What Motivates Betel Quid Chewers to Quit? An Analysis of Several Cessation-Relevant Variables.

Introduction: Betel quid (BQ) is globally the fourth most consumed psychoactive substance. It is consumed by an estimated 600 million people worldwide, accounting for nearly 8% of the world's population. There have been very few studies assessing chewers' motivation to quit. Objectives: In the current study, we sought to understand the relationship between several cessation-relevant variables and chewers' motivation to quit. Hypotheses: Based on analogous research on cigarette smoking, we hypothesized that the following cessation-relevant variables would be associated with motivation to quit: health risk perceptions, number of chews per day, cost, degree of BQ dependence, withdrawal symptoms, number of quit attempts, reasons for use, personal health improvement, and type of BQ chewed. Methods: A total of 351 adult BQ chewers from Guam participated in the survey and served as the sample for the analyses. Results: Majority of chewers want to quit and intend to quit. Chewers relatively high in motivation to quit evinced greater health risk perceptions of BQ chewing, greater perceived health benefits to quitting, and a greater number of past quit attempts, compared to those relatively low in motivation to quit. Conclusions: Understanding which factors are associated with chewers' motivation to quit can be helpful for designing BQ cessation programs. The results suggest that BQ cessation programs could be improved by an increased emphasis on information about the negative health effects of BQ chewing and relapse-prevention.

Facilitator experiences and lessons learned from the Betel nut intervention trial (BENIT).

BACKGROUND: The Betel Nut Intervention Trial (BENIT; ClinicalTrials.gov - NCT02942745) is the first known randomized intervention trial specifically designed for areca nut chewers in the western Pacific region who want to quit. The current study is a separate, exploratory study that examined the experiences of the BENIT facilitators during its implementation in Guam and Saipan of the Northern Mariana Islands and the extent to which the BENIT protocol was adapted to meet the participants' and facilitators' needs. METHODS: All six BENIT program facilitators completed an online survey consisting of quantitative (Likert scale) and qualitative (open-ended) questions. Survey items were grouped as follows: facilitator demographics, prior training and preparation, BENIT experience, beliefs about the program's effectiveness, and beliefs about protocol adaptations. RESULTS: Most of the facilitators felt prepared to deliver the BENIT program after several weeks of moderately intensive training. Facilitators felt the BENIT program was generally effective and that the "trigger logs" and "self-monitoring logs" worked as intended. However, they also noted that more time and support would have been helpful to overcome some of the obstacles inherent to implementing a novel program. CONCLUSION: The current findings can be used to inform, modify, and tailor subsequent areca nut cessation programs in Micronesian communities and to improve future versions of BENIT.

The Betel Nut Intervention Trial (BENIT)-A Randomized Clinical Trial for Areca Nut and Betel Quid Cessation: Primary Outcomes.

BACKGROUND: Areca nut and betel quid (ANBQ) chewing is a widespread carcinogenic habit. The BENIT (ClinicalTrials-NCT02942745) is the first known randomized trial designed for ANBQ chewers. METHODS: We compared the intensive behavioral treatment intervention condition (IC) with the control condition (CC) in the BENIT and included a 5-stage early stopping rule. We report the primary analysis at stage 3. English-literate adults in Guam and Saipan who self-identified as ANBQ chewers with tobacco were enrolled between August 2016 and August 2020. IC participants (n = 88) received five in-person sessions over 22 days and a brochure containing quitting advice. CC participants (n = 88) received only the brochure. Participants were assessed at baseline and on day 22 of follow-up. Self-reported chewing status at day 22 was determined by a composite of two survey items with disparate wording and response options for cross-verification. RESULTS: Cessation rates were 38.6% (IC) and 9.1% (CC). Proportional hazards regression revealed a p = 0.0058, which met the Stage 3 criteria for significance, and an estimated reduction in ANBQ chewing for IC compared to the CC of 71% (95% CI: 41%-88%). CONCLUSIONS: Robust self-reported intervention effects at day 22 suggest that intensive cessation programs such as BENIT should be further developed and implemented on a larger scale.

