Flavored e-cigarette use: Characterizing youth, young adult, and adult users.

The purpose of this study is to investigate how the use of flavored e-cigarettes varies between youth (12-17 years old), young adults (18-29 years old), and older adults (30 + years old). Cross-sectional surveys of school-going youth (n = 3907) and young adult college students (n = 5482) in Texas, and young adults and older adults (n = 6051) nationwide were administered in 2014-2015. Proportions and 95% confidence intervals were used to describe the percentage of e-cigarette use at initiation and in the past 30 days that was flavored, among current e-cigarette users. Chi-square tests were applied to examine differences by combustible tobacco product use and demographic factors. Most e-cigarette users said their first and "usual" e-cigarettes were flavored. At initiation, the majority of Texas school-going youth (98%), Texas young adult college students (95%), and young adults (71.2%) nationwide said their first e-cigarettes were flavored to taste like something other than tobacco, compared to 44.1% of older adults nationwide. Fruit and candy flavors predominated for all groups; and, for youth, flavors were an especially salient reason to use e-cigarettes. Among adults, the use of tobacco flavor at initiation was common among dual users (e-cigarettes + combustible tobacco), while other flavors were more common among former cigarette smokers (P = 0.03). Restricting the range of e-cigarette flavors (e.g., eliminating sweet flavors, like fruit and candy) may benefit youth and young adult prevention efforts. However, it is unclear what impact this change would have on adult smoking cessation.

Carbapenemase-producing Enterobacteriaceae in hospital wastewater: a reservoir that may be unrelated to clinical isolates.

BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) are an emerging infection control problem in hospitals worldwide. Identifying carriers may help reduce potential spread and infections. AIM: To assess whether testing hospital wastewater for CPE can supplement patient-based screening for infection prevention purposes in a hospital without a recognized endemic CPE problem. METHODS: Wastewater collected from hospital pipework on 16 occasions during February to March 2014 was screened for CPE using chromID(®) CARBA agar and chromID(®) CPS agar with a 10µg ertapenem disc and combination disc testing. Minimum inhibitory concentrations were determined using British Society for Antimicrobial Chemotherapy methodology and carbapenemase genes detected by polymerase chain reaction or whole-genome sequencing. Selected isolates were typed by pulsed-field gel electrophoresis. FINDINGS: Suspected CPE were recovered from all 16 wastewater samples. Of 17 isolates sent to the Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, six (four Citrobacter freundii and two Enterobacter cloacae complex) were New Delhi metallo-ß-lactamase (NDM) producers and the remaining 11 (six Klebsiella oxytoca and five Enterobacter cloacae complex) were Guiana-Extended-Spectrum-5 (GES-5) producers, the first to be described among Enterobacteriaceae in the UK. The four NDM-producing C. freundii, two NDM-producing E. cloacae complex, and four out of five GES-5-producing E. cloacae complex were each indistinguishable isolates of the same three strains, whereas the six GES-5-producing K. oxytoca overall shared 79% similarity. CONCLUSION: CPE are readily isolated from hospital wastewater using simple culture methods. There are either undetected carriers of CPE excreting into the wastewater, or these CPE represent colonization of the pipework from other sources. Surveillance of hospital wastewater for CPE does not appear helpful for infection control purposes within acute hospitals.

Genetic variation among 82 pharmacogenes: The PGRNseq data from the eMERGE network.

Genetic variation can affect drug response in multiple ways, although it remains unclear how rare genetic variants affect drug response. The electronic Medical Records and Genomics (eMERGE) Network, collaborating with the Pharmacogenomics Research Network, began eMERGE-PGx, a targeted sequencing study to assess genetic variation in 82 pharmacogenes critical for implementation of "precision medicine." The February 2015 eMERGE-PGx data release includes sequence-derived data from ∼5,000 clinical subjects. We present the variant frequency spectrum categorized by variant type, ancestry, and predicted function. We found 95.12% of genes have variants with a scaled Combined Annotation-Dependent Depletion score above 20, and 96.19% of all samples had one or more Clinical Pharmacogenetics Implementation Consortium Level A actionable variants. These data highlight the distribution and scope of genetic variation in relevant pharmacogenes, identifying challenges associated with implementing clinical sequencing for drug treatment at a broader level, underscoring the importance for multifaceted research in the execution of precision medicine.

Design and anticipated outcomes of the eMERGE-PGx project: a multicenter pilot for preemptive pharmacogenomics in electronic health record systems.

