Impact of regulatory tightening of the Hungarian tobacco retail market on availability, access and cigarette smoking prevalence of adolescents.

INTRODUCTION: Policies that reduce tobacco retail density to decrease tobacco use among the youth are critical for the tobacco endgame. This paper reviews a Hungarian tobacco regulatory measure, which, since 2013, has confined the sale of tobacco products exclusively to so-called National Tobacco Shops, summarises the changes in the national tobacco retail marketplace and reports on analyses of the impact of this intervention on illegal sales to minors and adolescent smoking behaviour. METHODS: We reviewed the available national statistical data on the structure and dynamics of the tobacco retail market. Changes in lifetime and current (past 30 days) use of cigarettes among Hungarian adolescents aged 13-17 years were assessed using data from international youth surveys on health behaviours collected in 2010-2020. RESULTS: Since the start of policy implementation, the density of tobacco shops in Hungary decreased by 85%, from 4.1 to 0.6 per 1000 persons. The prevalence of lifetime and current cigarette smoking among adolescents declined by 13-24 percentage points (pp) and by 4.8-15 pp, respectively. The rate of illegal sales of tobacco products to minors decreased by 27.6 pp, although the prevalence of compensatory access strategies, especially asking others to buy cigarettes for minors, increased. CONCLUSIONS: After a significant decrease in the nationwide availability of licensed tobacco retailers, Hungary experienced short-term reductions in youth smoking prevalence. However, the sporadic implementation of complementary, evidence-based tobacco control strategies might limit further declines in youth smoking initiation and tobacco product use.

Longitudinal Monitoring of Clinician-Patient Video Visits During the Peak of the COVID-19 Pandemic: Adoption and Sustained Challenges in an Integrated Health Care Delivery System.

BACKGROUND: Numerous prior opinion papers, administrative electronic health record data studies, and cross-sectional surveys of telehealth during the pandemic have been published, but none have combined assessments of video visit success monitoring with longitudinal assessments of perceived challenges to the rapid adoption of video visits during the pandemic. OBJECTIVE: This study aims to quantify (1) the use of video visits (compared with in-person and telephone visits) over time during the pandemic, (2) video visit successful connection rates, and (3) changes in perceived video visit challenges. METHODS: A web-based survey was developed for the dual purpose of monitoring and improving video visit implementation in our health care system during the COVID-19 pandemic. The survey included questions regarding rates of in-person, telephone, and video visits for clinician-patient encounters; the rate of successful connection for video visits; and perceived challenges to video visits (eg, software, hardware, bandwidth, and technology literacy). The survey was distributed via email to physicians, advanced practice professionals, and clinicians in May 2020. The survey was repeated in March 2021. Differences between the 2020 and 2021 responses were adjusted for within-respondent correlation across surveys and tested using generalized estimating equations. RESULTS: A total of 1126 surveys were completed (511 surveys in 2020 and 615 surveys in 2021). In 2020, only 21.7% (73/336) of clinicians reported no difficulty connecting with patients during video visits and 28.6% (93/325) of clinicians reported no difficulty in 2021. The distribution of the percentage of successfully connected video visits ("Over the past two weeks of scheduled visits, what percentage did you successfully connect with patients by video?") was not significantly different between 2020 and 2021 (P=.74). Challenges in conducting video visits persisted over time. Poor connectivity was the most common challenge reported by clinicians. This response increased over time, with 30.5% (156/511) selecting it as a challenge in 2020 and 37.1% (228/615) in 2021 (P=.01). Patients not having access to their electronic health record portals was also a commonly reported challenge (109/511, 21.3% in 2020 and 137/615, 22.3% in 2021, P=.73). CONCLUSIONS: During the pandemic, our health care delivery system rapidly adopted synchronous patient-clinician communication using video visits. As experience with video visits increased, the reported failure rate did not significantly decline, and clinicians continued to report challenges related to general network connectivity and patient access to technology.