Ethnicity, Coronavirus Disease-Related Stress, and E-cigarette Use and Cigarette Smoking Among Young Adults: A Longitudinal Study.

INTRODUCTION: Research has rarely examined ethnic differences in exposure to coronavirus disease (COVID)-related stress in relation to smoking and e-cigarette use. AIMS AND METHODS: Using pre- and post-COVID data from a sample of predominantly Asian American (AA) and Native Hawaiian and Pacific Islander (NHPI) young adults, this study aimed to test the effects of ethnicity on cigarette smoking and e-cigarette use through exposure to COVID-related stress. Young adults from Hawaii who provided pre-COVID data in or before January 2020 were followed up with in March-May 2021. N = 1907 (mean age = 24.9 [SD = 2.9], 56% women) provided complete data relevant to the current analysis at both waves of data collection. Structural equation modeling was used to test the effects of ethnicity (white, Asian [eg, Japanese, Chinese], Filipino, NHPI, and other) on pre- to post-COVID changes in cigarette and e-cigarette use via effects on COVID-related stress. RESULTS: Relative to Asian young adults, members of all other ethnic groups (NHPI, Filipino, white, and other) indicated greater exposure to COVID-related stress. Higher levels of COVID-related stress were associated with increased dual-use status and increased current e-cigarette and cigarette use frequencies. Higher COVID-related stress mediated the effects of NHPI, Filipino, and other ethnicity on increased dual-use status. CONCLUSIONS: The current data indicate that young adults of vulnerable ethnic groups who experience higher COVID-related stress are at increased risk for dual use of cigarettes and e-cigarettes. IMPLICATIONS: The findings imply that tobacco use prevention and treatment efforts may need to pay increased attention to racial or ethnic groups that have experienced greater adverse impact of the COVID-19 pandemic.

Salivary Areca and tobacco alkaloids for bioverification in the Betel Nut Intervention Trial.

BACKGROUND: The Betel Nut Intervention Trial (BENIT) is the first known randomized controlled intervention trial designed to help minority Pacific Islanders in Guam and Saipan quit chewing the carcinogenic Areca catechu nut (AN). We report the BENIT's saliva bioverification results against the self-reported chewing status ("quitter" or "chewer") at day 22 follow-up. MATERIAL AND METHODS: AN-specific (arecoline, arecaidine, guvacoline, and guvacine) and tobacco-specific (nicotine, cotinine, and hydroxycotinine) alkaloids were analyzed in saliva from 176 BENIT participants by an established and sensitive liquid chromatography mass spectrometry-based assay. RESULTS: The combined four AN alkaloid levels decreased from baseline in quitters (n = 50) and chewers (n = 108) by 32% and 9%, respectively. In quitters, decreases were significant for arecoline (p = 0.044)-the most prominent AN alkaloid, along with arecaidine (p = 0.042) and nicotine (p = 0.011). In chewers, decreases were significant only for hydroxycotinine (p = 0.004). Similar results were obtained when quitters and chewers were stratified by treatment arm. DISCUSSION: Salivary AN alkaloid levels generally agreed with self-reported chewing status, which suggests the former can be used to verify the latter. CONCLUSION: Our results can help to objectively evaluate compliance and program effectiveness in AN cessation programs.

Trajectories of e-cigarette advertising exposure, e-cigarette use and cigarette smoking in a sample of young adults from Hawaii.

