Self-reported knowledge of tetrahydrocannabinol and cannabidiol concentration in cannabis products among cancer patients and survivors.

PURPOSE: Cannabis use may introduce risks and/or benefits among people living with cancer, depending on product type, composition, and nature of its use. Patient knowledge of tetrahydrocannabinol (THC) or cannabidiol (CBD) concentration could provide information for providers about cannabis use during and after treatment that may aide in risk and benefit assessments. This study aimed to examine knowledge of THC or CBD concentration among patients living with cancer who consume cannabis, and factors associated with knowledge of cannabinoid concentrations. METHODS: People living with cancer who consumed cannabis since their diagnosis (n = 343) completed an anonymous, mixed-mode survey. Questions assessed usual mode of delivery (MOD), knowledge of THC/CBD concentration, and how source of acquisition, current cannabis use, and source of instruction are associated with knowledge of THC/CBD concentration. Chi-square and separate binary logistic regression analyses were examined and weighted to reflect the Roswell Park patient population. RESULTS: Less than 20% of people living with cancer had knowledge of THC and CBD concentration for the cannabis products they consumed across all MOD (smoking- combustible products, vaping- vaporized products (e-cigarettes), edibles-eating or drinking it, and oral- taking by mouth (pills)). Source of acquisition (smoking-AOR:4.6, p < 0.01, vaping-AOR:5.8, p < 0.00, edibles-AOR:2.6, p < 0.04), current cannabis use (edibles-AOR:5.4, p < 0.01, vaping-AOR: 11.2, p < 0.00, and oral-AOR:9.3, p < 0.00), and source of instruction (vaping only AOR:4.2, p < 0.05) were found to be variables associated with higher knowledge of THC concentration. CONCLUSION: Self-reported knowledge of THC and CBD concentration statistically differed according to MOD, source of acquisition, source of instruction, and current cannabis use.

Youth Use of e-Cigarette Flavor and Device Combinations and Brands Before vs After FDA Enforcement.

Importance: The US Food and Drug Administration's Center for Tobacco Products (CTP) prioritized its enforcement efforts against nontobacco, nonmenthol (ie, sweet)-flavored cartridge e-cigarettes in February 2020. Within-person e-cigarette initiation, continuation, and switching behaviors among youth are unknown following CTP's prioritized enforcement efforts. Objective: To describe transitions in youths' e-cigarette flavor/device combination use, brand use, nicotine use, and frequency of use following CTP's e-cigarette enforcement prioritization. Design, Setting, and Participants: The US population-based, nationally representative Population Assessment of Tobacco and Health cohort study included data collected in 2019 and 2021 from youth aged 12 to 17 years. The data were analyzed from February to June 2023. Exposure: e-cigarette use (past 30 days), flavor/device combination used, brand used, nicotine use, and frequency of use. Main Outcomes and Measures: Transitions in e-cigarette use, flavor/device combination used, brand used, nicotine use, and frequency of use between 2019 and 2021 among 9088 youth aged 12 to 17 years in 2019; prevalence of e-cigarette use, flavor/device combination used, and brand used in 2019 (n = 8771) and 2021 (n = 5574) among youth aged 14 to 17 years in each year. Results: The 2019 sample included 8771 youth. The population of those aged 12 to 17 years was 49.0% female (95% CI, 48.7%-49.3%) and 51.0% male (95% CI, 50.8%-51.3%). Participants were 15.4% Black (95% CI, 15.0%-15.7%), 24.1% Hispanic (95% CI, 23.9%-24.4%), 75.9% non-Hispanic (95% CI, 75.6%-76.1%), 69.1% White (95% CI, 68.5%-69.8%), and 15.5% another race (95% CI, 14.9%-16.1%). Among youth ages 12 to 17 years who did not use e-cigarettes in 2019, 531 (6.5%) initiated use in 2021 (95% CI, 5.9%-7.1%); among them, 415 (76.8%) initiated with a combination other than a sweet cartridge (95% CI, 72.2%-80.8%). Among youth ages 12 to 17 who used e-cigarettes in 2019, 360 (47.8%) continued use in 2021 (95% CI, 44.0%-51.1%). Continuation rates were similar for those who used sweet-cartridge e-cigarettes (144 [51.5%]; 95% CI, 45.7%-57.3%) and those who used other combinations (204 [47.6%]; 95% CI, 42.8%-52.4%) in 2019. Among those who continued e-cigarette use in 2021, 121 (84.0%) of those who used sweet-cartridge e-cigarettes in 2019 switched to a different combination (95% CI, 77.0%-89.2%). Overall, among youth who used e-cigarettes in 2021, 177 (53%) used a sweet-disposable combination, 32 (11%) used a sweet-cartridge, and no individual brand was used by more than 10%. Conclusions and Relevance: The results of this longitudinal cohort study of youth in the US suggest that most youth who initiated or continued e-cigarette use in 2021 used flavor/device combinations that were excluded from CTP's enforcement priorities. Restrictions and enforcement efforts that only cover a subset of products may be ineffective at preventing youth flavored e-cigarette use.

