Tobacco Use and Respiratory Symptoms Among Adults: Findings From the Longitudinal Population Assessment of Tobacco and Health (PATH) Study 2014-2016.

INTRODUCTION: We examined the relationship between current tobacco use and functionally important respiratory symptoms. METHODS: Longitudinal cohort study of 16 295 US adults without COPD in Waves 2-3 (W2-3, 2014-2016) of the Population Assessment of Tobacco and Health Study. Exposure-Ten mutually exclusive categories of tobacco use including single product, multiple product, former, and never use (reference). Outcome-Seven questions assessing wheezing/cough were summed to create a respiratory symptom index; cutoffs of ≥2 and ≥3 were associated with functional limitations and poorer health. Multivariable regressions examined both cutoffs cross-sectionally and change over approximately 12 months, adjusting for confounders. RESULTS: All tobacco use categories featuring cigarettes (>2/3's of users) were associated with higher risk (vs. never users) for functionally important respiratory symptoms at W2, for example, at symptom severity ≥ 3, risk ratio for exclusive cigarette use was 2.34 [95% CI, 1.92, 2.85] and for worsening symptoms at W3 was 2.80 [2.08, 3.76]. There was largely no increased symptom risk for exclusive use of cigars, smokeless tobacco, hookah, or e-cigarettes (adjustment for pack-years and marijuana attenuated the cross-sectional e-cigarette association from 1.53(95% CI 0.98, 2.40) to 1.05 (0.67, 1.63); RRs for these products were also significantly lower compared to exclusive use of cigarettes. The longitudinal e-cigarette-respiratory symptom association was sensitive to the respiratory index cutoff level; exclusive e-cigarette use was associated with worsening symptoms at an index cutoff ≥ 2 (RR = 1.63 [1.02, 2.59]) and with symptom improvement at an index cutoff of ≥ 3 (RR = 1.64 [1.04, 2.58]). CONCLUSIONS: Past and current cigarette smoking drove functionally important respiratory symptoms, while exclusive use of other tobacco products was largely not associated. However, the relationship between e-cigarette use and symptoms was sensitive to adjustment for pack-years and symptom severity. IMPLICATIONS: How noncigarette tobacco products affect respiratory symptoms is not clear; some studies implicate e-cigarettes. We examined functionally important respiratory symptoms (wheezing/nighttime cough) among US adults without COPD. The majority of adult tobacco users smoke cigarettes and have higher risk of respiratory symptoms and worsening of symptoms, regardless of other products used with them. Exclusive use of other tobacco products (e-cigarettes, cigars, smokeless, hookah) was largely not associated with functionally important respiratory symptoms and risks associated with their use was significantly lower than for cigarettes. The association for e-cigarettes was greatly attenuated by adjustment for cigarette pack-years and sensitive to how symptoms were defined.

Exposure to Television Alcohol Brand Appearances as Predictor of Adolescent Brand Affiliation and Drinking Behaviors.

Adolescence and the transition to adulthood is an important developmental stage in the emergence of health risk behaviors, specifically underage alcohol use. Adolescents consume a tremendous amount of screened media (primarily streamed television), and media depictions of behaviors is prospectively linked to youth initiation of behaviors. With the arrival of streamed media technology, alcohol advertising can be nested within television content. This study describes alcohol brand depictions in television and evaluates impact of exposure to such depictions on adolescent drinking outcomes. A national sample of 2012 adolescents (Mage = 17.07; SD = 1.60 years, range 15-20; 50.70% female) reported on television viewership, alcohol brand affiliation, and drinking behavior, with follow-up one year later. Ten series (that remain relevant to youth today) across television ratings from a single television season were content coded for presence/salience of alcohol brand appearances. Adjusting for covariates (e.g., peer/parent drinking, youth sensation seeking, movie alcohol brand exposure), higher exposure to brand appearances in the television shows was associated with youth drinking. Aspirational and usual brand to drink corresponded to television alcohol brand prominence, and television brand exposure was independently associated with drinking initiation and hazardous drinking.

Youth Access to Tobacco Products in the United States: Findings From Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study.

OBJECTIVES: Tobacco products in the US market are growing in diversity. Little is known about how youth access tobacco products given this current landscape. METHODS: Data were drawn from 15- to 17-year-olds from the Wave 1 youth sample of the US nationally representative Population Assessment of Tobacco and Health (PATH) Study. Past 30-day tobacco users were asked about usual sources of access to 12 different tobacco products, and if they had been refused sale because of their age. RESULTS: Among 15- to 17-year-olds, social sources ("someone offered" or "asked someone") were the predominant usual source of access for each tobacco product. "Bought by self" was the usual source of access for users of smokeless (excluding snus, 23.2%), cigarillos (21.0%), cigarettes (13.8%), hookah (12.0%), and electronic cigarettes (10.5%). Convenience stores and/or gas stations were the most often selected retail source for all products except hookah. Among youth who attempted purchase, 24.3% were refused sale of cigarettes, 23.9% cigarillos, and 13.8% smokeless tobacco. CONCLUSIONS: Most 15- to 17-year-old tobacco users obtain tobacco products through social sources; however, among those who purchased tobacco, the majority report not being refused sale because of age. At the time of survey, cigarette and cigar sales to under 18 years were prohibited in all 50 states, and electronic cigarettes sales in 47 states and two territories. 2014 Annual Synar Reports signaled increasing trends in retail violations of state and/or district laws prohibiting tobacco product sales to under 18 years. Monitoring illicit youth sales, conducting compliance check inspections, and penalizing violations remain important to reduce youth tobacco access at retail venues. IMPLICATIONS: Access to the spectrum of tobacco products by youth in the United States remains predominantly through social sources. However, of the minority of youth tobacco users in 2014 who purchased tobacco themselves, a few reported being refused sale: Convenience stores and/or gas stations were the most common retail source for tobacco products. The strategies of monitoring illicit youth sales, conducting compliance checks, and penalizing violations remain important to reduce youth tobacco access at retail venues. Limiting sources of youth tobacco access remains an important focus to reduce the burden of tobacco on the public health.