We describe here the design and initial implementation of the eMERGE-PGx project. eMERGE-PGx, a partnership of the Electronic Medical Records and Genomics Network and the Pharmacogenomics Research Network, has three objectives: (i) to deploy PGRNseq, a next-generation sequencing platform assessing sequence variation in 84 proposed pharmacogenes, in nearly 9,000 patients likely to be prescribed drugs of interest in a 1- to 3-year time frame across several clinical sites; (ii) to integrate well-established clinically validated pharmacogenetic genotypes into the electronic health record with associated clinical decision support and to assess process and clinical outcomes of implementation; and (iii) to develop a repository of pharmacogenetic variants of unknown significance linked to a repository of electronic health record-based clinical phenotype data for ongoing pharmacogenomics discovery. We describe site-specific project implementation and anticipated products, including genetic variant and phenotype data repositories, novel variant association studies, clinical decision support modules, clinical and process outcomes, approaches to managing incidental findings, and patient and clinician education methods.

Factor VIII inhibitors: von Willebrand factor makes a difference in vitro and in vivo.

BACKGROUND: The important association between von Willebrand factor (VWF) and factor VIII (FVIII) has been investigated for decades, but the effect of VWF on the reactivity of FVIII inhibitory antibodies, referred to as inhibitors, is still controversial. OBJECTIVE: To investigate the interaction among VWF, FVIII and FVIII inhibitory antibodies. METHODS: Three sources of inhibitors were used for in vitro studies, including the plasma from immunized VWF(null) FVIII(null) mice, purified plasma IgG from human inhibitor patients, or human monoclonal antibody from inhibitor patients' B-cell clones. Inhibitors were incubated with recombinant human FVIII (rhFVIII) either with or without VWF. The remaining FVIII activity was determined by chromogenic assay and inhibitor titers were determined. For in vivo studies, inhibitors and rhFVIII were infused into FVIII(null) or VWF(null) FVIII(null) mice followed by a tail clip survival test. RESULTS: VWF has a dose-dependent protective effect on FVIII, limiting inhibitor inactivation of FVIII in both mouse and human samples. A preformed complex of VWF with FVIII provides more effective protection from inhibitors than competitive binding of antibodies and VWF to FVIII. The protective effect of VWF against FVIII inactivation by inhibitors was further confirmed in vivo by infusing inhibitors and FVIII into FVIII(null) or VWF(null) FVIII(null) mice followed by a tail clip survival test. CONCLUSION: Our results demonstrate that VWF exerts a protective effect, reducing inhibitor inactivation of FVIII, both in vitro and in vivo.

Measuring obesity among school-aged youth in India: a comparison of three growth references.

OBJECTIVE: To compare three growth references that can be used to assess the weight status of school-aged youth living in India, with a particular focus on identifying overweight and obese youth. STUDY DESIGN: Cross-sectional study. Kappa scores were used to measure agreement between growth references. Regression models were used to test for differences in weight status by grade level, gender, and school type, using each growth reference. SETTING: Private (n=4) and Government schools (n=4) in Delhi, India. PARTICIPANTS: Students (n=1818) in eighth and tenth grade attending the schools. MAIN OUTCOME MEASURES: Weight status was derived using age- and gender-specific cut-points provided by: (a) a national growth reference specific to India; (b) an international reference recommended by the International Obesity Task Force (IOTF); and (c) a new international reference recommended by the World Health Organization (WHO). RESULTS: The IOTF reference consistently classified participants in a lower weight status category, compared with the national reference (k=0.57) and the WHO reference (k=0.69). The agreement between the WHO and the national references was higher (k=0.84). CONCLUSIONS: To date, all published studies of childhood obesity in India have used the IOTF reference, the national reference, or an old WHO reference to measure weight status among school-going youth. The new WHO reference may be a better choice. Compared to the IOTF reference, it does not appear to underestimate obesity and can still be used to compare trends, globally.

Why are urban Indian 6th graders using more tobacco than 8th graders? Findings from Project MYTRI.