Use of Electronic Nicotine Delivery Systems or Cigarette Smoking After US Food and Drug Administration-Prioritized Enforcement Against Fruit-Flavored Cartridges.

Importance: The Center for Tobacco Products (CTP) of the US Food and Drug Administration prioritized its enforcement efforts against non-tobacco-, non-menthol- (fruit-) flavored cartridge electronic nicotine delivery systems (ENDS) in February 2020. Objective: To evaluate adults' use of ENDS and cigarette smoking following the CTP's prioritized enforcement efforts against fruit-flavored cartridge ENDS. Design, Setting, and Participants: In this population-based, nationally representative US cohort study, data were collected from the Population Assessment of Tobacco and Health Study from December 2018 to November 2019 (hereafter referred to as 2019) and/or from September 2020 to December 2020 (Adult Telephone Survey, hereafter referred to as 2020). Adults (aged ≥21 years) who used ENDS in the past 30 days and smoked cigarettes in the past 30 days or quit smoking cigarettes in the past year (n = 3173) were evaluated. Data were analyzed from January 1, 2022, to May 2, 2023. Exposure: ENDS flavor-device combinations used. Main Outcomes and Measures: Outcome measures were cross-sectional prevalence of ENDS flavor-device combinations used in 2019 (n = 2654) and 2020 (n = 519) and longitudinal transitions in cigarette smoking (cessation [no smoking in the past 30 days in 2020 among those who smoked in 2019; n = 876] and relapse [smoking in the past 30 days in 2020 among those who recently quit in 2019; n = 137]) as a function of ENDS flavor-device combination used in 2019. Results: The sample in 2019 included 2654 individuals (55% male [95% CI, 53%-58%]). Among those who used ENDS and smoked cigarettes, fruit-flavored cartridge ENDS use decreased from 13.9% (95% CI, 12.1%-15.9%) in 2019 to 7.9% (95% CI, 5.1%-12.1%) in 2020 (P = .01), whereas fruit-flavored disposable ENDS use increased from 4.0% (95% CI, 3.1%-5.1%) in 2019 to 14.5% (95% CI, 11.6%-18.0%) in 2020 (P < .001). Patterns were similar among those who recently quit smoking. Neither cigarette cessation nor relapse rates differed between those who used ENDS that were vs were not prioritized for enforcement efforts (cessation: 23.4% [95% CI, 18.1%-29.7%] vs 26.4% [95% CI, 22.4%-30.8%]; adjusted odds ratio, 1.12; 95% CI, 0.57-2.21; relapse: 32.7% [95% CI, 17.1%-53.4%] vs 29.8% [95% CI, 20.3%-41.3%]; adjusted odds ratio, 0.96; 95% CI, 0.24-3.84). Conclusions and Relevance: In this nationally representative US cohort study of adults who smoked cigarettes and used ENDS, fruit-flavored cartridge ENDS use was nearly halved between 2019 and 2020. Cigarette cessation and relapse rates did not differ between those who used ENDS targeted by CTP and those who used other ENDS.

Electronic nicotine delivery systems (ENDS) flavours and devices used by adults before and after the 2020 US FDA ENDS enforcement priority: findings from the 2018 and 2020 US ITC Smoking and Vaping Surveys.

