Structural Components of Integrated Behavioral Health Care: A Comparison of National Programs.

Initiatives that support and incentivize the integration of behavioral health and general medical care have become a focus of government strategies to achieve the triple aim of improved health, better patient experience, and reduced costs. The authors describe the components of four large-scale national initiatives aimed at integrating care for a wide range of behavioral health needs. Commonalities across these national initiatives highlight health care and social services needs that must be addressed to improve care for people with co-occurring behavioral health and general medical conditions. These findings can inform how to design, test, select, and align the most promising strategies for integrated care in a variety of settings.

Primary and Behavioral Health Care Integration Program: Impacts on Health Care Utilization, Cost, and Quality.

This article describes an extension of the RAND Corporation's evaluation of the Substance Abuse and Mental Health Services Administration's Primary and Behavioral Health Care Integration (PBHCI) grants program. PBHCI grants are designed to improve the overall wellness and physical health status of people with serious mental illness or co-occurring substance use disorders by supporting the integration of primary care and preventive PH services into community behavioral health centers where individuals already receive care. From 2010 to 2013, RAND conducted a program evaluation of PBHCI, describing the structure, process, and outcomes for the first three cohorts of grantee programs (awarded in 2009 and 2010). The current study extends previous work by investigating the impact of PBHCI on consumers' health care utilization, total costs of care to Medicaid, and quality of care in three states. The evidence suggests that PBHCI was successful in reducing frequent use of emergency room and inpatient services for physical health conditions, reducing costs of care, and improving follow-up after hospitalization for a mental illness. However, PBHCI evidence does not suggest that PBHCI had a consistent effect on quality of preventive care and health monitoring for chronic physical conditions. These findings can guide the design of future cohorts of PBHCI clinics to build on the strengths with respect to shifting emergency department and inpatient care to less costly and more effective settings and address the continuing challenge of integrating care between specialty behavioral health providers and general medical care providers.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care.

BACKGROUND: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both). AIMS OF THE STUDY: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development. METHODS: We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included. RESULTS: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31). DISCUSSION: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes. LIMITATIONS: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care. IMPLICATIONS FOR HEALTH POLICIES: Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts. IMPLICATIONS FOR FURTHER RESEARCH: There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

Impact of a mental health based primary care program on emergency department visits and inpatient stays.

OBJECTIVE: Integrating primary care services into specialty mental health clinics has been proposed as a method for improving health care utilization for medical conditions by adults with serious mental illness. This paper examines the impact of a mental health based primary care program on emergency department (ED) visits and hospitalizations. METHOD: The program was implemented in seven New York City outpatient mental health clinics in two waves. Medicaid claims were used to identify patients treated in intervention clinics and a control group of patients treated in otherwise similar clinics in New York City. Impacts of the program were estimated using propensity score adjusted difference-in-differences models on a longitudinally followed cohort. RESULTS: Hospital stays for medical conditions increased significantly in intervention clinics relative to control clinics in both waves (ORs = 1.21 (Wave 1) and 1.33 (Wave 2)). ED visits for behavioral health conditions decreased significantly relative to controls in Wave 1 (OR = 0.89), but not in Wave 2. No other significant differences in utilization trends between the intervention and control clinics were found. CONCLUSION: Introducing primary care services into mental health clinics may increase utilization of inpatient services, perhaps due to newly identified unmet medical need in this population.

Impact of a Mental Health Based Primary Care Program on Quality of Physical Health Care.

We examine the impact of mental health based primary care on physical health treatment among community mental health center patients in New York State using propensity score adjusted difference in difference models. Outcomes are quality indicators related to outpatient medical visits, diabetes HbA1c monitoring, and metabolic monitoring of antipsychotic treatment. Results suggest the program improved metabolic monitoring for patients on antipsychotics in one of two waves, but did not impact other quality indicators. Ceiling effects may have limited program impacts. More structured clinical programs to may be required to achieve improvements in quality of physical health care for this population.

The Air Force Deployment Transition Center: Assessment of Program Structure, Process, and Outcomes.

