index formed a normal distribution with a mean of 4.77 (SD = 1.77). In adjusted analyses, not having completed education beyond high school was associated with less risk, as was having sex with females. Conversely, meeting sex partners online was associated with greater risk, as was reporting that sex partners were drunk during sex. The obtained normal distribution of sexual-risk behaviors suggests a corresponding need to "target and tailor" clinic-based counseling and prevention services for YBMSM. Avoiding sex when partners are intoxicated may be an especially valuable goal of counseling sessions.

Experiences of Antihomosexual Attitudes and Young Black Men Who Have Sex with Men in the South: A Need for Community-Based Interventions.

PURPOSE: In 2012, Jackson, Mississippi, had the third highest incidence rate of human immunodeficiency virus (HIV) among young Black men who have sex with men (MSM). The goal of this qualitative study (the initial phase of an HIV prevention clinical trial) was to explore how cultural norms regarding antihomosexual attitudes interfere with the safe sex practices and relationship norms of young Black MSM in Mississippi. METHODS: Nine focus groups (N = 54) were conducted with young Black MSM aged 18-29. Participants were recruited through medical providers at local sexually transmitted infection clinics and through community organizers at local LGBT outreach programs. The data were analyzed through the use of grounded theory, multiple coders for consistency and intercoder reliability, and a qualitative data analysis software. RESULTS: Three major themes were identified during the analysis: (1) resiliency and condom use, (2) inconsistent condom use among closeted young Black MSM, and (3) intimate partner violence (IPV) among closeted young Black MSM. Black MSM in Mississippi continue to be highly stigmatized within their social networks (i.e., families, sexual partners, and community). CONCLUSIONS: The findings suggest that cultural and community norms regarding antihomosexual attitudes may be a barrier to the practices of safe sex and a contributing factor to IPV among young Black MSM. There is a need for tailored interventions that address these cultural norms and establish social and community support for young Black MSM in Mississippi.

Acceptance of and experiences utilising expedited partner therapy among African-American juvenile girls.

UNLABELLED: Background The aim of this study was to describe acceptance of and experiences utilising expedited partner therapy (EPT) among African-American girls recruited from short-term juvenile detention centres. METHODS: Ninety-five detained African-American girls (aged 13-17 years) completed audio computer-assisted self-interviews (ACASI) and self-collected vaginal swab specimens assayed for chlamydia and gonorrhoea. EPT was offered to sexually transmissible infection (STI)-positive participants (n=51); follow-up phone interviews assessed medication delivery to partners. Summary statistics described EPT acceptance frequency. Generalised estimating equations assessed correlates of acceptance. Nine semi-structured interviews elicited EPT experiences. RESULTS: EPT was offered 69 times, accepted by 70% (n=37) girls and provided to 68% (n=36) of girls. Acceptance was significantly associated with sexual risk behaviours such as infrequent partner STI prevention discussion (OR=3.2, 95% CI: 1.0,-10.1, P=0.048) and≥4 lifetime sex partners (OR=3.3, 95% CI: 1.0-11.0, P=0.048). Discontinued relationships were the most common barrier to EPT acceptance. Emergent interview themes included sense of responsibility, which appeared to motivate acceptance and help overcome identified discomfort with partner disclosure conversations. CONCLUSIONS: Future research is needed to determine EPT efficacy among African-American juvenile populations and feasibility of its use outside of research settings.

Developmental investigation of age at sexual debut and subsequent sexual risk behaviours: a study of high-risk young black males.

UNLABELLED: Background The purpose of this study was to identify unmediated associations of early sexual debut (ESD) on the current safer sex practices of young Black men (YBM). METHODS: A cross-sectional study of YBM (n=697) attending clinics treating sexually transmissible diseases (STIs) in three cities was conducted. ESD was dichotomised at the age of 13 years and under. A series of regression models were used to test the moderating effects of ESD and perceived parental monitoring (PPM). A regression model also tested the effect of years of sexual experience (YSE) on sexual risk behaviours, while controlling for ESD. RESULTS: Mean age of debut was 13.95 years. ESD results varied with significance for pregnancy (P<0.001), sexual partners (P<0.001), and ever having chlamydia (assessed by self report), but this final association was only found for older males (P=0.03). PPM held no moderating effect on any of the sexual risk outcomes. YSE was correlated with an increase in recent unprotected vaginal sex (AOR=1.19, 95%CI=1.10-1.27) and having a pregnant partner at the time of enrolment (AOR=1.30, 95%CI=1.17-1.43). CONCLUSIONS: The findings provide mixed evidence for unmediated associations of ESD among young Black males. The study strongly posits that ESD may actually be a mediating variable rather than a causal explanation for sexual risk. The findings also suggest that advancing YSE foster diminishing vigilance in safer sex practices. These outcomes should be utilised to inform intervention development.