BACKGROUND: In February 2020, the US Food and Drug Administration (FDA) prioritised enforcement efforts against flavoured prefilled cartridge/pod electronic nicotine delivery systems (ENDS), with the exception of tobacco and menthol. This study examined changes between prepriority enforcement (2018) and early postenforcement (February-June 2020) among adults on: ENDS flavours and devices used most often; location of last purchase of fruit/other-flavoured cartridges (covered under the enforcement priority); and smoking and vaping. METHODS: Prevalence estimates came from 1608 adult frequent (≥weekly) ENDS users (current smokers (n=1072), ex-smokers (n=536)) who participated in the 2018 and/or 2020 US ITC Smoking and Vaping Surveys. Transitions between flavours/devices and changes in smoking/vaping were assessed among baseline respondents who were followed up in 2020 (n=360). Respondents self-reported the ENDS device (disposable, cartridge/pod or tank) and the flavor that they used most often: (1) tobacco flavors (tobacco/tobacco-menthol mix) or unflavored; (2) menthol/mint; (3) fruit/other flavors. RESULTS: Compared to 2018, in the first 5 months of the 2020 enforcement priority, there were significant increases in the prevalence of fruit/other-flavoured cartridges (7.9% to 12.4%,p=0.026) and menthol/mint cartridges (7.1% to 13.0%, p<0.01) and decreases in tobacco-flavoured tanks (15.5% to 10.0%,p=0.002) and fruit/other-flavoured tanks (38.7% to 33.6%,p=0.038). Fewer than 10% of adults used disposables in 2018 and 2020. Among the cohort sample, the most pronounced transitions between flavours/devices occurred among those who used flavoured cartridges covered under the enforcement priority (54.6% switched to a flavour and/or device excluded from enforcement). There was an increase in purchasing fruit/other-flavoured cartridges online and a decrease in retail locations except for vape shops. Overall, there were few changes in smoking and vaping behaviours. CONCLUSIONS: Between 2018 and the early phase of the FDA's 2020 enforcement priority, prevalence of menthol/mint and fruit/other-flavoured cartridges increased among adults. Half of vapers using cartridge flavours covered in the enforcement switched to other flavours and/or devices that were exempt, with the exception of disposables. The extent to which more comprehensive restrictions may be problematic for adults who prefer a range of ENDS flavours remains uncertain.

Transcranial Magnetic Stimulation for Long-Term Smoking Cessation: Preliminary Examination of Delay Discounting as a Therapeutic Target and the Effects of Intensity and Duration.

Background: Repetitive transcranial magnetic stimulation (rTMS) is a novel treatment for smoking cessation and delay discounting rate is novel therapeutic target. Research to determine optimal therapeutic targets and dosing parameters for long-term smoking cessation is needed. Due to potential biases and confounds introduced by the COVID-19 pandemic, we report preliminary results from an ongoing study among participants who reached study end prior to the pandemic. Methods: In a 3 × 2 randomized factorial design, participants (n = 23) received 900 pulses of 20 Hz rTMS to the left dorsolateral prefrontal cortex (PFC) in one of three Durations (8, 12, or 16 days of stimulation) and two Intensities (1 or 2 sessions per day). We examined direction and magnitude of the effect sizes on latency to relapse, 6-month point-prevalence abstinence rates, research burden, and delay discounting rates. Results: A large effect size was found for Duration and a medium for Intensity for latency to relapse. Increasing Duration increased the odds of abstinence 7-8-fold while increasing Intensity doubled the odds of abstinence. A large effect size was found for Duration, a small for Intensity for delay discounting rate. Increasing Duration and Intensity had a small effect on participant burden. Conclusion: Findings provide preliminary support for delay discounting as a therapeutic target and for increasing Duration and Intensity to achieve larger effect sizes for long-term smoking cessation and will provide a pre-pandemic comparison for data collected during the pandemic. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [NCT03865472].

Cardiovascular Outcomes among Combustible-Tobacco and Electronic Nicotine Delivery System (ENDS) Users in Waves 1 through 5 of the Population Assessment of Tobacco and Health (PATH) Study, 2013-2019.

BACKGROUND: Prior studies have not clearly established risk of cardiovascular disease (CVD) among smokers who switch to exclusive use of electronic nicotine delivery systems (ENDS). We compared cardiovascular disease incidence in combustible-tobacco users, those who transitioned to ENDS use, and those who quit tobacco with never tobacco users. METHODS: This prospective cohort study analyzes five waves of Population Assessment of Tobacco and Health (PATH) Study data, Wave 1 (2013-2014) through Wave 5 (2018-2019). Cardiovascular disease (CVD) incidence was captured over three intervals (Waves 1 to 3, Waves 2 to 4, and Waves 3 to 5). Participants were adults (40+ years old) without a history of CVD for the first two waves of any interval. Change in tobacco use status, from exclusive past 30 day use of any combustible-tobacco product to either exclusive past 30 day ENDS use, dual past 30 day use of ENDS and combustible-tobacco, or no past 30 day use of any tobacco, between the first two waves of an interval was used to predict onset of CVD between the second and third waves in the interval. CVD incidence was defined as a new self-report of being told by a health professional that they had congestive heart failure, stroke, or a myocardial infarction. Generalized estimating equation (GEE) analyses combined 10,548 observations across intervals from 7820 eligible respondents. RESULTS: Overall, there were 191 observations of CVD among 10,548 total observations (1.7%, standard error (SE) = 0.2), with 40 among 3014 never users of tobacco (1.5%, SE = 0.3). In multivariable models, CVD incidence was not significantly different for any tobacco user groups compared to never users. There were 126 observations of CVD among 6263 continuing exclusive combustible-tobacco users (adjusted odds ratio [AOR] = 1.44; 95% confidence interval (CI) 0.87-2.39), 15 observations of CVD among 565 who transitioned to dual use (AOR = 1.85; 0.78-4.37), and 10 observations of CVD among 654 who quit using tobacco (AOR = 1.18; 0.33-4.26). There were no observations of CVD among 53 who transitioned to exclusive ENDS use. CONCLUSIONS: This study found no difference in CVD incidence by tobacco status over three 3 year intervals, even for tobacco quitters. It is possible that additional waves of PATH Study data, combined with information from other large longitudinal cohorts with careful tracking of ENDS use patterns may help to further clarify this relationship.