OBJECTIVE: To investigate why urban Indian 6th graders may be using more tobacco than urban Indian 8th graders. DESIGN: Cross-sectional survey of students conducted in the summer of 2004, as the baseline evaluation tool for a group-randomised tobacco prevention intervention trial (Project MYTRI). Mixed-effects regression models were used to (1) examine the relationship between 15 psychosocial risk factors and current use of any tobacco, by grade; and (2) examine differences in psychosocial risk factors, by grade. SETTING: Thirty-two private (high socioeconomic status (SES)) and government (low-mid SES) schools in two large cities in India (Delhi and Chennai). SUBJECTS: Students in the 6th and 8th grade in these schools (n = 11642). Among these, 50.6% resided in Delhi (v Chennai), 61.4% attended a government school (v a private school), 52.9% were enrolled in 6th grade (v 8th), and 54.9% were male (v female). MAIN OUTCOME MEASURE: Current (past 30 day) use of any tobacco, including chewing tobacco (for example, gutkha), bidis, or cigarettes. RESULT: Almost all psychosocial factors were significantly related to tobacco use, for students in both grades. Some of the strongest correlates included social susceptibility to and social norms about use. Exposure to tobacco advertising was a strong correlate of tobacco use for 6th graders, but not for 8th graders. Sixth graders scored lower than 8th graders on almost all factors, indicating higher risk. CONCLUSIONS: The "risk profile" of 6th graders suggests they would be vulnerable to use and to begin using tobacco, as well as to outside influences that may encourage use.

Weight-related attitudes and behaviors of adolescent boys and girls who are encouraged to diet by their mothers.

OBJECTIVE: To assess the relationships between mothers' reports of dieting and encouraging adolescents to diet and adolescents' reports of their own dieting practices and weight-related concerns. DESIGN: Cross-sectional study of parent interviews and adolescent surveys in an ethnically-diverse sample. SUBJECTS: A total of 810 adolescents (n=381 boys and n=429 girls) and their mothers. RESULTS: Mothers' dieting was associated with their adolescent girls' weight-related concerns and behaviors, but these associations were not significant after adjusting for girls' body mass index (BMI). In contrast, mothers' encouragement for sons to diet was associated with sons' binge eating, dieting and other weight-control behaviors, even after controlling for sons' BMI. Compared with mothers who did not encourage their child to diet, mothers who encouraged their child to diet were significantly heavier women and were more likely to view their child as overweight. Forty-three percent of boys and 46% of girls who were encouraged by their mothers to diet were classified as nonoverweight by federal guidelines. CONCLUSIONS: Boys who are encouraged by their mothers to diet may be at risk for health-compromising eating and dieting behaviors, particularly binge-eating, fasting, eating a little bit of food and skipping meals. Parents who are concerned about their children's weight should be educated to encourage healthy eating habits and physical activity to promote their children's health, including healthy weight control.

Characteristics of vegetarian adolescents in a multiethnic urban population.

PURPOSE: To examine the prevalence of adolescents' vegetarianism in a multiethnic, urban population, and its correlates with demographic, personal, weight-related, and behavioral factors. METHODS: Self-report and anthropometric data were collected from a representative sample of 4746 adolescents from 31 public middle schools and high schools in the Twin Cities area of Minnesota. Students answered questions concerning vegetarianism, food and weight, and health behaviors. Height and weight were directly measured. Comparisons were made between self-reported vegetarians and nonvegetarians; these analyses also assessed gender and race/ethnicity interactions. In the second set of analyses, demographic and behavioral characteristics of more restricted and semi-vegetarians were examined. Analyses were done by logistic regression. RESULTS: Teenage vegetarians comprise about 6% of the sample. The vegetarians were more likely than nonvegetarians to be female, not black, weight- and body-conscious, dissatisfied with their bodies, and involved in a variety of healthy and unhealthy weight control behaviors. Vegetarians more often reported having been told by a physician that they had an eating disorder and were more likely to have contemplated and attempted suicide. Vegetarian males were found to be an especially high risk group for unhealthy weight control practices. Few ethnic group differences among vegetarians were noted. Adolescents who did not eat chicken and fish were at lower risk than those who also ate chicken and fish. CONCLUSIONS: Adolescent vegetarians are at greater risk than others for involvement in unhealthy and extreme weight control behaviors. Vegetarian males are at particularly high risk. Vegetarianism among adolescents may therefore be a signal for preventive intervention. Adolescents who choose to become vegetarians may also need to learn how to healthfully do so.

Russian-American partners for prevention. Adaptation of a school-based parent-child programme for alcohol use prevention.