Multiple tobacco product use among US adolescents and young adults.

OBJECTIVE: To assess the extent to which multiple tobacco product use among adolescents and young adults falls outside current Food and Drug Administration (FDA) regulatory authority. METHODS: We conducted a web-based survey of 1596 16-26-year-olds to assess use of 11 types of tobacco products. We ascertained current (past 30 days) tobacco product use among 927 respondents who ever used tobacco. Combustible tobacco products included cigarettes, cigars (little filtered, cigarillos, premium) and hookah; non-combustible tobacco products included chew, dip, dissolvables, e-cigarettes, snuff and snus. We then fitted an ordinal logistic regression model to assess demographic and behavioural associations with higher levels of current tobacco product use (single, dual and multiple product use). RESULTS: Among 448 current tobacco users, 54% were single product users, 25% dual users and 21% multiple users. The largest single use category was cigarettes (49%), followed by hookah (23%), little filtered cigars (17%) and e-cigarettes (5%). Most dual and multiple product users smoked cigarettes, along with little filtered cigars, hookah and e-cigarettes. Forty-six per cent of current single, 84% of dual and 85% of multiple tobacco product users consumed a tobacco product outside FDA regulatory authority. In multivariable analysis, the adjusted risk of multiple tobacco use was higher for males, first use of a non-combustible tobacco product, high sensation seeking respondents and declined for each additional year of age that tobacco initiation was delayed. CONCLUSIONS: Nearly half of current adolescent and young adult tobacco users in this study engaged in dual and multiple tobacco product use; the majority of them used products that fall outside current FDA regulatory authority. This study supports FDA deeming of these products and their incorporation into the national media campaign to address youth tobacco use.

Public support for raising the age of sale for tobacco to 21 in the United States.

OBJECTIVES: The vast majority of tobacco users began before the age of 21. Raising the tobacco sales age to 21 has the potential to reduce tobacco use initiation and progression to regular smoking. Our objective was to assess the level of public support nationally for 'Tobacco 21' initiatives in the USA. METHODS: The Social Climate Survey of Tobacco Control, a cross-sectional dual-frame survey representing national probability samples of adults was administered in 2013. Respondents were asked to state their agreement level with, 'The age to buy tobacco should be raised to 21.' RESULTS: Of 3245 respondents, 70.5% support raising the age to buy tobacco to 21. The majority of adults in every demographic and smoking status category supported raising the tobacco sales age to 21. In multivariable analyses, support was highest among never smokers, females, African-Americans and older adults. CONCLUSIONS: This national study demonstrates broad public support for raising the sales age of tobacco to 21 and will help facilitate wide dissemination of initiatives to increase the legal purchase age at national, state and local levels. Increasing public awareness about the susceptibility and rapid addiction of youth to nicotine may further increase public support for raising the tobacco sale age to 21.

A dual-frame sampling methodology to address landline replacement in tobacco control research.

OBJECTIVES: We assessed the comparability of self-reported smoking prevalence estimates from a dual-frame survey with those from two large-scale, national surveys. METHODS: The Social Climate Survey of Tobacco Control (SCS-TC) obtained self-reported current smoking status via a dual-frame methodology in the fall of 2010. One frame used random digit dialling procedures and consisted of households with a landline telephone; the other frame consisted of a population-based probability-based online panel. Current smoking prevalence was compared with national estimates from the 2010 National Health Interview Survey (NHIS) and the 2009-2010 National Health and Nutrition Examination Survey (NHANES). RESULTS: 18.3% (95% CI 17.0% to 19.6%) of SCS-TC respondents reported current smoking. NHIS and NHANES estimates found 19.4% (95% CI 18.8% to 20.1%) and 20.3% (95% CI 18.7% to 22.1%), respectively, reporting current smoking. CONCLUSIONS: Prevalence estimates for cigarette smoking obtained from the dual-frame SCS-TC are comparable to those from other national surveys. A mixed-mode approach may be a useful strategy to transition cross-sectional surveys with established trend data to newer dual-frame designs to maintain compatibility with surveys from previous years and to include the growing number of households that do not have landline telephones.