Daily Cannabis Use Is a Barrier to Tobacco Cessation Among Tobacco Quitline Callers at 7-Month Follow-up.

INTRODUCTION: Cannabis use is increasing among cigarette smokers in the United States. Prior studies suggest that cannabis use may be a barrier to smoking cessation. Yet, the extent to which this is the case among adults seeking to quit tobacco use remains unclear. Tobacco quitlines are the most common provider of no-cost treatment for adults who use smoke in the United States. This study investigated the association between cannabis use and smoking cessation outcomes among quitline callers. AIMS AND METHODS: Participants included callers to the New York State Smokers' Quitline, who were seeking to quit smoking cigarettes and were contacted for outcome assessment 7 months after intake. Thirty-day point prevalence abstinence rates were calculated and compared among cannabis use groups, based on frequency of past-30-day cannabis use at baseline (none: 0 days, occasional: 1-9 days, regular: 10-19 days, and daily: 20-30 days). RESULTS: Approximately 8.3% (n = 283) of participants (n = 3396) reported past-30-day cannabis use at baseline. Callers with daily cannabis use (20-30 days per month) had significantly lower odds of 30-day abstinence, relative to those who did not use cannabis (odds ratio = 0.5; 95% confidence interval [0.3, 0.9]). CONCLUSIONS: Daily cannabis use appears to be associated with poorer smoking cessation treatment outcomes among adults seeking to quit smoking cigarettes via a quitline. Because quitlines are among the most accessible, affordable, and frequently utilized community-based treatments available in the United States, and the prevalence of cannabis use is increasing among cigarette smokers, detailed inquiry into cannabis use might enhance cigarette smoking cessation outcomes. IMPLICATIONS: Quitlines are free of cost and accessible to millions of smokers in the United States. The current study found an inverse relationship between daily cannabis use at baseline and 30-day abstinence from cigarette smoking at 7-month follow-up among New York State Smokers' Quitline callers. Findings suggest that daily cannabis use may be a barrier to smoking cessation and sustained abstinence among those seeking help to stop smoking cigarettes.

Factors associated with changes in flavored tobacco products used: Findings from wave 2 and wave 3 (2014-2016) of the population assessment of tobacco and health (PATH) study.

INTRODUCTION: Flavored non-cigarette tobacco product use is widespread in the U.S. The availability of flavor options could be playing a role in recent increases in use, especially for non-cigarette tobacco products, among youth and young adults. Little is known about specific flavor preferences of youth and adult flavored tobacco product users, as well as how preferences may change over time. METHODS: This study analyzes PATH Study data from completed Wave 2 (2014-2015) and Wave 3 (2015-2016) youth (12-17 years), and adult (18 + years) interviews to estimate the prevalence of flavored non-cigarette tobacco product use. We assess flavor switching by examining changes between flavors and characteristics of those who changed flavors between waves. RESULTS: Across age groups, and at both waves, fruit-flavored products were the most frequently used flavor by past 30-day electronic nicotine delivery systems (ENDS), cigar, cigarillo, and hookah users. In the past 30 days, a higher proportion of youth and young adults used candy/sweets-flavored ENDS than adults. Among adult ENDS users, the odds of changing flavors were highest among younger users and decreased with increasing age. CONCLUSIONS: Flavored tobacco product use is prevalent across non-cigarette tobacco products. Stability in the number of flavors used, as well as specific flavors, is higher among adult tobacco users, while the use of multiple flavors, and change in specific flavor, is more prevalent among youth tobacco users. Additional longitudinal research can further examine the role flavors play in appeal, product trial, and switching.

Home Tobacco Use Policies and Exposure to Secondhand Tobacco Smoke: Findings from Waves 1 through 4 of the Population Assessment of Tobacco and Health (PATH) Study.