BACKGROUND: The Russian-American Partners for Prevention was an adaptation and evaluation of the Slick Tracy Home Team Program which was developed in Minnesota in order to delay the onset of drinking. The Slick Tracy Home Team Program was the first intervention of Project Northland, a large 3 year community trial of the efficacy of a public health intervention for under age drinking. METHODS: The programme was administered through schools, but involved parents using engaging and fun homework activities. The Russian version was implemented in fifth-grade classrooms in 20 Moscow schools with 1,212 students surveyed at baseline. Students were surveyed again after programme implementation (n = 1,182), of whom 980 were present at baseline. Parents of 1,078 students were surveyed by telephone after programme implementation. RESULTS: The results demonstrated the successful recruitment and retention of 20 Moscow schools in a research project, acceptability of programme materials in Russia, high participation rates, changes in students' knowledge about problems associated with under age drinking and some evidence about increases in parent-child communication about alcohol use. As in the USA, no changes in students' alcohol use rates were observed at the end of the first year of the 3 year programme. CONCLUSION: Russian youth, as compared to Americans, began drinking at earlier ages, received fewer prevention messages from their parents, and had fewer prevention programmes in school. The results suggested that carefully implemented and evaluated replications of the US Project Northland interventions might provide effective and appropriate school-based programmes for Russia.

How did Project Northland reduce alcohol use among young adolescents? Analysis of mediating variables.

Project Northland is a randomized trial designed to create, implement and evaluate multilevel, community-wide strategies to prevent alcohol use among adolescents. This paper will focus on the mediating outcomes of the early adolescent phase of Project Northland when the students in the study cohort were in Grades 6-8. The project was conducted in 24 school districts and adjacent communities in northeastern Minnesota. The intervention consisted of social-behavioral curricula in schools, peer leadership activities, parental involvement and education, and community-wide activities. At the end of 3 years of intervention, significantly fewer students in the intervention school districts reported alcohol use than students in the reference districts. Mediation analyses were conducted to investigate if the intervention's effects on mediating variables could explain the reduction in alcohol use. Important mediators of Project Northland's effect on alcohol use were: (1) peer influence to use, including normative estimates, (2) functional meanings of alcohol use, (3) attitudes and behaviors associated with alcohol and drug problems like stimulus seeking, rule violations and bad judgement, and (4) parent-child alcohol-related communication around alcohol use. In addition, among those who did not use alcohol at baseline, self-efficacy to refuse offers of alcohol was a significant mediator.

Project ARM: alcohol risk management to prevent sales to underage and intoxicated patrons.

Clear policies and expectations are key to increasing responsible service of alcohol in licensed establishments. Few training programs focus exclusively on owners and managers of alcohol establishments to reduce the risk of alcohol service. Project ARM: Alcohol Risk Management is a one-on-one consultation program for owners and managers. Participants received information on risk level, policies to prevent illegal sales, legal issues, and staff communication. This nonrandomized demonstration project was implemented in five diverse bars. Two waves of underage and pseudo-intoxicated purchase attempts were conducted pre- and postintervention in the five intervention bars and nine matched control bars. Underage sales decreased by 11.5%, and sales to pseudo-intoxicated buyers decreased by 46%. Results were in the hypothesized direction but not statistically significant. A one-on-one, outlet-specific training program for owners and managers is a promising way to reduce illegal alcohol sales, particularly to obviously intoxicated individuals.

Prevalence of marked overweight and obesity in a multiethnic pediatric population: findings from the Child and Adolescent Trial for Cardiovascular Health (CATCH) study.

OBJECTIVE: Determine the prevalence of marked overweight and obesity among children in the Child and Adolescent Trial for Cardiovascular Health (CATCH), identify high risk groups, and compare findings to other recent studies. DESIGN: Cohort study. SUBJECTS/SETTING: Five thousand one hundred-six school children who were participants in CATCH at baseline (age approximately 9 years) during 1991 and 4,019 of those children who had follow-up data from 1994 (age approximately 1 years) available. METHODS: Body mass index (BMI), triceps and subscapular skinfolds, subscapular to triceps skinfold (S/T) ratio, and an estimate of body fat distribution from skinfolds was calculated. Findings were compared to population-based reference data from the First National Health and Nutrition Examination Survey, 1971 to 1973 (NHANES I), to data from the Bogalusa Heart Study, and to data from the Third National Health and Nutrition Examination Survey, 1988 to 1994 (NHANES III). RESULTS: Children in CATCH were markedly heavier and fatter than the NHANES I population and more comparable to the NHANES III population, especially those in the upper percentiles. The prevalence of obesity based on BMI and triceps skinfolds >95th percentile among CATCH children was higher in boys than in girls at both baseline (boys 9.1%, girls 8.6%) and follow-up (boys 11.7%, girls 7.2%). It was higher among African-Americans and Hispanics than whites for both sexes. S/T ratios did not differ appreciably from those observed in the NHANES I reference population, suggesting that body fat distribution was more stable over time than BMI and skinfolds. APPLICATIONS: Our findings support other recent reports that American children, especially African-American and Hispanic children, are becoming heavier and fatter. Preventive measures are warranted, especially for high-risk youth.