AIM: To test whether intrapersonal growth in e-cigarette advertising exposure over time is associated with growth in e-cigarette use and/or cigarette smoking. DESIGN: Longitudinal study using four waves of data were collected in 6-month intervals between 2018 and 2020. SETTING AND PARTICIPANTS: Participants were 2327 young adults recruited from colleges in Hawaii, USA. MEASUREMENTS: Data were collected on demographics, e-cigarette advertising exposure measured using the cued- recall method and recent (past 30-day) cigarette and e-cigarette use. FINDINGS: The average trajectory for e-cigarette advertising exposure over time was significant and upward [M slope = 0.18 (0.14-0.22), P < 0.0001]. However, average trajectories for e-cigarette [M slope = -0.08 (-0.18 to 0.02), P = 0.09] and cigarette [M slope = -0.14 (-0.30 to 0.02), P = 0.07] use were not. There were significant differences in individual level trajectories across participants for advertising exposure [σ2 = 0.12 (0.10-0.14), P < 0.0001], e-cigarette use [σ2 = 0.22 (0.14-0.30), and cigarette smoking (σ2 = 0.17 [0.09-0.25], P < 0.0001). Individuals with an increasing rate of advertising exposure showed an increasing rate of e-cigarette use [B = 0.63 (0.36-0.90), P < 0.0001). Neither initial level of, nor rate of change in, advertising exposure was significantly associated with cigarette smoking growth factors (P > 0.05). Higher initial level of e-cigarette use was associated with higher initial level of cigarette smoking [B = 0.89 (0.69-1.09), P < 0.0001] but decreased rate of cigarette smoking over time [B = -0.12 (-0.20 to -0.04) P = 0.003]. Rate of change in e-cigarette use was not associated with the rate of change in cigarette smoking (P > 0.05). CONCLUSIONS: Increased exposure to e-cigarette advertising appears to be associated with increased e-cigarette use but not with increased cigarette smoking. Higher initial level of e-cigarette use appears to be associated with higher initial level of cigarette smoking but may be associated with a decreasing rate of cigarette smoking over time.

The Reasons for Betel Quid Chewing Scale (RBCS) for Ex-Chewers: Assessment of Factor Structure, Reliability, Validity and Measurement Invariance across Gender in a Guamanian Sample.

BACKGROUND: Over 600 million people chew betel nut worldwide and the behavior is classified by the World Health Organization (WHO) as a Group 1 carcinogen. Having a reliable and valid scale of reasons for chewing betel nut that can be used consistently across gender for both chewers and ex-chewers will assist practitioners to create culturally appropriate risk reduction and cessation programs and address an important public health concern.Purpose/Objectives: We sought to: 1) examine factor structure, reliability, and validity of the Reasons for Chewing Scale (RBCS) for ex-chewers; 2) examine the influence of social-cultural factors on chewing behaviors; and 3) examine if measurement invariance (MI) of the RBCS held consistently across gender groups. METHODS: A Confirmatory Factor Analysis (CFA), a multigroup CFA for testing measurement invariance (MI), and Structural Equation Modeling (SEM) were applied to the RBCS using a convenience sample of (N = 223) of ex-chewers from Guam. RESULTS: The majority of the items in the RBCS were found to be moderately or strongly correlated to each other. The CFA model fit the ex-chewers' data well and the model suggested that the RBCS was found to be reliable and valid. The multi-group CFA showed this scale functions equivalently for both male and female groups.Conclusions/Importance: The RBCS is a valid and reliable measure that is invariant across gender and type of ex-chewer.

Heat-not-burn Tobacco Products and the Increased Risk for Poly-tobacco Use.

Objectives: In this study, we tested the use of ecigarette, cigarette, and dual use of both as predictors of heat-not-burn (HNB) tobacco product use onset among young adults, and examined common predictors of smoking cessation as predictors of HNB product use. Methods: We collected data from 2229 young adults [mean age = 21.1 (SD = 2.1); 55% women] in Hawaii, at 2 time-points 6 months apart. Results: Current cigarette-only use was the strongest concurrent predictor of HNB product use, followed by dual use, and ecigarette-only use. Among HNB product never users at Wave 1, dual and ecigarette-only use at Wave 1 significantly predicted HNB product use onset at Wave 2. Among cigarette smokers who had never used an HNB product at Wave 1, current use of ecigarette for help with smoking cessation predicted increased odds of HNB product use at 6-month follow-up. Conclusions: Although promoted as a safer alternative for exclusive cigarette smokers, HNB products may increase the risk of dual or poly-tobacco product use among young adults, including current exclusive e-cigarette users. Surveillance of HNB product use as a modified risk tobacco product may need to consider the effects of HNB products on poly-tobacco use among young people.

Social media's influence on e-cigarette use onset and escalation among young adults: What beliefs mediate the effects?