Creating Effective Media Messaging for Rural Smoke-free Policy.

OBJECTIVES: Objectives were to (1) explore perceived effectiveness of existing smoke-free print advertisements in rural communities and (2) generate message content, characteristics, and media delivery channels that resonate with residents. DESIGN AND SAMPLE: Qualitative methods design. Thirty-nine rural adults recruited by community partners. MEASURES: Content analysis of findings from individuals in four focus groups who participated in general discussion and reviewed eight print ads related to secondhand smoke (SHS) and smoke-free policy. RESULTS: Six content themes were identified: smoking/SHS dangers, worker health, analogies, economic impact, rights, and nostalgia. Seven message characteristics were recognized: short/to the point, large enough to read, graphic images, poignant stories, statistics/charts/graphs, message sender, and messages targeting different groups. Four media delivery channels were considered most effective: local media, technology, billboard messages, and print materials. CONCLUSIONS: Seeking input from key informants is essential to reaching rural residents. Use of analogies in media messaging is a distinct contribution to the literature on effective smoke-free campaigns. Other findings support previous studies of effective messaging and delivery channels. Further research is needed to examine effectiveness of themes related to message content in smoke-free ads and delivery strategies. Effective media messaging can lead to policy change in rural communities to reduce exposure to SHS.

Elevated sexual risk behaviors among postincarcerated young African American males in the South.

The dramatic racial disparities in the rates of HIV/STIs(sexually transmitted infections) among African Americans make understanding broader structural factors that increase the risk for HIV/STIs crucial. The current study of young 564 African American men attending STI clinics investigated whether those who had ever been incarcerated reported recent sexual behaviors relatively more risky than their counterparts who had never been incarcerated. Participants were recruited from clinics treating STIs in three southern U.S. cities. Males 15 to 23 years of age who identified as Black/African American and reported recent (past 2 months) sexual activity were eligible. Linear mixed-effects models and generalized estimating equation models were used to assess associations between baseline incarceration history and sexual risk behavior over a 6-month follow-up period. Mean age was 19.6 years (SD = 1.87). At baseline, 240 (42.6%) men reported history of incarceration. Incarceration history predicted several risk behaviors over a 6-month follow-up period. Compared with those with no incarceration history, men previously incarcerated reported a desire to conceive a pregnancy (ß = .40, p = .02), were less likely to have used a condom at last sex act (odds ratio = .91, p = .02) and were more likely to have used drugs and alcohol before sex in the past 2 months (ß = .69, p < .001; ß = .41, p < .001). A history of incarceration may influence the sexual risk behavior of young African American males. Prevention programs and interventions should intensify support for postincarceration African American males to help mitigate this behavior.

"It's just a way of fitting in:" Tobacco use and the lived experience of lesbian, gay, and bisexual appalachians.

UNLABELLED: Lesbian, gay, and bisexual (LGB) people are affected by multiple health disparities and risk factors, including tobacco use. Few studies to date have examined tobacco use specifically in rural LGB populations, and none has investigated the intersections of identity, rural LGB culture, and tobacco. The purpose of this study was to explore the perspective of Appalachian LGB people regarding tobacco use. METHODS: . Nineteen LGB-identified Appalachian residents participated in audiotaped, semi-structured interviews. Two authors analyzed and coded transcripts through constant comparison, and determined themes through consensus. RESULTS: Five themes emerged: the convergence of Appalachian and LGB identities, tacit awareness of LGB identity by others, culture and tobacco use, perceived associations with tobacco use, and health beliefs and health care. CONCLUSIONS: LGB Appalachians connect stress and culture to tobacco, but seem less aware that partial concealment of their identity might be a source of the stress that could influence their smoking.