BACKGROUND: The 2006 Surgeon General's Report recommended the elimination of smoking in homes as an effective protective measure against the harmful effects of secondhand tobacco smoke exposure. This study aims to examine trends in the prevalence and levels of the adoption of home tobacco use policies specifically for cigarettes, e-cigarettes, smokeless tobacco, and the relationships between home tobacco use policies and self-reported exposure to secondhand tobacco smoke. METHODS: This study utilizes data from Wave 1 (2013-2014) through Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health (PATH) Study, a large prospective cohort study of youths and adults in the United States which collected information about both smoke-free and tobacco-free home policies. We present the weighted, population-based, self-reported prevalence of home tobacco use policies overall and by product, and the average number of self-reported hours of secondhand smoke (SHS) exposure by levels of home tobacco policy and by survey wave. In addition, we examine the characteristics of those who adopted (by yes or no) a home tobacco use ban between survey waves. RESULTS: We found a high prevalence of completely tobacco-free home policies (69.5%). However, 10.6% of adults allow the use of any type of tobacco product inside their homes, and 19.8% have a policy allowing the use of some types of tobacco products and banning the use of others. Adults with a complete tobacco use ban inside their homes were more likely to be nonusers of tobacco (79.9%); living with children in the home (71.8%); at or above the poverty level (70.8%); non-white (76.0%); Hispanic (82.7%); and aged 45 or older (71.9%). The adoption of 100% tobacco-free home policies is associated with a 64% decrease in secondhand smoke exposure among youths and a 69% decrease in exposure among adults. CONCLUSIONS: Most US adults have implemented tobacco-free home policies; however, there is still exposure to SHS in the home, for both adults and children, particularly in the homes of tobacco users. Additional research should investigate tobacco-free home policies for different types of products and what effect they have on future tobacco use behaviors.

Cardiovascular Risk Factor and Disease Measures from the Population Assessment of Tobacco and Health (PATH) Study.

BACKGROUND: Cardiovascular disease is a key health condition associated with tobacco use; however, clinical measures are not typically possible in population-based studies. In this paper, we assess the reliability and validity of self-reported cardiovascular risk factors and diseases in a large nationally representative study of tobacco use and health outcomes. METHODS: This paper analyzes self-reported cardiovascular risk factors and disease among adults age 40 years and older based on U.S. nationally representative data from the Population Assessment of Tobacco and Health (PATH) Study. Prevalence of cardiovascular risk factors (self-reported high blood pressure, high cholesterol, diabetes and family history of premature heart disease, BMI ≥ 35, and tobacco use) and cardiovascular disease (self-reported heart attack, stroke and/or congestive heart failure (CHF)) were considered along with ratings of physical functioning, fatigue, and general health. RESULTS: Self-reported cardiovascular disease was found to be associated with functional health measures (walking up a flight of stairs) and general ratings of health. Prospective analyses found strong correlations between sequential data collection waves for history of hypertension, elevated cholesterol and CHF, while more modest correlations were noted for stroke and heart attack. The overall prevalence of cardiovascular disease and hypertension was comparable to those from the National Health and Nutrition Examination Survey (NHANES). CONCLUSIONS: These analyses suggest reliability and concurrent validity regarding self-reported cardiovascular risk factors and disease assessed in the PATH Study.

Biomarkers of Exposure among USA Adult Hookah Users: Results from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014).

Hookah smoking has become common in the USA, especially among young adults. This study measured biomarkers of exposure to known tobacco product toxicants in a population-based sample of exclusive, established hookah users. Urinary biomarker data from 1753 adults in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study were used to compare geometric mean concentrations of biomarkers of exposure in exclusive, established past 30-day hookah users to never users of tobacco. Geometric mean ratios were calculated comparing hookah user groups with never users adjusting for age, sex, race/ethnicity, education, past 30-day marijuana use, secondhand smoke exposure and creatinine. Past 30-day hookah users (n = 98) had 10.6 times the urinary cotinine level of never tobacco users. Compared to never tobacco users, past 30-day hookah users had 2.3 times the level of the carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a metabolite of the tobacco-specific nitrosamine (TSNA) 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), 1.3 times higher polycyclic aromatic hydrocarbons (PAHs) 3-hydroxyfluorene and 1-hydroxypyrene, 1.8 times higher levels of acrylonitrile, 1.3 times higher levels of acrylamide, and 1.2 times higher levels of acrolein exposure. These data indicate that hookah use is a significant source of exposure to nicotine, carcinogens, and respiratory toxicants.

Dosing parameters for the effects of high-frequency transcranial magnetic stimulation on smoking cessation: study protocol for a randomized factorial sham-controlled clinical trial.