It is often accepted as common knowledge that military personnel benefit from decompression time between a war zone and the home station. To capitalize on the potential benefits of a decompression period paired with support services, the U.S. Air Force established the Deployment Transition Center (DTC) at Ramstein Air Base in Germany in July 2010. The DTC provides airmen returning from combat missions with an opportunity to decompress and share lessons learned before returning to their home stations. The authors of this study evaluate the structure, processes, and outcomes of the DTC program. They find that, although a majority of participants found the DTC program worthwhile, a comparison of DTC participants and similar airmen who did not participate the program shows no evidence that the program helps reduce posttraumatic stress disorder symptoms, depressive symptoms, binge drinking, or social conflicts with family and coworkers. In addition, one of the DTC program elements appears to be similar to posttraumatic debriefing interventions, which several studies have found to be either ineffective or harmful. For these reasons, if the main goals of the DTC program are to improve behavioral health and social conflict outcomes, the authors recommend that the DTC program be discontinued or redesigned and Air Force resources invested in alternative programs. However, if the DTC program has other goals, such as providing rest and relaxation to airmen after a difficult deployment or capturing after-action information, then the authors recommend that these goals be documented and the DTC program be more specifically tailored to them.

Prioritizing quality measure concepts at the interface of behavioral and physical healthcare.

OBJECTIVE: Integrated healthcare models can increase access to care, improve healthcare quality, and reduce cost for individuals with behavioral and general medical healthcare needs, yet there are few instruments for measuring the quality of integrated care. In this study, we identified and prioritized concepts that can represent the quality of integrated behavioral health and general medical care. DESIGN: We conducted a literature review to identify candidate measure concepts. Experts then participated in a modified Delphi process to prioritize the concepts for development into specific quality measures. SETTING: United States. PARTICIPANTS: Expert behavioral health and general medical clinicians, decision-makers (policy, regulatory and administrative professionals) and patient advocates. MAIN OUTCOME MEASURES: Panelists rated measure concepts on importance, validity and feasibility. RESULTS: The literature review identified 734 measures of behavioral or general medical care, which were then distilled into 43 measure concepts. Thirty-three measure concepts (including a segmentation strategy) reached a predetermined consensus threshold of importance, while 11 concepts did not. Two measure concepts were 'ready for further development' ('General medical screening and follow-up in behavioral health settings' and 'Mental health screening at general medical healthcare settings'). Among the 31 additional measure concepts that were rated as important, 7 were rated as valid (but not feasible), while the remaining 24 concepts were rated as neither valid nor feasible. CONCLUSIONS: This study identified quality measure concepts that capture important aspects of integrated care. Researchers can use the prioritization process described in this study to guide healthcare quality measures development work.

Enrollment of Specialty Mental Health Clinics in a State Medicaid Program to Promote General Medical Services.

OBJECTIVE: To promote integrated general medical care for individuals with serious mental illness, the New York State Office of Mental Health (OMH) established regulations allowing specialty mental health clinics to provide Medicaid-reimbursable health monitoring (HM) and health physicals (HP). This study examined clinics' enrollment in this program to understand its potential to reach individuals with serious mental illness. METHODS: Information on enrollment and characteristics of clinics (N=500) was obtained from OMH administrative databases. Clinic enrollment in the HM/HP program was examined for the program's first five years (2010-2015). Logistic regression models accounting for the clustering of multiple clinics within agencies were used to examine characteristics associated with enrollment. RESULTS: A total of 291 of 500 (58%) licensed clinics in New York State in 2015 enrolled in the HM/HP program, potentially reaching 62% of all Medicaid enrollees with serious mental illness seen in specialty mental health clinics in the state. State-operated clinics were required to participate, and had 91% enrollment. Over half of hospital-affiliated and freestanding mental health clinics elected to enroll (53% and 54%, respectively). In adjusted models, enrollment was higher among freestanding clinics compared with hospital-affiliated clinics, higher in larger than smaller clinics, and higher in county-operated than in private nonprofit clinics. CONCLUSIONS: The high level of enrollment in the HM/HP program indicates strong interest among mental health clinics in providing general medical care services. However, supplemental policies may be needed to extend the program to areas of the mental health system where barriers to general medical care services are highest.