5-a-day Power Plus: process evaluation of a multicomponent elementary school program to increase fruit and vegetable consumption.

The 5-a-Day Power Plus program targeted multiethnic fourth- and fifth-grade students in 10 intervention and 10 control urban elementary schools in St. Paul, Minnesota, to increase fruit and vegetable consumption. The intervention included behavioral curricula in classrooms, parental involvement, school food service changes, and food industry support. Process evaluation was conducted by using surveys and classroom and lunchroom observations to assess the characteristics of teachers and food service staff, the degree the intervention was implemented as intended, and exteral factors that may have affected the program results. Results showed high levels of participation, dose, and fidelity for all of the intervention components, with the exception of parental involvement. The process evaluation findings help explain why the increase in fruit and vegetable consumption occurred mostly at school lunch and not at home. Future intervention research should focus on creating new and potent strategies for parental involvement and for increasing the appeal and availability of vegetables.

The Minnesota DARE PLUS Project: creating community partnerships to prevent drug use and violence.

The research community has criticized Drug Abuse Resistance Education (D.A.R.E.) because the extant literature indicates a lack of evidence that the elementary school program prevents drug use. Yet D.A.R.E. continues to be the most widely implemented drug use prevention program in the United States and has considerable community support. To date, the junior high D.A.R.E. program has not been evaluated. The Minnesota DARE PLUS Project is a randomized trial of 24 schools and communities. During 1999-2001, students in eight schools will receive the junior high D.A.R.E. curriculum in 7th grade; eight schools also will receive the curriculum as well as additional parent involvement, peer leadership, and community components in the 7th and 8th grades; and eight schools will serve as controls. This article describes the background and conceptualization, the curriculum and additional intervention components, and the evaluation methods of the DARE PLUS Project.

Project Northland high school interventions: community action to reduce adolescent alcohol use.

Project Northland is a randomized community trial initially implemented in 24 school districts and communities in northeastern Minnesota, with goals of delaying onset and reducing adolescent alcohol use using community-wide, multiyear, multiple interventions. The study targets the Class of 1998 from the 6th to 12th grades (1991-1998). The early adolescent phase of Project Northland has been completed, and reductions in the prevalence of alcohol use at the end of 8th grade were achieved. Phase II of Project Northland, targeting 11th- and 12th-grade students, uses five major strategies: (1) direct action community organizing methods to encourage citizens to reduce underage access to alcohol, (2) youth development involving high school students in youth action teams, (3) print media to support community organizing and youth action initiatives and communicate healthy norms about underage drinking (e.g., providing alcohol to minors is unacceptable), (4) parent education and involvement, and (5) a classroom-based curriculum for 11th-grade students. This article describes the background, design, implementation, and process measures of the intervention strategies for Phase II of Project Northland.

Do friendships change behaviors, or do behaviors change friendships? Examining paths of influence in young adolescents' alcohol use.

PURPOSE: This study examined support for models of peer influence, which postulates that young adolescents whose friends use alcohol will also engage in that behavior, and of peer selection, whereby young adolescents seek out friends whose drinking behavior is similar to their own. METHODS: Data for this study are from 1804 adolescents participating in Project Northland, a school- and community-based alcohol use prevention trial. Using latent variable structural equation modeling, a series of models examined directions of influence between participant alcohol use and friend drug use over three points in Grades 7, 8, and 9. RESULTS: Findings indicated that higher levels of friends' drug use led to increased participant alcohol use. The reverse-order relationship (i.e., greater participant involvement in alcohol leading to more drug use among friends) was not supported by these data. Finally, best-fitting models supported the notion that both participants' alcohol use and the alcohol and other drug use of friends were highly stable over time. CONCLUSIONS: Similarity in drinking behavior among adolescent friends may be more related to processes of peer influence than to processes of peer selection. Findings support the utility of alcohol use prevention programs that equip younger teens with skills to resist peer influences to use alcohol.