BACKGROUND: Despite the considerable success of comprehensive tobacco control efforts, tobacco use remains one of the greatest preventable causes of death and disease today. Over half of all smokers in the US make quit attempts every year, but over 90% relapse within 12 months, choosing the immediate reinforcement of smoking over the long-term benefits of quitting. Conceptual and empirical evidence supports continued investigation of high frequency repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex in reducing relapse and decreasing cigarette consumption. While this evidence is compelling, an optimal dosing strategy must be determined before a long-term efficacy trial can be conducted. The goal of this study is to determine a dosing strategy for 20 Hz rTMS that will produce the best long-term abstinence outcomes with the fewest undesirable effects. METHODS: This is a fully crossed, double-blinded, sham-controlled, 3x2x2 randomized factorial study. The three factors are duration (stimulation days: 8, 12, and 16); intensity (900 or 1800 pulses per day); and sham control. Participants (n = 258) will consist of adults (18-65) who are motivated to quit smoking cigarettes and who will be followed for 6 months post-quit. Outcomes include latency to relapse, point prevalence abstinence rates, delay discounting rates, cognitive-behavioral skills acquisition, and multiple measures of potential undesirable effects that impact participant compliance. DISCUSSION: This study integrates existing theoretical concepts and methodologies from neuropsychology, behavioral economics, brain stimulation, clinical psychology, and the evidence-based treatment of tobacco dependence in the development of a promising and innovative approach to treat tobacco dependence. This study will establish an optimal dosing regimen for efficacy testing. Findings are expected to have a significant influence on advancing this approach as well as informing future research on clinical approaches that combine rTMS with other evidence-based treatments for tobacco dependence and perhaps other addictions. TRIAL REGISTRATION: Clinical Trials NCT03865472 (retrospectively registered). The first participant was fully enrolled on November 26, 2018. Registration was posted on March 7, 2019.

The treasure of now and an uncertain future: Delay discounting and health behaviors among cancer survivors.

BACKGROUND: The identification of new therapeutic targets to improve health behaviors among cancer survivors (CS) is likely to improve cancer treatment outcomes. Delay discounting (DD) rate is the degree to which one devalues rewards as a function of time to receipt. Lower DD rates (ie, prioritizing long-term over immediate rewards) are associated with healthier behaviors. CS often experience distress and thoughts of early mortality that can potentially shift priorities to the present and negatively impact DD rates, especially when newly diagnosed. Understanding relations between DD and health behaviors among CS will contribute to the examination of DD as a therapeutic target for improving health behaviors for CS. METHOD: CS (n = 1001) were recruited from a web panel and administered a web-based questionnaire. Multivariate models examined relations among DD rate, years since diagnosis, and 10 health behavior indicators. We hypothesized that 1) higher DD rates would be associated with fewer years since diagnosis, and 2) lower DD rates would be associated with healthier behaviors, moderated by years since diagnosis. RESULTS: In general, higher DD rates were associated with fewer years since diagnosis. Higher DD rates were associated with more alcohol consumption, cigarette smoking, other tobacco use, tanning booth use, and conversely, greater adherence to annual primary care visits. A significant interaction between DD rate and years since diagnosis was not found. CONCLUSION: Lower DD rates are associated with several important healthy lifestyle behaviors. DD rate is a promising therapeutic target for new interventions to improve multiple health behaviors among CS.

Developing Community-Based Primary Health Care for Complex and Vulnerable Populations in the Vancouver Coastal Health Region: HealthConnection Clinic.

INTRODUCTION: Designing, delivering, and evaluating high-performing primary health care services for complex and vulnerable subpopulations are challenging endeavors. However, there is a relative paucity of research evidence available to support such work. OBJECTIVE: To provide a case study using HealthConnection Clinic, a public primary care center located in Metropolitan Vancouver's North Shore. METHODS: Developmental evaluation approach operationalizing the 10 Building Blocks of High-Performing Primary Care framework using qualitative and quantitative methods. RESULTS: The clinic provided valuable insights to policymakers and researchers related to development of the Building Blocks' foundational elements, particularly engaged leadership, empanelment, and data-driven improvement. The study highlighted the key enablers, achievements, challenges, and barriers related to operationalizing each Building Block. The Building Blocks were a useful heuristic that enabled the development and evaluation of primary care for complex subpopulations. Particularly salient from a Canadian policy perspective was the demonstration that system integration was possible when highly engaged leaders from a Regional Health Authority and a Division of Family Practice shared a common vision and purpose. HealthConnection Clinic's entrepreneurial spirit has enabled the development of innovative, evidence-based tools such as the AMPS complexity assessment tool (attachment, medical conditions, psychological/mental health/addictions challenges, and socioeconomic status), designed to identify and assess biopsychosocial complexity and needs. The study also highlighted the importance of incorporating community orientation and equity into developmental work. CONCLUSION: The study demonstrates how the Building Blocks approach can be adapted to operationalize high-performing primary care standards in settings serving complex and vulnerable populations.