General Medical Outcomes From the Primary and Behavioral Health Care Integration Grant Program.

OBJECTIVE: Primary and Behavioral Health Care Integration (PBHCI) grants aim to improve the health of people with serious mental illness by integrating primary and preventive general medical services into behavioral health settings. This report describes the general medical outcomes of persons served by early cohorts of programs, funded in 2009 or 2010, that participated in this national demonstration project. METHODS: A quasi-experimental, difference-in-differences design was used to compare changes in general medical health among consumers served at three PBHCI clinics (N=322) and three clinics that were selected as matched control sites (N=469). Propensity-score weighting was used to adjust for baseline differences between PBHCI and control clinic populations. Baseline data were collected between 2010 and 2012; follow-up data were collected approximately one year later. General medical outcomes included blood pressure; body mass index; cholesterol, triglyceride, and blood glucose or HbA1c levels; and self-reported tobacco smoking. RESULTS: Compared with consumers served at control clinics, PBHCI consumers had better outcomes for cholesterol: mean reductions in total cholesterol were greater by 36 mg/dL (p<.01), mean reductions in low-density lipoprotein cholesterol were greater by 35 mg/dL (p<.001), and mean increases in high-density lipoprotein cholesterol were greater by 3 mg/dL (p<.05). No significant PBHCI effects were observed for the other health indicators. CONCLUSIONS: Approximately one year of PBHCI treatment resulted in statistically and potentially clinically significant improvements in cholesterol but not in other general medical outcomes examined. More rigorous implementation of integrated care in community behavioral health settings may be needed to further improve the health of adults with serious mental illness.

Integrating Primary Care Into Community Mental Health Centers: Impact on Utilization and Costs of Health Care.

OBJECTIVE: This evaluation was designed to assess the impact of providing integrated primary and mental health care on utilization and costs for outpatient medical, inpatient hospital, and emergency department treatment among persons with serious mental illness. METHODS: Two safety-net, community mental health centers that received a Substance Abuse and Mental Health Services Administration Primary and Behavioral Health Care Integration (PBHCI) grant were the focus of this study. Clinic 1 had a ten-year history of providing integrated services whereas clinic 2 began integrated services with the PBHCI grant. Difference-in-differences (DID) analyses were used to compare individuals enrolled in the PBHCI programs (N=373, clinic 1; N=389, clinic 2) with propensity score-matched comparison groups of equal size at each site by using data obtained from medical records. RESULTS: Relative to the comparison groups, a higher proportion of PBHCI clients used outpatient medical services at both sites following program enrollment (p<.003, clinic 1; p<.001, clinic 2). At clinic 1, PBHCI was also associated with a reduction in the proportion of clients with an inpatient hospital admission (p=.04) and a trend for a reduction in inpatient hospital costs per member per month of $217.68 (p=.06). Hospital-related cost savings were not observed for PBHCI clients at clinic 2 nor were there significant differences between emergency department use or costs for PBHCI and comparison groups at either clinic. CONCLUSIONS: Investments in PBHCI can improve access to outpatient medical care for persons with severe mental illness and may also curb hospitalizations and associated costs in more established programs.

SimCoach Evaluation: A Virtual Human Intervention to Encourage Service-Member Help-Seeking for Posttraumatic Stress Disorder and Depression.

This article describes RAND Corporation researchers' assessment of SimCoach, a computer program featuring a virtual human that speaks and gestures in a video game-like interface, designed to encourage service members, especially those with signs or symptoms of posttraumatic stress disorder (PTSD) or depression, to seek help to improve their psychological health. The assessment included a formative component assessing SimCoach's design, development, and implementation approaches and a summative component assessing outcomes among participants in a user experience survey and a randomized controlled trial (RCT). Results of the formative evaluation identified both strengths and opportunities for improvement. For example, although SimCoach development processes were well-aligned with best practices for software engineering, SimCoach content development and evaluation processes could have been more tightly coupled to best practices in psychological health. The summative evaluation RCT did not show any SimCoach-related benefit in intent to seek help compared with that of control users not exposed to any intervention. However, secondary outcomes indicated that SimCoach users had satisfying experiences without distress. If SimCoach development is continued, greater attention to clinical processes and outcomes is needed so that the program can have its intended impact on help-seeking for PTSD and depression.