American Indian/Alaska Native men are less likely to receive prostate-specific antigen testing and digital rectal exams from primary care providers than White men: a secondary analysis of the National Ambulatory Medical Care Survey from 2012-2018.

PURPOSE: (1) Identify the proportion of primary care visits in which American Indian/Alaska Native (AI/AN) men receive a prostate-specific antigen test (PSAT)and/or a digital rectal exam (DRE), (2) describe characteristics of primary care visits in which AI/AN receive PSA and/or DRE, and (3) identify whether AI/AN receive PSA and/or DRE less often than non-Hispanic White (nHW) men. METHODS: This was a secondary analysis of the National Ambulatory Medical Care Survey (NAMCS) during 2013-2016 and 2018 and the NAMCS Community Health Center (CHC) datasets from 2012-2015. Weighted bivariate and multivariable tests analyzed the data to account for the complex survey design. RESULTS: For AI/AN men, 1.67 per 100 visits (95% CI = 0-4.24) included a PSATs (or PSAT) and 0 visits included a DRE between 2013-2016 and 2018. The rate of PSA for non-AI/AN men was 9.35 per 100 visits (95% CI = 7.78-10.91) and 2.52 per 100 visits (95% CI = 1.61-3.42) for DRE. AI/AN men were significantly less likely to receive a PSA than nHW men (aOR = 0.09, 95% CI = 0.01-0.83). In CHCs, AI/AN men experienced 4.26 PSAT per 100 visits (95% CI = 0.96-7.57) compared to 5.00 PSAT per 100 visits (95% CI = 4.40-5.68) for non-AI/AN men. DRE rates for AI/AN men was 0.63 per 100 visits (95% CI = 0-1.61) compared to 1.05 per 100 (95% CI = 0.74-1.37) for non-AI/AN men. There was not a statistically significant disparity in the CHC data regarding PSA (OR = 0.91, 95% CI = 0.42-1.98) or DRE (OR = 0.75, 95% CI = 0.15-3.74), compared to nHW men. CONCLUSION: Efforts are needed to better understand why providers may not use PSA and DRE with AI/AN men compared to nHW men.

Prehospital Time Disparities for Rural Patients with Suspected STEMI.

BACKGROUND: Rural patients with ST-elevation myocardial infarction (STEMI) may be less likely to receive prompt reperfusion therapy. This study's primary objective was to compare rural versus urban time intervals among a national cohort of prehospital patients with STEMI. METHODS: The ESO Data Collaborative (Austin, TX), containing records from 1,366 emergency medical services agencies, was queried for adult 9-1-1 responses with suspected STEMI from 1/1/2018-12/31/2019. The scene address for each encounter was classified as either urban or rural using the 2010 US Census Urban Area Zip Code Tabulation Area relationship. The primary outcome was total EMS interval (9-1-1 call to hospital arrival); a key secondary outcome was the proportion of responses that had EMS intervals under 60 minutes. Generalized estimating equations were used to determine whether rural versus urban differences in interval outcomes occurred when adjusting for loaded mileage (distance from scene to hospital) and patient and clinical encounter characteristics. RESULTS: Of 15,915,027 adult 9-1-1 transports, 23,655 records with suspected STEMI were included in the analysis. Most responses (91.6%, n = 21,661) occurred in urban settings. Median EMS interval was 37.6 minutes (IQR 30.0-48.0) in urban settings compared to 57.0 minutes (IQR 46.5-70.7) in rural settings (p < 0.01). Urban responses more frequently had EMS intervals <60 minutes (89.5%, n = 19,130), compared to rural responses (55.5%, n = 1,100, p < 0.01). After adjusting for loaded mileage, age, sex, race/ethnicity, abnormal vital signs, pain assessment, aspirin administration, and IV/IO attempt, rural location was associated with a 5.8 (95%CI 4.2-7.4) minute longer EMS interval than urban, and rural location was associated with a reduced chance of achieving EMS interval < 60 minutes (OR 0.40; 95%CI 0.33-0.49) as compared to urban location. CONCLUSION: In this large national sample, rural location was associated with significantly longer EMS interval for patients with suspected STEMI, even after accounting for loaded mileage.