As an extension of a previous cross-sectional study, this study employed prospective data to test positive outcome expectancy beliefs as mediators of social media's influence on e-cigarette use progression among young adults. Self-report data were collected from 2327 young adult college students (Mean age = 21.2; SD = 2.1; 54% women) between 2017 and 2019, every 6-month, at 3 time-points. Structural equation modeling was used to test the mediational models. Among baseline never e-cigarette users, higher affect regulation expectancies-e.g., beliefs that e-cigarette use results in feeling good, reduced boredom and stress-mediated the effects of higher baseline social media e-cigarette exposure on e-cigarette use onset one year later. Among baseline lifetime e-cigarette users, higher positive sensory, positive "smoking" experience, and affect regulation expectancy beliefs mediated the effects of higher social media e-cigarette exposure at baseline on increased current e-cigarette use one year later. E-cigarette content on social media may persuade young adults to try e-cigarettes by imparting the sense that e-cigarettes make one feel good and help reduce stress. E-cigarette content on social media that promote e-cigarette flavors and e-cigarettes as cleaner and a socially more acceptable alternative to cigarettes may work to escalate e-cigarette use among experimenters. Efforts to prevent e-cigarette use onset and escalation may need to target the outcome expectancy beliefs influenced by social media.

Predictors of marijuana vaping onset and escalation among young adults.

BACKGROUND: Little is known about factors that influence marijuana vaping among young people. We examined cigarette, e-cigarette and marijuana use experiences, social network characteristics and exposure to direct e-cigarette marketing as predictors of marijuana vaping initiation and escalation. METHODS: One-year prospective data were collected between 2017 and 2019 from 2327 young adults (Mean age = 21.2; SD = 2.1; 54 % women) attending 2-year and 4-year colleges in Hawaii. RESULTS: Among participants who were never marijuana users at baseline, being a dual user of cigarette and e-cigarette at baseline was the strongest predictor of marijuana vaping initiation, followed by baseline cigarette-only and e-cigarette-only use. Higher prevalence of regular marijuana users in one's social networks, but not e-cigarette users or cigarette smokers, significantly predicted marijuana vaping initiation a year later. Among baseline current e-cigarette users and lifetime marijuana users, higher presence in social networks of individuals who frequented vape shops at baseline was a significant predictor of increased current marijuana vaping at one-year follow-up. CONCLUSIONS: Dual use of cigarette and e-cigarette and greater presence in social networks of marijuana users and people who frequent vape shops appear to be robust predictors of marijuana vaping onset and escalation among young adults. In addition to promoting e-cigarette use prevention/cessation, efforts to control marijuana vaping may need to consider promoting smoking prevention/cessation and the effects of increasing prevalence of marijuana use.

Rationale and design of a randomized, controlled, superiority trial on areca nut/betel quid cessation: The Betel Nut Intervention Trial (BENIT).

BACKGROUND: Areca nut (AN) is the seed endosperm of the Areca catechu L. palm and a Group 1 carcinogen chewed by 10-20% of the world population. AN is often chewed with Piper betle L. leaf, slaked lime, and tobacco to form a betel quid (BQ). The negative health effects associated with AN/BQ consumption warrant the need for an evidence-based cessation program. However, systematic research on AN/BQ cessation is rare. METHODS/DESIGN: The Betel Nut Intervention Trial (BENIT; trial #NCT02942745) is a randomized controlled trial designed to test the efficacy of an intensive AN/BQ cessation program. The trial is ongoing in Guam and Saipan with adult chewers who include tobacco in their BQ. Enrolled participants are assessed for their primary (chewing status) and secondary (saliva bio-verification) outcome at baseline, 22 days, and 6 months. Participants randomized into the control arm receive an educational booklet while those randomized into the intervention arm receive the educational booklet and a 22-day cessation program modeled after a smoking cessation program and led by trained facilitators. Information on chewing behavior (history, reasons for chewing, and AN/BQ composition and dependency) are collected. The intervention effectiveness is assessed using the logistic mixed model to compare cessation status between randomization groups. DISCUSSION: AN/BQ chewing affects a large population of people, many of whom live in low and moderate income countries in the Asia-Pacific region. Although the BENIT focuses on chewers in Guam and Saipan, it has the potential for greater regional and global importance.