Hiding the tobacco power wall reduces cigarette smoking risk in adolescents: using an experimental convenience store to assess tobacco regulatory options at retail point-of-sale.

OBJECTIVES: This experiment tested whether changing the location or visibility of the tobacco power wall in a life sized replica of a convenience store had any effect on adolescents' susceptibility to future cigarette smoking. METHODS: The study was conducted in the RAND StoreLab (RSL), a life sized replica of a convenience store that was developed to experimentally evaluate how changing aspects of tobacco advertising displays in retail point-of-sale environments influences tobacco use risk and behaviour. A randomised, between-subjects experimental design with three conditions that varied the location or visibility of the tobacco power wall within the RSL was used. The conditions were: cashier (the tobacco power wall was located in its typical position behind the cash register counter); sidewall (the tobacco power wall was located on a sidewall away from the cash register); or hidden (the tobacco power wall was located behind the cashier but was hidden behind an opaque wall). The sample included 241 adolescents. RESULTS: Hiding the tobacco power wall significantly reduced adolescents' susceptibility to future cigarette smoking compared to leaving it exposed (ie, the cashier condition; p=0.02). Locating the tobacco power wall on a sidewall away from the cashier had no effect on future cigarette smoking susceptibility compared to the cashier condition (p=0.80). CONCLUSIONS: Hiding the tobacco power wall at retail point-of-sale locations is a strong regulatory option for reducing the impact of the retail environment on cigarette smoking risk in adolescents.

Care Transitions to and from the National Intrepid Center of Excellence (NICoE) for Service Members with Traumatic Brain Injury.

Improvised explosive devices (IEDs) have been one of the leading causes of death and injury among U.S. troops. Those who survive an IED blast or other injuries may be left with a traumatic brain injury (TBI) and attendant or co-occurring psychological symptoms. In response to the need for specialized services for these populations, the U.S. Department of Defense (DoD) established the National Intrepid Center of Excellence (NICoE) in Bethesda, Maryland, in 2010. The NICoE's success in fulfilling its mission is impacted by its relationships with home station providers, patients, and their families. The RAND Corporation was asked to evaluate these relationships and provide recommendations for strengthening the NICoE's efforts to communicate with these groups to improve patients' TBI care. Through surveys, site visits, and interviews with NICoE staff, home station providers, service members who have received care at the NICoE, and the families of these patients, RAND's evaluation examined the interactions between the NICoE and the providers responsible for referring patients and implementing treatment plans.

Public-Private Partnerships for Providing Behavioral Health Care to Veterans and Their Families: What Do We Know, What Do We Need to Learn, and What Do We Need to Do?

American veterans and their family members struggle with behavioral health problems, yet few engage in treatment to address these problems. Barriers to care include trouble accessing treatment and limited communication between civilian and military health care systems, which treat veterans and their family members separately. Even though the Department of Veterans Affairs (VA) is making efforts to address barriers to care, more work is needed to effectively serve veterans and their families. Public-private partnerships have been discussed as a potential solution and could include collaborations between a public agency, such as the VA, and a private organization, such as a veteran service organization, private industry, or private hospital. Despite the call for such partnerships, not much is known about what a public-private partnership would entail for addressing behavioral health concerns for veterans and their families. The health care literature is sparse in this area, and published examples and recommendations are limited. Thus, the authors wrote this article to inform the creation of public-private partnerships to better serve veterans and their families. The article outlines nine key components for public-private partnerships addressing veteran behavioral health care. These components are supported by qualitative interview data from five successful public-private partnerships that serve veterans and their families. This study will assist policymakers in the VA and other federal agencies in developing and fostering public-private partnerships to address the behavioral health care needs of veterans and their families. The article also discusses next steps for research and policymaking efforts with regard to these partnerships.

The effects of prior authorization policies on medicaid-enrolled children's use of antipsychotic medications: evidence from two mid-Atlantic states.