Characterization of Head Acceleration Exposure During Youth Football Practice Drills.

Many head acceleration events (HAEs) observed in youth football emanate from a practice environment. This study aimed to evaluate HAEs in youth football practice drills using a mouthpiece-based sensor, differentiating between inertial and direct HAEs. Head acceleration data were collected from athletes participating on 2 youth football teams (ages 11-13 y) using an instrumented mouthpiece-based sensor during all practice sessions in a single season. Video was recorded and analyzed to verify and assign HAEs to specific practice drill characteristics, including drill intensity, drill classification, and drill type. HAEs were quantified in terms of HAEs per athlete per minute and peak linear and rotational acceleration and rotational velocity. Mixed-effects models were used to evaluate the differences in kinematics, and generalized linear models were used to assess differences in HAE frequency between drill categories. A total of 3237 HAEs were verified and evaluated from 29 football athletes enrolled in this study. Head kinematics varied significantly between drill categorizations. HAEs collected at higher intensities resulted in significantly greater kinematics than lower-intensity drills. The results of this study add to the growing body of evidence informing evidence-based strategies to reduce head impact exposure and concussion risk in youth football practices.

An Evaluation of Breast and Cervical Cancer Screening Outcomes in an Education and Patient Navigation Program in Rural and Border Texas.

This study examines breast and cervical cancer screening uptake in a cancer education and patient navigation (PN) program for residents of rural and border counties in Texas by level of participation (education only, PN only, or education and PN). Data collected from March 1, 2012, to November 5, 2016, included 6663 follow-up surveys from participants aged 21-74. Logistic regression models assessed program participation on the odds of completing breast or cervical cancer screening. For women aged 40-74 years (N = 4942; mean age = 52 years), 58.4% reported a mammogram within 6 months on average from initial contact. In the breast cancer screening model, women who only received PN (OR: 6.06, CI: 4.87-7.53) or who participated in both the education plus PN program (OR: 3.33, CI: 2.77-4.02) had higher odds of mammogram screening compared to women who only received education. For women aged 21-64 years (N = 6169; mean age = 46 years), 37.7% received a Papanicolaou (Pap) test within 6 months on average from initial contact. In the Pap screening model, both education and PN (OR: 3.23, CI: 2.66-3.91) and PN only (OR: 2.35, CI: 1.88-2.93) groups had higher odds of screening for cervical cancer compared to those only receiving education. Graphed predicted probabilities examined significant interactions between race/ethnicity/language and program participation (P < 0.0001) for both screenings. PN, solely or in combination with education, is an effective strategy to increase screening for breast and cervical cancer, beyond educational outreach efforts alone, among un-/underserved, racially/ethnically diverse women in rural and border Texas counties.

Predictors of Enrollment of Older Smokers in Six Smoking Cessation Trials in the Lung Cancer Screening Setting: The Smoking Cessation at Lung Examination (SCALE) Collaboration.