Barriers to Quitting Areca Nut Consumption and Joining a Cessation Program as Perceived by Chewer and Nonchewer Populations in Guam.

Background: Areca nut (AN) is a carcinogenic substance consumed by roughly 600 million individuals worldwide with increasing popularity in Guam. In response, a cessation program was developed and implemented in Guam and Saipan. However, to improve its delivery, it is necessary to understand the reasons influencing recruitment and participation, such as why a chewer may not want to quit or join a cessation program. Objective: To explore barriers inhibiting chewers from quitting AN chewing and from participating in a cessation program. Methods: Nine individual and group discussions were facilitated with a convenience sample of 17 chewers and nonchewers in Guam in 2017. The mean age of the participants was 36.4 years. Recurring themes relating to reasons for not quitting and not joining a cessation program were extracted. Results: Results produced three general categories-Sociocultural, Behavioral, and Accessible. Each category encompasses different attributes concerning reasons not to quit chewing (e.g. addiction, enabling community, or belief that AN is harmless), and reasons influencing lack of participation in a cessation program (e.g. time, transportation, or relatability). Conclusions: Current findings suggest chewers are unaware of the harmful effects of AN. Also, they may not comprehend the purpose of a cessation program. In addition, the likelihood of chewers participating in a cessation program is influenced by their level of comfort with the program and personnel, and whether a program addresses their time and transportation limitations.

Adolescent betel nut use in Guam: beliefs, attitudes and social norms.

Betel (areca) nut is an addictive substance chewed with or without tobacco widely in Asia and the Pacific, including the U.S.-affiliated Pacific Islands (USPI). Betel nut use has been found to cause oral cancer. Research suggests that most betel nut use initiation occurs in adolescence. However, very little is currently known about the etiology of adolescent betel nut use. The present study reports findings of a formative, qualitative research conducted to understand the attitudinal and social factors associated with adolescent betel nut use in USAPI. The objective was to develop a theoretical framework of adolescent betel nut etiology that would guide the development of a prevention program. Semi-structured interviews were conducted with 20 adolescent betel nut users (M age = 14.5; SD = 2.2) from Guam. Findings suggested a framework of adolescent betel nut etiology in which intrapersonal, social, and environmental factors influence betel nut use behavior. The framework is consistent with ecological frameworks of adolescent substance use in which proximal personal and social influences on adolescent substance use occur within the context of a wider socio-cultural context conducive to adolescent substance use. Specifically, we found that beliefs such as betel nut tastes good and induces relaxation represent some of the betel nut use motives; parental permissiveness and peer and sibling use encourage betel nut use; and cultural acceptance and easy accessibility to betel nuts provide an environmental context conducive to betel nut use. Findings are discussed in the context of developing an adolescent betel nut use prevention program.

Adolescent Tobacco and Betel Nut Use in the US-Affiliated Pacific Islands: Evidence From Guam.

PURPOSE: To determine the prevalence of, and the risk and protective factors associated with, tobacco product use among adolescents in Guam, a US-Affiliated Pacific Island (USAPI) territory. To examine disparities in risk and protective factors across indigenous and nonindigenous groups. DESIGN: Quantitative; cross-sectional. SETTING: Middle and high schools in Guam. SAMPLE: The Global Youth Tobacco Survey sample included a representative sample of 2449 6th to 12th graders (71% response rate). Sample for the supplemental study included 670 middle school students (76% response rate across randomly selected classrooms). MEASURES: Self-reported measures of lifetime and past 30-day tobacco and betel nut use, social competence, resistance self-efficacy, risk perceptions, friend and family tobacco product use, and ease of access to tobacco products. ANALYSIS: Multilevel logistic regression and analysis of covariance. RESULTS: The prevalence rates of current cigarette, smokeless tobacco, and e-cigarette use among middle school students were 8%, 8%, and 25%, respectively. Ability to resist social pressure to use tobacco/betel nut use was strongly associated with lower likelihood of tobacco (odds ratio [OR] = 0.76; 95% confidence interval [CI]: 0.68-0.84) and betel nut use (OR = 0.74; 95% CI: 0.67-0.82). Indigenous Pacific Islanders scored significantly lower on protective and higher on risk factors. CONCLUSION: Tobacco product use rates among Guam middle school students appear to be 4 to 5 times higher than the US national average rates. There is an urgent need for developing tobacco and betel nut use prevention programs for USAPI youth that are tailored to the needs of indigenous Pacific Islanders.