OBJECTIVE: The purpose of this study was to examine the impact of prior authorization policies on the receipt of antipsychotic medication for Medicaid-enrolled children. METHODS: Using de-identified administrative Medicaid data from two large, neighboring, mid-Atlantic states from November 2007 through June 2011, we identified subjects <18 years of age using antipsychotics, from the broader group of children and adolescents receiving behavioral health services or any psychotropic medication. Prior authorization for antipsychotics was required for children in State A <6 years of age from September 2008, and for children <13 years of age from August 2009. No such prior authorizations existed in State B during that period. Filled prescriptions were identified in the data using national drug codes. Using a triple-difference strategy (using differences among the states, time periods, and differences in antidepressant prescribing rates among states over the same time periods), we examined the effect of the prior authorization policy on the rate at which antipsychotic prescriptions were filled for Medicaid-enrolled children and adolescents. RESULTS: The impact of prior authorization policies on antipsychotic medication use varied by age: Among 6-12 year old children, the impact of the prior authorization policy on antipsychotic medication prescribing was a modest but statistically significant decrease of 0.47% after adjusting for other factors; there was no effect of the prior authorization among children 0-5 years. CONCLUSIONS: Prior authorization policies had a modest but statistically significant effect on antipsychotic use in 6-12 year old children, but had no impact in younger children. Future research is needed to understand the utilization and clinical effects of prior authorization and other policies and interventions designed to influence antipsychotic use in children.

Focusing on the five A's: a comparison of homeless and housed patients' access to and use of pharmacist-provided smoking cessation treatment.

INTRODUCTION: The prevalence of smoking remains high among the medically underserved and could be related to disparities in access to and use of smoking cessation treatments. METHODS: This study implemented and tracked providers' use of the 5 A's intervention for tobacco use (Ask, Assess, Advise, Assist, Arrange) with homeless (n = 260) and housed (n = 226) adults attending a free medical clinic, including referrals to and use of an on-site pharmacist-led smoking cessation service. RESULTS: Among patients whose tobacco use was Asked about and Assessed (97%), homeless (vs. housed) patients were more likely to smoke (59% vs. 39%; P = 0.008). Among current smokers, there were no homeless-housed disparities in receipt of Advice to quit smoking (84% vs. 78%; P = 0.22) or Arrangement of treatment (36% vs. 31%; P = 0.46). Overall, among patients for whom treatment was Arranged, homeless patients were less likely than housed patients to attend the smoking cessation program (25% vs. 48%; P = 0.04). However, among those that attended any treatment (i.e., were Assisted to quit), homeless and housed patients attended similar numbers of sessions and used pharmacotherapy at similar rates. CONCLUSIONS: Providers may reduce homeless-housed disparities in smoking by offering special Assist(ance) to homeless smokers that reduces barriers to initially accessing treatment services.

Evaluation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) Grant Program: Final Report.

Excess morbidity and mortality in persons with serious mental illness is a public health crisis. Numerous factors contribute to this health disparity, including illness and treatment-related factors, socioeconomic and lifestyle-related factors, and limited access to and poor quality of general medical care. Primary and Behavioral Health Care Integration (PBHCI), one of the Substance Abuse and Mental Health Services Administration's service grant programs, is intended to improve the overall wellness and physical health status of people with serious mental illness, including individuals with co-occurring substance use disorders, by making available an array of coordinated primary care services in community mental health and other community-based behavioral health settings where the population already receives care. This article describes the results of a RAND Corporation evaluation of the PBHCI grants program. The evaluation was designed to understand PBHCI implementation strategies and processes, whether the program leads to improvements in outcomes, and which program models and/or model features lead to better program processes and consumer outcomes. Results of the evaluation showed that PBHCI grantee programs were diverse, varying in their structures, procedures, and the extent to which primary and behavioral health care was integrated at the program level. Overall, PBHCI programs also served many consumers with high rates of physical health care needs, although total program enrollment was lower than expected. The results of a small, comparative effectiveness study showed that consumers served at PBHCI clinics (compared to those served at matched control clinics) showed improvements on some (e.g., markers of dyslipidemia, hypertension, diabetes) but not all of the physical health indicators studied (e.g., smoking, weight). Finally, we found that program features, such as clinic hours, regular staff meetings, and the degree of service integration, increased consumer access to integrated care, but that access to integrated care was not directly associated with improvements in physical health. Implications of the study results for programs and the broader field, plus options for future PBHCI-related research are discussed.