SIGNIFICANCE: Increased rates of smoking cessation will be essential to maximize the population benefit of low-dose CT screening for lung cancer. The NCI's Smoking Cessation at Lung Examination (SCALE) Collaboration includes eight randomized trials, each assessing evidence-based interventions among smokers undergoing lung cancer screening (LCS). We examined predictors of trial enrollment to improve future outreach efforts for cessation interventions offered to older smokers in this and other clinical settings. METHODS: We included the six SCALE trials that randomized individual participants. We assessed demographics, intervention modalities, LCS site and trial administration characteristics, and reasons for declining. RESULTS: Of 6285 trial- and LCS-eligible individuals, 3897 (62%) declined and 2388 (38%) enrolled. In multivariable logistic regression analyses, Blacks had higher enrollment rates (OR 1.5, 95% CI 1.2,1.8) compared to Whites. Compared to "NRT Only" trials, those approached for "NRT + prescription medication" trials had higher odds of enrollment (OR 6.1, 95% CI 4.7,7.9). Regarding enrollment methods, trials using "Phone + In Person" methods had higher odds of enrollment (OR 1.6, 95% CI 1.2,1.9) compared to trials using "Phone Only" methods. Some of the reasons for declining enrollment included "too busy" (36.6%), "not ready to quit" (8.2%), "not interested in research" (7.7%), and "not interested in the intervention offered" (6.2%). CONCLUSION: Enrolling smokers in cessation interventions in the LCS setting is a major priority that requires multiple enrollment and intervention modalities. Barriers to enrollment provide insights that can be addressed and applied to future cessation interventions to improve implementation in LCS and other clinical settings with older smokers. IMPLICATIONS: We explored enrollment rates and reasons for declining across six smoking cessation trials in the lung cancer screening setting. Offering multiple accrual methods and pharmacotherapy options predicted increased enrollment across trials. Enrollment rates were also greater among Blacks compared to Whites. The findings offer practical information for the implementation of cessation trials and interventions in the lung cancer screening context and other clinical settings, regarding intervention modalities that may be most appealing to older, long-term smokers.

Factors Affecting Patient Adherence to Lung Cancer Screening.

OBJECTIVES: The National Lung Screening Trial (NLST) demonstrated a 20% reduction in mortality with low-dose computed tomography (CT) for lung cancer screening (LCS). The NLST found the greatest benefit to LCS for patients who underwent annual screening for a full 3-year follow-up period. The adherence to serial imaging in the NLST was 95%. METHODS: We conducted a prospective study of 268 patients who presented for LCS and who were not enrolled in a research study to determine the adherence to recommended follow-up imaging and biopsy at a single center. We evaluated the correlations among sociodemographic characteristics, Lung Imaging and Reporting Data System, and adherence. RESULTS: Only 48% of the patient population received recommended follow-up (either imaging or biopsy) after their referent LCS. Patients with abnormal LCS (Lung Imaging and Reporting Data System 3 or 4) were more likely to adhere to the recommended follow-up (additional imaging or biopsy) compared with those with negative screens. Sex, ethnicity, smoking status, and household income were not correlated with adherence to screening and biopsy. CONCLUSIONS: The benefits from LCS observed in the NLST may be undermined by low adherence to follow-up screening. Studies targeting LCS patients to bolster adherence to follow-up are needed.

Smoking prevalence and desire to quit among employees in Transylvanian foster care homes.

OBJECTIVES: Few studies have investigated smoking habits among foster care home children and employees, who are at high risk for smoking. Additionally, there are no published studies on the intention to quit smoking among employees of the Romanian Child Protection system, a gap we address in this manuscript. METHODS: A repeated cross-sectional survey was conducted among foster care employees in three Transylvanian counties (Mures, Sibiu, Covasna) in January 2014 to February 2015 (baseline) and September-December 2016 (follow-up). A foster home-based smoking prevention and cessation intervention targeting employees and children was conducted between the two waves. Multivariate logistic regression analysis was conducted to determine associations between socio-demographics, reasons for smoking, tobacco use patterns, reasons for quitting, and tobacco policy attitudes on intention to quit (dependent variable), controlling for participation in the smoking prevention intervention. RESULTS: 305 employees participated in the baseline (76.4% of females, 23.6% of males) and 304 employees in the follow-up surveys (68.8% of females, 31.2% of males) after the smoking prevention and cessation intervention. At baseline, 34.8% of respondents reported that no one was smoking within the foster care home, which increased to 59.1% at follow-up (p < 0.001). Being male and a high level of professional satisfaction were the only correlates of intention to quit in the bivariate models at baseline. Professional satisfaction and a belief that smoking is bad for one's health were the only correlates of intention to quit at follow-up. In multivariable models, professional satisfaction was the only consistent predictor of intention to quit at both time points (OR 5.63, 95% CI 1.71-18.56; OR 4.98, 95% CI 1.43-17.30). CONCLUSIONS: Efforts should be made to promote cessation among foster care employees that includes evidence-based support, along with compliance to policies that prohibit smoking indoors to reinforce cessation efforts.