Internalized smoking stigma in relation to quit intentions, quit attempts, and current e-cigarette use.

BACKGROUND: Reducing the social acceptability of smoking is associated with lowered smoking prevalence. However, denormalization strategies can also contribute to the stigmatization that some smokers may feel about their smoking. Smoking stigma may be more acute if smokers are also members of other stigmatized groups, such as racial/ethnic minorities. This study examined correlates of smoking self- and felt-stigma and discrimination, among current smokers. METHODS: Participants were recruited in the United States via a national commercial consumer panel to complete a cross-sectional, Web-based survey. Participants were 1528 current cigarette smokers aged 14 and older. Measures included the Internalized Stigma of Smoking Inventory (ISSI), Heaviness of Smoking Index, quit intentions, past-year quit attempts, and current use of electronic cigarettes (e-cigarettes). RESULTS: Self-stigma was significantly associated with higher intent to quit in the next 6 months (odds ratio [OR] = 2.47, P < .01) and in the next 30 days (OR = 4.21, P < .01), relative to no intention to quit, as well as having made 1 or 2 quit attempts in the past year (OR = 1.60, P < .01) or 3 or more quit attempts (OR = 1.74, P < .01) and associated with daily e-cigarette use (OR = 1.73, P < .05). Felt-stigma was positively associated with intent to quit in the next 30 days (OR = 1.54, P < .01), having made 3 or more quit attempts in the past year (OR = 1.35, P < .01), and both daily (OR = 2.05, P < .05) and some-day (OR = 1.30, P < .05) e-cigarette use. Discrimination was associated only with increased odds of daily e-cigarette use (OR = 1.83, P < .05). CONCLUSIONS: Smokers who reported greater feelings of stigmatization about their smoking were more likely to report having made recent quit attempts, report a stronger intention quit smoking in the future, and report use of e-cigarettes, suggesting that feelings of self-and felt-stigmatization are related to greater motivation to stop smoking.

Inhaled medication usage in post-menopausal women and lifetime tobacco smoke exposure: The Women's Health Initiative Observational Study.

OBJECTIVE: While active smoking is a causal agent in respiratory disease, the independent role of secondhand smoke (SHS) merits further investigation. We investigated associations between lifetime active smoking and exposure to secondhand smoke - studied independently - and current use of 1 or more inhaled medications as a surrogate for prevalent pulmonary disease in post-menopausal women. STUDY DESIGN: Information on lifetime active and passive tobacco exposure and inhaled pulmonary medication usage at enrollment was collected from 88,185 postmenopausal women aged 50-79 enrolled in the Women's Health Initiative Observational Study from 1993 to 1998 at 40 centers in the United States. Participants were recruited from localities surrounding the study centers using a variety of methods, including informational mailings and mass media campaigns. MAIN OUTCOME MEASURES: Multivariate adjusted regression models were used to estimate odds ratios and 95% CI according to levels of active smoking and SHS exposure, and trends were tested across categories. RESULTS: Ever active smokers had an overall OR of 1.97 (95% CI 1.58-2.45) for having one or more prescribed inhaled medication compared with never-smoking women not exposed to active or passive smoke. The overall OR for using inhalers for never-smoking women exposed to any SHS compared with the same reference group was 1.33 (95% CI 1.07-1.65). In a quantified analysis of SHS, never-smoking women with the highest levels of lifetime SHS exposure had an estimated risk of inhaled medication usage of 1.74 (95% CI 1.32-2.30). CONCLUSIONS: The risk of requiring one or more prescribed inhaled medications for pulmonary disease was significantly higher in post-menopausal women who ever smoked or who had lifetime exposure to SHS.

A Follow-Up Community Survey of Knowledge and Beliefs About Cancer and Genetics.

The purpose of this study is to assess changes since the launch of the US Surgeon General's campaign in the public's beliefs about the role of genetics in the etiology of cancer, as well as changes in recording family health history. We conducted a survey of 480 Western New York adults, assessing: (1) experiences with cancer, (2) beliefs about cancer and genetics, and (3) practices of recording family health history. Most respondents were aware of the importance of family history. The sample also showed increased knowledge about cancer and genetics compared with a previous survey. However, only 7 % kept written records that included medical conditions, which was not different from a previous survey. Time constraints, apathy, and reluctance to find out negative health information were the most reported barriers. Results suggest a need for continued education of the public, with increased emphasis on written family health records.

Associations between lifetime tobacco exposure with infertility and age at natural menopause: the Women's Health Initiative Observational Study.