An Examination of New York State's Integrated Primary and Mental Health Care Services for Adults with Serious Mental Illness.

The poor physical health of adults with serious mental illnesses is a public health crisis. Greater integration of mental health and primary medical care services at the clinic and system levels could address this need. In New York state, there are several ongoing initiatives that promote integrated care for adults with serious mental illness, provided or coordinated by community mental health center staff. This study examines three initiatives. Data were collected by RAND through site visits and surveys of mental health clinic administrators and associated professionals. Results showed that Primary and Behavioral Health Care Integration grantees developed infrastructure that supported a broad scope of primary and preventive health care services; these broad changes appeared to contribute to clinic-wide culture shifts toward integration and shared accountability for consumers' "whole person" health. Clinics participating in the Medicaid Incentive tended to implement only those services for which they could bill, which resulted in newly identified consumer physical health care needs but did not help consumers to connect to physical health care services. Finally, while administrators and providers were optimistic that Medicaid Health Homes have potential to improve access to care for adults with serious mental illness, the newness of the initiative made it difficult to assess the degree to which Health Home networks would meet these goals. We conclude with recommendations to state policymakers, clinical providers, and technical assistance providers and recommendations for future research, all designed to strengthen New York state's integrated care initiatives for adults with serious mental illness.

Quantifying the persistence of pro-smoking media effects on college students' smoking risk.

PURPOSE: To quantify the persistence of pro-smoking media exposure effects on college students' intentions to smoke and smoking refusal self-efficacy. METHOD: A total of 134 college students (ages 18-24 years) were enrolled in an ecological momentary assessment study in which they carried handheld data collection devices for 3 weeks and reported their exposures to pro-smoking media as they occurred in the real world. Smoking intentions and smoking refusal self-efficacy were assessed after each exposure to pro-smoking media and at random prompts during each day of the 3-week assessment period. A generalized additive model was used to determine how long the effect of an exposure to pro-smoking media persisted. RESULTS: The effect of pro-smoking media exposures persisted for 7 days. After exposure, smoking intentions immediately increased (.56; 95% confidence interval [CI]: [.26, .87]) and then steadily decreased (-.12; 95% CI: [-.19, -.05]) each day for 7 days, while smoking refusal self-efficacy immediately decreased (-.42; 95% CI: [-.75, -.10]) and then steadily increased (.09; 95% CI: [.02, .16]) each day for 7 days. Daily changes occurring after 7 days were not statistically significant, suggesting that smoking intentions and refusal self-efficacy had stabilized and were no longer affected by pro-smoking media exposure. CONCLUSIONS: Exposures to pro-smoking media may have strong implications for emerging young adults smoking risk as the impact of an individual exposure appears to persist for at least a week.

Middle and high school students' exposure to alcohol- and smoking-related media: a pilot study using ecological momentary assessment.

The goals of this study were to assess the feasibility of using Ecological Momentary Assessment (EMA) to measure adolescents' exposure to alcohol and smoking-related media. A sample of 20 middle and high school students completed a 2-week EMA protocol in which they monitored exposures to alcohol and smoking-related media. Results showed that adolescents were highly compliant with the study protocol. A total of 255 exposures to alcohol (67%) and smoking (33%) were captured, representing an average of 8.50 (SD = 5.82) alcohol-related media exposures and 4.25 (SD = 3.67) smoking-related media exposures per participant, during the study period. Exposures tended to occur in the afternoon (52% alcohol; 54% smoking), at point of sale (44% alcohol; 65% smoking), and on days leading up to the weekend (57% alcohol; 57% smoking). Exposures were also likely in the presence of family (69% alcohol; 56% smoking). Overall, results of this small pilot provide preliminary evidence that EMA is a useful tool for tracking and characterizing middle and high school students' real-world exposures to alcohol- and smoking-related media. Future studies may suggest mechanisms by which media exposures lead to youth uptake of drinking and smoking behaviors.