The Effects of Health Disparities on Perceptions About Lung Cancer Screening (LCS): Survey Results of a Patient Sample.

Lung cancer screening (LCS) is currently advocated in a subset of current or former smokers with a thirty pack-year smoking history or higher. Studies report that few patients meeting the criteria for screening are undergoing LCS. We conducted a survey to assess if barriers to LCS (race, ethnicity, and socioeconomic status) affect the perceptions about LCS that could influence screening uptake. We did not detect different perceptions based on race, ethnicity, or socioeconomic status; however, our survey found that fewer barriers and more benefits to LCS may be perceived in patients who undergo other types of health screening and more benefits for those with internet capable devices.

Perceived health effects of vaping among Hungarian adult e-cigarette-only and dual users: a cross-sectional internet survey.

BACKGROUND: Knowledge about the health effects of e-cigarette use (or vaping) among past and current combustible cigarette users is limited. Several studies have assessed vaping-related adverse events (AEs) and beneficial health effects, however, most studies focused on AEs in general and examined only a few physiological changes that vapers experience. This study aims to explore self-reported AEs and perceived health changes due to e-cigarette use among Hungarian adult e-cigarette-only users (former smokers who switched completely to e-cigarette use) and dual users (smokers who use e-cigarettes and combustible tobacco cigarettes concomitantly). METHODS: A cross-sectional, web-based survey of 1042 adult Hungarian e-cigarette users was conducted in 2015. Participants reported AEs and changes in physiological functions since they switched from smoking to e-cigarette use or while dually using e-cigarettes and combustible cigarettes. Confirmatory factor analysis with covariates was applied to explain perceived health changes due to e-cigarette-only use and dual use. RESULTS: Dual users (17.6%) were significantly more likely to report AEs of vaping than e-cigarette-only users (26.2% vs. 11.8%, p < 0.001). Experiencing health improvements were significantly more likely among e-cigarette-only users than for dual users for all surveyed physiological functions. E-cigarette-only users reported larger effects of vaping on sensory, physical functioning, and mental health factors compared to dual users. Self-reported changes in sensory and physical functioning were significantly higher among individuals using e-cigarettes more than a year and people who were past heavy smokers (smoked ≥20 cigarettes per day). Gender was related to sensory improvement only; males reported greater improvement than females. CONCLUSIONS: The majority of e-cigarette-only users reported more perceived beneficial changes in physiological functions and fewer AEs than dual users. Perceived short-term benefits of e-cigarette use may reinforce users despite the uncertainty of long-term health consequences. Health professionals should provide balanced information regarding the possible short- and long-term positive and negative health effects of e-cigarette use during consultations with patients.

A Qualitative Systematic Review of Cigarette Smoking Cessation Interventions for Persons Living with HIV.

Persons living with HIV (PLWH) have disproportionately high rates of both cigarette smoking and tobacco-induced negative health outcomes. The goal of this qualitative systematic review was to identify gaps in the existing literature and future directions for smoking cessation support for PLWH. Three online databases were searched from their inception through December 31, 2017, using designated search terms. Peer-reviewed English-language articles that documented an intervention designed to increase smoking cessation among PLWH were reviewed. Data were abstracted using a standardized form to document study and intervention characteristics and results. Thirty-two articles, describing 28 unique intervention studies, met inclusion criteria. Interventions consisted primarily of combinations of counseling, pharmacotherapy, and the use of information and communications technology; few interventions were implemented at the clinic level. Thirteen interventions resulted in significant improvements in cessation-related outcomes. Information and communications technology and clinic-level interventions had the greatest potential for increasing smoking cessation among PLWH. Efficacious interventions designed for PLWH in the US South, and for groups of PLWH facing additional health disparities (e.g., communities of color and sexual and gender minorities), are needed. There is also a need for more rigorous research designs to test the efficacy of interventions designed to increase cessation-related outcomes among PLWH.