Content analysis of internet marketing strategies used to promote flavored electronic cigarettes.

INTRODUCTION: Flavored e-cigarette (ECIG) use and Internet marketing have increased in the U.S. This study examined the content used to promote flavored ECIG liquids on retailer websites. METHODS: Four ECIG liquid retailers from four U.S. geographic regions (n = 16) were randomly selected. Menthol, apple, and tobacco flavored liquids were purchased in April of 2016 (n = 144, 48 unique flavors). Staff analyzed the text and image descriptors displayed on liquid bottles and retailer websites and coded content for presence of specific flavor, taste/smell, chemesthesis (i.e., touch), America/patriotic, and product quality/potentially modified risk content. A follow-up of retailer websites was conducted in March 2018. RESULTS: Nearly all (97.9%) ECIG liquids included a description that promoted flavor. Most descriptions including images of something other than an ECIG liquid bottle (e.g., 62% of tobacco ECIG liquid images included dried tobacco leaves, 43% of menthol ECIG liquid images included mint leaves or ice, 62% of apple ECIG liquid images included an apple). Images often promoted product sensations (e.g., cool, ice), sweet tastes of other products (e.g., chocolate, apple pie), or other appeals (e.g., America). Menthol and apple descriptions/images were more likely than tobacco descriptions/images to promote appeals related to chemesthesis (e.g., cool, warm, moist; p < .05). Most flavors were still available in 2018 and included the same flavor descriptions from 2016. CONCLUSIONS: Flavored ECIG liquid marketing often includes text descriptions and images that appeal to consumer sensations. Studies are needed to examine how access to point-of-sale Internet advertisements influences attitudes, perceptions, and purchasing of ECIG products, especially among at-risk populations such as youth.

E-cigarette Advertising Exposure, Explicit and Implicit Harm Perceptions, and E-cigarette Use Susceptibility Among Nonsmoking Young Adults.

Introduction: This study tested whether exposure to e-cigarette advertising increases e-cigarette use susceptibility among nonsmoking young adults by promoting explicit and implicit attitudes toward e-cigarettes as a safer and healthier alternative to combustible cigarettes. Methods: Young adult current nonsmokers who had never used an e-cigarette (n = 393; mean age = 22.1, standard deviation = 3.9; 66% women) were randomly assigned to one of the three conditions that involved viewing real-world, print e-cigarette ads. Two of the three conditions were experimental conditions where ads with different predominant themes (harm reduction ["Health"] versus social enhancement ["Social"] focused) were interspersed among ads of everyday objects. The third condition was the Control condition involving ads of everyday objects only. Participants provided data on explicit (ie, self-reported harm perceptions) and implicit (ie, Implicit Association Test) attitudes toward e-cigarette use and e-cigarette use intentions. Hypotheses were tested using structural equation modeling. Results: Relative to Control participants, participants in Health and Social conditions were more likely to show higher implicit attitudes toward e-cigarettes as a safer alternative to cigarettes. Only the Social condition, relative to Control, had a significant effect on lower explicit harm perceptions of e-cigarette versus cigarette use. The Social condition had a significant indirect effect on e-cigarette use susceptibility, mediated by explicit harm perceptions. Conclusions: Social enhancement-themed ads may communicate the reduced harm messages more strongly among young adults so as to affect both explicit and implicit attitudes and, through these, e-cigarette use susceptibility. Regulatory bodies may need to scrutinize reduced harm claims communicated through social enhancement-themed ads. Implications: The findings imply that implicit and explicit health benefit or reduced harm claims in e-cigarette marketing may be propagated via ads that use social enhancement gimmicks to attract youth and young adults. As the US Food and Drug Administration develops regulations on e-cigarette marketing, informed decisions need to be made that address harm reduction needs of current smokers as well as e-cigarette use onset among nonsmokers. In regard to the latter, e-cigarette marketing may need to be studied closely to monitor implicit and explicit health benefit claims that are coupled with the use of visual and textual gimmicks in ads that intend to make e-cigarettes more appealing to youth and young adults.