BACKGROUND: Several studies have investigated the association of tobacco use with infertility and age at natural menopause, yet few have explored secondhand smoke (SHS) exposure with these outcomes. This study offers a comprehensive, quantified secondary data analysis of these issues using the Women's Health Initiative Observational Study (WHI OS). PURPOSE: This study examines associations between lifetime tobacco exposure-active smoking and SHS-and infertility and natural menopause (before age 50). METHODS: Information on smoking, lifetime fertility status, and age at natural menopause was collected and available from 93 676 postmenopausal women aged 50-79 enrolled in the WHI OS from 1993 to 1998 at 40 centres in the USA. Multivariate-adjusted regression models were used to estimate ORs and 95% CI according to levels of active smoking and SHS exposure, and trends were tested across categories. RESULTS: Overall, 15.4% of the 88 732 women included in the analysis on infertility met criteria for the condition. 45% of the 79 690 women included in the analysis on natural menopause (before age 50) met criteria for the condition. Active-ever smokers had overall OR's of 1.14 (95% CI 1.03 to 1.26) for infertility, and 1.26 (95% CI 1.16 to 1.35) for earlier menopause than never-smoking women. Never-smoking women with the highest levels of lifetime SHS exposure had adjusted OR's of 1.18 (95% CI 1.02 to 1.35) for infertility, and 1.18 (95% CI 1.06 to 1.31) for earlier menopause. Active-ever smokers reached menopause 21.7 months earlier than the mean of 49.4 years for never-smokers not exposed to SHS, and women exposed to the highest level of SHS reached menopause 13.0 months earlier. CONCLUSIONS: Active smoking and SHS exposure are associated with increased risk of infertility and natural menopause occurring before the age of 50 years.

Associations of lifetime active and passive smoking with spontaneous abortion, stillbirth and tubal ectopic pregnancy: a cross-sectional analysis of historical data from the Women's Health Initiative.

OBJECTIVE: To examine the associations between tobacco exposure and adverse pregnancy outcomes using quantitative measures of lifetime active smoking and secondhand smoke (SHS) exposure. METHODS: Historical reproductive data on 80 762 women who participated in the Women's Health Initiative Observational Study were examined with a cross-sectional analysis. We assessed self-reported lifetime active and passive tobacco smoke exposure, self-reported spontaneous abortions, stillbirths and ectopic pregnancies. RESULTS: When compared with never-smoking women, participants who were ever active smokers during their reproductive years had ORs (OR) of 1.16 (95% CI 1.08 to 1.26) for 1 or more spontaneous abortions, 1.44 (95% CI 1.20 to 1.73) for 1 or more stillbirths, and 1.43 (95% CI 1.10 to 1.86) for 1 or more ectopic pregnancies. Never-smoking women participants with the highest levels of lifetime SHS exposure, including childhood >10 years, adult home >20 years and adult work exposure >10 years, when compared with never-smoking women with no SHS exposure had adjusted ORs of 1.17 (95% CI 1.05 to 1.30) for spontaneous abortion, 1.55 (95% CI 1.21 to 1.97) for stillbirth, and 1.61 (95% CI 1.16 to 2.24) for ectopic pregnancy. CONCLUSIONS: Women who were ever-smokers during their reproductive years had significantly greater estimates of risk for spontaneous abortion, stillbirth and tubal ectopic pregnancy. Never-smoking women with the highest levels of lifetime exposure to SHS had significantly increased estimates of risk for spontaneous abortion, stillbirth and tubal ectopic pregnancy.

Five years after the Hawai'i smoke-free law: tourism and hospitality economic indicators appear unharmed.

Opponents of Hawai'i's smoke-free law argued that such a law would lead to a decrease in tourism. The purpose of this study is to determine if there is evidence of an adverse impact of Hawai'i's smoke-free law on tourism utilizing data obtained from Hawai'i's Department of Business, Economic Development & Tourism website for tourists from the United States. Descriptive statistics were reported before and after the law and linear regression was used to assess the relationship between the implementation of the law and changes in indicators of tourism while adjusting for underlying economic factors. The most pronounced fluctuations observed with all tourism indicators occurred around the time the US entered the recession (December 2007), with steady increases following the end of the US recession. While controlling for economic and seasonal trends, the presence of the smoke-free law was associated with an increase in arrivals (ß= 42847.9; 95% CI: 16303.3, 69392.5), accommodation employees (ß= 969.0; 95% CI: 351.1, 1586.8) and food services & beverage places employees (ß=3390.8; 95% CI: 2326.9, 4454.7). Fluctuations in tourism indicators are likely to be associated with greater economic forces, such as decreasing GDP and consumer confidence in the United States and greater global economic trends, rather than the smoke-free law.