Patterns of alternative tobacco product experimentation among ever smoker adolescents.

OBJECTIVES: Alternative tobacco product (ATP) use is popular among adolescents in Western countries, however, little is known about factors influencing ATP experimentation in Europe. The aim of this study was to explore factors associated with ATP experimentation, and to identify patterns of ATP experimentation among Hungarian adolescents who had ever tried manufactured cigarette smoking. METHODS: Logistic regression analyses were applied to estimate the relationship between individual cigarette smoking experiences, social smoking influences, demographics, and ATP experimentation (roll-your-own (RYO) cigarettes, cigars/cigarillos, waterpipe, traditional pipe and flavoured cigarettes) in a cross-sectional sample of 8th and 11th grade students (N = 1,067, 56.0% of girls) who had ever tried manufactured cigarette smoking in six metropolitan cities of Hungary. Latent class analysis (LCA) was performed to identify patterns of different ATP use. RESULTS: Almost 90% of the sample had ever tried ATPs and significantly more commonly older (91.8%) versus younger (79.8%) students. Waterpipe was the most popular product to try followed by flavoured cigarettes, cigars/cigarillos, RYO cigarettes, and pipe. Boys were more likely to report ATP experimentation compared to girls. Younger age of cigarette smoking experimentation, greater frequency of past month cigarette smoking and history of ever daily smoking for 30 days showed strong association with ATP experimentation. Students with one or more smoking friends were more vulnerable to experiment with ATPs. Weekly allowance, school academic achievement and household smoking exposure showed no effect on the experimentation. LCA identified four subgroups of ATP experimenters comprising intense polytobacco experimenters (38.4%), mainly waterpipe experimenters (34.2%), moderate polytobacco experimenters (14.9%), and less interested experimenters (12.5%). CONCLUSION: Tobacco prevention programmes targeting adolescents should emphasize the risks of using ATPs in addition to manufactured cigarettes. Accessibility of ATPs should be better regulated and restrictions should be strongly enforced in order to prevent potential harmful consequences of adolescent polytobacco use.

Risk factors for multidrug-resistant tuberculosis among tuberculosis patients in Serbia: a case-control study.

BACKGROUND: Multidrug resistant (MDR) tuberculosis (TB) represents TB which is simultaneous resistant to at least rifampicin (R) and isoniazid (H). Identifying inadequate therapy as the main cause of this form of the disease and explaining the factors leading to its occurrence, numerous social determinants that affect the risk of developing resistance are highlighted. The objectives of the study was to identify independent factors of MDR-TB among tuberculosis patients. METHODS: Case-control study was conducted from 1st September 2009 to 1st June 2014 in 31 healthcare institutions in Serbia where MDR-TB and TB patients were treated. TB patients infected with MDR- M. tuberculosis and non MDR- M. tuberculosis strain were considered as cases and controls, respectively. Cases and controls were matched by the date of hospitalization. The data was collected using structured questionnaire with face to face interview. Bivariate and multivariable logistic regression analysis (MLRA) were used to identify determinants associated with MDR-TB. RESULTS: A total of 124 respondents, 31 cases and 93 controls were participated in the study. MLRA identified six significant independent risk factors for the occurrence of MDR-TB as follows: monthly income of the family (Odds ratio (OR) = 3.71; 95% Confidence Interval (CI) = 1.22-11.28), defaulting from treatment (OR = 3.33; 95% CI = 1.14-9.09), stigma associated with TB (OR = 2.97; 95% CI = 1.18-7.45), subjective feeling of sadness (OR = 4.05; 95% CI = 1.69-9.70), use of sedatives (OR = 2.79; 95% CI = 1.02-7.65) and chronic obstructive pulmonary disease (OR = 4.51; 95% CI = 1.07-18.96). CONCLUSION: In order to reduce burden of drug resistance, strategies of controlling MDR-TB in Serbia should emphasize multi-sectorial actions, addressing health care and social needs of TB patients.