Communities mobilizing for change on alcohol: outcomes from a randomized community trial.

OBJECTIVE: Communities Mobilizing for Change on Alcohol (CMCA) was a randomized 15-community trial of a community organizing intervention designed to reduce the accessibility of alcoholic beverages to youths under the legal drinking age. METHOD: Data were collected at baseline before random assignment of communities to intervention or control condition, and again at follow-up after a 2.5-year intervention. Data collection included in-school surveys of twelfth graders, telephone surveys of 18- to 20-year-olds and alcohol merchants, and direct testing of the propensity of alcohol outlets to sell to young buyers. Analyses were based on mixed-model regression, used the community as the unit of assignment, took into account the nesting of individual respondents or alcohol outlets within each community, and controlled for relevant covariates. RESULTS: Results show that the CMCA intervention significantly and favorably affected both the behavior of 18- to 20-year-olds (effect size = 0.76, p<.01) and the practices of on-sale alcohol establishments (effect size = 1.18, p<.05), may have favorably affected the practices of off-sale alcohol establishments (effect size = 0.32, p = .08), but had little effect on younger adolescents. Alcohol merchants appear to have increased age-identification checking and reduced propensity to sell to minors. Eighteen- to 20-year-olds reduced their propensity to provide alcohol to other teens and were less likely to try to buy alcohol, drink in a bar or consume alcohol. CONCLUSIONS: Community organizing is a useful intervention approach for mobilizing communities for institutional and policy change to improve the health of the population.

Effectiveness of monetary incentives for recruiting adolescents to an intervention trial to reduce smoking.

BACKGROUND: The study objective is to evaluate the effect of monetary incentives on response rates of adolescents to a smoking-related survey as the first step toward participation in an intervention trial. METHODS: A sample of 4,200 adolescent members of a managed care organization were randomized to one of four incentive groups: a $2 cash group, a $15 cash group, a $200 prize drawing group, or a no-incentive group. We compared group-specific response rates and willingness to be contacted about future study activities, as well as costs. RESULTS: Incentives increased survey response rates (55% response without incentive vs. a 69% response with incentive), with response of 74% in the $15 cash group, 69% in the token group, and 63% with a prize incentive. Incentives did not adversely affect willingness of adolescents to be contacted about a smoking intervention, (65% willing with incentives vs. 60% without, P = 0.03). In terms of cost per additional survey completed, token and prize groups were marginally more expensive than the no-incentive group ($0.40 and $1.42, respectively) while the large cash incentive was substantially more costly ($11.37). CONCLUSIONS: Monetary incentives improve response rates to a mailed survey, without adverse impact on willingness to further participate in intervention activities. However, a variety of issues must be considered when using incentives for recruitment to intervention studies.

An evaluation of a theatre production to encourage non-smoking among elementary age children: 2 Smart 2 Smoke.

OBJECTIVE: To evaluate the impact of a theatre production on smoking-related attitudes, norms, and intentions of children in grades 1-6 (aged 6-12 years). DESIGN: Seventeen schools were randomly selected among 160 that were participating in the implementation of the theatre production 2 Smart 2 Smoke. Schools that participated in the theatre production after 3 December 1997 were assigned as control schools. Assignment of schools to a given date for the theatre production was a random process. Students in grades 1-6 were surveyed before and after the theatre production and associated activities. The data were examined for pretest-posttest differences and intervention-control differences. The school was the unit of analysis. SETTING: Elementary schools in the Twin Cities metropolitan area. PARTICIPANTS: Students in grades 1-6 in 17 elementary schools. INTERVENTION: Two plays 2 Smart 2 Smoke for grades 1-3 (6-8 year olds) and grades 4-6 (9-12 year olds), respectively, with follow-up activities for the classroom and home. A national theatre company performed the plays at the schools. MAIN OUTCOME MEASURES: Intention to smoke in the future, normative expectations about how many people smoke, functional meanings of smoking, expected outcomes of smoking. RESULTS: 10% more students reported that they would never smoke a cigarette after the theatre production. Students in grades 4-6 showed changes in the functional meanings and expected outcomes of smoking. Students in grades 1-3 showed changes in normative expectations. CONCLUSIONS: Further research on the impact of live theatre productions as a smoking prevention strategy is recommended.