Confirmatory factor analysis and structural equation modeling of socio-cultural constructs among chamorro and non-chamorro micronesian betel nut chewers.

Objectives: Betel nut chewing is embedded within the cultures of South Asia, and Southeast Asia, and the Western Pacific. The determinants of betel nut consumption are complex. Ongoing consumption of betel nut is affected by cultural, social, and drug-specific effects (i.e. dependence). This study's first objective was to assess the psychometric properties (i.e. reliability and validity) of the socio-cultural constructs in a survey developed for betel nut chewers. The study's second objective was to investigate the influence of socio-cultural variables on betel nut chewing behaviors among Chamorro and non-Chamorro Micronesians in Guam. Design: The current study was a secondary analysis of a larger study (N = 600; n = 375 chewers and n = 225 former chewers) that examined socio-cultural factors that influence why chewers chew betel nut, along with assessing chewing behaviors, perceptions of risks, probability of changing behaviors, and methods that could be used to reduce use or quit. The socio-cultural constructs of the survey were analyzed using confirmatory factor analysis and structural equation modeling. Results: The socio-cultural factors were a sufficient fit with data and the instrument is reliable and valid, as indicated by various model fit indices (χ2 (13) = 18.49 with p = .14, TLI = .99, CFI = 1.00, SRMR = .02, RMSEA = .03 with 90% CIs [.00,.07]). Cronbach's alpha, the sign and magnitude of the factor loadings, the inter-factor correlations, and the large proportion of variance extracted for each factor, all indicate that the instrument is reliable and valid. Additionally, multivariate analyses showed that socio-cultural reasons were important contributing or chewing betel nut. Participants cited chewing because their friends and family members chewed, the behavior is embedded within their culture, and it would be considered rude and disrespectful to not chew. Conclusion: Based on the findings, this study provides important implications pertaining to creating culturally appropriate cessation programs.

Warning Statements and Safety Practices Among Manufacturers and Distributors of Electronic Cigarette Liquids in the United States.

Introduction: Prior to the US Food and Drug Administration's (FDA) regulation of electronic cigarettes and warning statements related to nicotine addiction, there was no critical examination of manufacturer/distributor voluntary practices that could potentially inform FDA actions aimed to protect consumers. This study examined the content of warning statements and safety characteristics of electronic cigarette liquid bottles using a national sample. Methods: Research staff randomly selected four electronic cigarette liquid manufacturers/distributors from four US geographic regions. Staff documented the characteristics of product packaging and content of warning statements on 147 electronic cigarette liquids (0-30 mg/ml of nicotine) purchased online from 16 manufacturers/distributors in April of 2016. Results: Data showed that 97.9% of the electronic cigarette liquid bottles included a warning statement, most of which focused on nicotine exposure rather than health. Only 22.4% of bottles used a warning statement that indicated the product "contained nicotine." Of bottles that advertised a nicotine-based concentration of 12 mg/ml, 26% had a warning statements stated that the product "contains nicotine." None of the statements that indicated that the product "contained nicotine" stated that nicotine was "addictive." All bottles had a safety cap and 12% were in plastic shrink-wrap. Fifty-six percent of the websites had a minimum age requirement barrier that prevented under-aged persons from entering. Conclusions: Most manufacturers/distributors printed a warning statement on electronic cigarette liquid bottles, but avoided warning consumers about the presence and the addictiveness of nicotine. Studies are needed to examine manufacturer/distributor modifications to product packaging and how packaging affects consumer behaviors. Implications: These data can inform future FDA requirements related to the packaging and advertising of e-cigarette liquids; regulation related to the content of warning statements, including exposure warning statements, which are not currently mandated; and requirements on websites or language on packaging to help manufacturers adhere to the minimum age of purchase regulation. The data can also be used to help FDA develop additional guidance on the framing of statements on packaging that helps consumers make informed decisions about purchasing the product or protecting young people from use or unintentional exposure to the product.