Continued smoking versus spontaneous quitting among pregnant women living in a high risk environment.

OBJECTIVES: In Hungary, 37% of women living in poverty were smokers in 2012. There are no valid data of pregnant women's spontaneous smoking cessation. METHODS: Our retrospective cohort study (2009-2012) targeted the most underdeveloped regions with an estimated 6-8.5% of Roma population. The sample (N = 12,552) represented 76% of the target population i.e. women in four counties in a year delivering live born babies. Chi-square probe and multivariable logistic regression model (p < 0.05) were used to assess relationship between socio-demographic characteristics and spontaneous cessation. RESULTS: Prior to pregnancy, the overall smoking rate was 36.8%. That of women in deep poverty and Roma was 49.7% and 51.1%, respectively. 70.3% of smokers continued smoking during the pregnancy. Among them 80.6% lived in deep poverty. Spontaneous quitting rate was 23.0%. Factors correlated with continued smoking included being Roma (OR = 1.95), undereducated (OR = 2.66), living in homes lacking amenities (OR = 1.48), and having regularly smoking partner (OR = 2.07). Cessation was promoted by younger age (≤ 18 years) (OR = 0.18), being married (OR = 0.50), and the first pregnancy. CONCLUSIONS: Tailored cessation programmes are needed for Roma, older, low-income, and multiparous women who are less likely to quit on their own. Engaging husbands/partners is essential to reduce smoking among pregnant women and second-hand smoke exposure.

Susceptibility to cigarette smoking among middle and high school e-cigarette users in Canada.

There is a growing concern that the historic reductions in tobacco consumption witnessed in the past decades may be undermined by the rapid increase in e-cigarette use. This study examined the association between e-cigarette use and future intention to smoke cigarettes among middle and high school students who had never smoked cigarettes. Data were drawn from the 2014-2015 Canadian Student Tobacco, Alcohol and Drugs Survey (n=25,637). A multivariable logistic regression model was used to examine the association between e-cigarette use and susceptibility to cigarette smoking. In addition, an inverse probability of treatment weighted regression adjustment method (doubly robust estimator), which models both the susceptibility to smoking and the probability of e-cigarette use, was conducted. About 10% of the students had ever tried an e-cigarette. There were higher rates of ever e-cigarette use among students in grades 10-12 (12.5%) than those in grades 7-9 (7.3%). Students who had ever tried an e-cigarette had higher odds of susceptibility to cigarette smoking (adjusted odds ratio=2.16, 95% confidence interval=1.80-2.58) compared to those that had never tried an e-cigarette. Current use of an e-cigarette was associated with higher odds of smoking susceptibility (adjusted odds ratio=2.02, 95% confidence interval=1.43-2.84). Similar results were obtained from the doubly robust estimation. Among students who had never smoked cigarettes, e-cigarette use was associated with a higher susceptibility to cigarette smoking.

The Short-term Effects of ASPIRA: A Web-based, Multimedia Smoking Prevention Program for Adolescents in Romania: A Cluster Randomized Trial.

INTRODUCTION: Although web-based, multimedia smoking prevention programs have been tested in several high-income countries, their efficacy in Central and Eastern Europe is unknown. The aim of this trial was to assess the short-term effects of ASPIRA, among Romanian and Hungarian speaking ninth graders in Tirgu Mures, Romania. ASPIRA is the Romanian acronym for the translated and adapted version of ASPIRE, "A Smoking Prevention Interactive Experience," an evidence-based smoking prevention program originally developed to prevent tobacco use among high school students in the United States. METHODS: Sixteen high schools in Tirgu Mures, Romania were randomized to receive five weekly sessions of the ASPIRA web-based, multimedia program or to a control condition. Socio-demographic data, psychosocial characteristics, and smoking behavior were collected from students at baseline and at 6 months. A hierarchical logistic regression analysis was conducted to test the efficacy of the intervention on smoking initiation and current smoking among 1369 students. RESULTS: Never-smoker students in the intervention arm were 35% less likely to report smoking initiation 6 months after the baseline assessment (OR = 0.65, 95%CI: 0.44-0.97). Reduced smoking initiation was observed most notably among students who were exposed to at least 75% of the ASPIRA program. There was no statistically significant effect of the intervention on current tobacco use (OR = 0.80, 95%CI: 0.44-1.46). CONCLUSIONS: ASPIRA, an adapted version of the evidence-based, multimedia ASPIRE program that was originally developed and tested in the United States may decrease smoking initiation among multi-ethnic adolescents in Central and Eastern Europe. IMPLICATIONS: (1). Web-based, multimedia smoking prevention programs may be effective tools to prevent smoking initiation among multi-ethnic adolescent communities in Central and Eastern Europe. (2). The degree of exposure is critical, only high exposure to the multimedia smoking prevention program is associated with reduced smoking initiation.

Tobacco use among children in Romanian foster care homes.

BACKGROUND: Children living in facilities under the supervision of child protection authorities are vulnerable to early smoking experimentation. This is the first study to report the prevalence and correlates of smoking behaviour among foster care home residents in Romania. METHODS: We conducted an in-person, cross-sectional survey of 914 resident children in 148 foster care homes of four Transylvanian counties. We included children <18 and those with complete tobacco use information in the analytical sample (n = 791). Sociodemographic, peer and foster family characteristics were evaluated for their influence on tobacco experimentation and past 30-day use. RESULTS: Respondents included 50.7% girls of average age 13.6 years (range 8-17). Almost half reported ever experimenting with tobacco (44.6%) and approximately one in four reported past 30-day use (25.9%). Factors significantly associated with an increased odds of smoking experimentation and past 30-day use in the multivariable model included being 13-17 years old (vs. <12 years), having friends who are current smokers, and having a sibling who smokes. Living in a home with a foster mother or foster father who smokes was associated with increased odds of experimentation and past-30 day use, respectively. The longer time living in foster care was associated with decreased odds of experimentation and past 30-day use controlling for all covariates. CONCLUSION: Anti-tobacco programmes that incorporate the role family and peers to reduce smoking are needed to address the high rates of use among Romanian foster care children.

Intention to Experiment With E-Cigarettes in a Cross-Sectional Survey of Undergraduate University Students in Hungary.

BACKGROUND: Electronic cigarettes are often used to promote cessation. Only a few studies have explored the motivations for e-cigarette experimentation among young adults. OBJECTIVES: The goals of this study were to assess the intention to try e-cigarettes among Hungarian university students and to develop a motivational scale to measure vulnerability to e-cigarette experimentation. METHODS: 826 Hungarian university students completed an internet-based survey in 2013 to measure motives for trying e-cigarettes. We conducted exploratory factor analyses and identified factors that promote and deter experimentation. Logistic regression analysis was performed to test the concurrent predictive validity of the identified motivational factors and we used these factors to predict e-cigarette experimentation, controlling for other known correlates of e-cigarette use. RESULTS: 24.9% of the participants have ever tried an e-cigarette and 17.2% of current nonsmokers experimented with the product. Almost 11% of respondents intended to try an e-cigarette in the future, yet only 0.6% were current e-cigarette users. Six factors were identified in the motivational scale for experimentation, four that promote usage (health benefits/smoking cessation; curiosity/taste variety; perceived social norms; convenience when smoking is prohibited) and two that deter usage (chemical hazard; danger of dependence). In a logistic regression analysis, the curiosity/taste factor was the only motivational factor significantly associated with the intention to try e-cigarettes in the future. CONCLUSIONS: This is the first study to test a motivational scale about what motivates e-cigarettes usage among university students. Additional research is needed to better understand these factors and their influence on e-cigarette uptake.