Energy drink consumption and the risk of alcohol use disorder among a national sample of adolescents and young adults.

OBJECTIVE: To assess the association between energy drink use and hazardous alcohol use among a national sample of adolescents and young adults. STUDY DESIGN: Cross-sectional analysis of 3342 youth aged 15-23 years recruited for a national survey about media and alcohol use. Energy drink use was defined as recent use or ever mixed-use with alcohol. Outcomes were ever alcohol use and 3 hazardous alcohol use outcomes measured with the Alcohol Use Disorders Identification Test (AUDIT): ever consuming 6 or more drinks at once (6+ binge drinking) and clinical criteria for hazardous alcohol use as defined for adults (8+AUDIT) and for adolescents (4+AUDIT). RESULTS: Among 15-17 year olds (n = 1508), 13.3% recently consumed an energy drink, 9.7% ever consumed an energy drink mixed with alcohol, and 47.1% ever drank alcohol. Recent energy drink use predicted ever alcohol use among 15-17-year-olds only (OR 2.58; 95% CI 1.77-3.77). Of these 15-17-year-olds, 17% met the 6+ binge drinking criteria, 7.2% met the 8+AUDIT criteria, and 16.0% met the 4+AUDIT criteria. Rates of energy drink use and all alcohol use outcomes increased with age. Ever mixed-use with alcohol predicted 6+ binge drinking (OR 4.69; 95% CI 3.70-5.94), 8+AUDIT (OR 3.25; 95% CI 2.51-4.21), and 4+AUDIT (OR 4.15; 95% CI 3.27-5.25) criteria in adjusted models among all participants, with no evidence of modification by age. CONCLUSIONS: Positive associations between energy drink use and hazardous alcohol use behaviors are not limited to youth in college settings.

Tobacco smoke incursions in multiunit housing.

OBJECTIVES: We sought to describe the prevalence of secondhand tobacco smoke incursions reported by multiunit housing (MUH) residents, pinpoint factors associated with exposure, and determine whether smoke-free building policy was associated with prevalence of reported tobacco smoke incursions. METHODS: Data are from a 2011 nationally representative dual-frame survey (random-digit-dial and Internet panels) of US adults aged 18 years and older. Individuals who lived in MUH and who reported no smoking in their homes for the past 3 months, whether or not they reported being smokers themselves, were included in this study. Incursions were defined as smelling tobacco smoke in their building or unit. RESULTS: Of 562 respondents, 29.5% reported smoke incursions in their buildings. Of these, 16% reported incursions in their own unit, 36.2% of which occurred at least weekly. Government-subsidized housing and partial smoke-free policies were associated with a higher likelihood of reporting smoke incursions. CONCLUSIONS: Many residents of multiunit housing are exposed to tobacco smoke in their units and buildings. Partial smoke-free policies do not appear to protect residents and might increase the likelihood of incursions in residents' individual units.

Relationship Between Tobacco Product Use and Health-Related Quality of Life Among Individuals With COPD in Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study.

Introduction: We examined the association between tobacco product use and health-related quality of life (HRQoL) among individuals with chronic obstructive pulmonary disease (COPD) in Waves 1-5 of the Population Assessment of Tobacco and Health (PATH) Study. Methods: Adults ≥40 years with an ever COPD diagnosis were included in cross-sectional (Wave 5) and longitudinal (Waves 1 to 5) analyses. Tobacco use included 13 mutually exclusive categories of past 30-day (P30D) single use and polyuse with P30D exclusive cigarette use and ≥5-year cigarette cessation as reference groups. Multivariable linear regression and generalized estimating equations (GEE) were used to examine the association between tobacco use and HRQoL as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 questionnaire. Results: Of 1670 adults, 79.4% ever used cigarettes; mean (standard error [SE]) pack years was 30.9 (1.1). In cross-sectional analysis, P30D exclusive cigarette use, and e-cigarette/cigarette dual use were associated with worse HRQoL compared to ≥5-year cigarette cessation. Compared to P30D exclusive cigarette use, never tobacco use and ≥5-year cigarette cessation were associated with better HRQoL, while e-cigarette/cigarette dual use had worse HRQoL. Longitudinally (n=686), e-cigarette/cigarette dual use was associated with worsening HRQoL compared to both reference groups. Only never tobacco use was associated with higher HRQoL over time compared to P30D exclusive cigarette use. Conclusions: E-cigarette/cigarette dual use was associated with worse HRQoL compared to ≥5-year cigarette cessation and exclusive cigarette use. Never use and ≥5-year cigarette cessation were the only categories associated with higher HRQoL compared to exclusive cigarette use. Findings highlight the importance of complete smoking cessation for individuals with COPD.

Alcohol marketing receptivity, marketing-specific cognitions, and underage binge drinking.

BACKGROUND: Exposure to alcohol marketing is prevalent and is associated with both initiation and progression of alcohol use in underage youth. The mechanism of influence is not well understood, however. This study tests a model that proposes alcohol-specific cognitions as mediators of the relation between alcohol marketing and problematic drinking among experimental underage drinkers. METHODS: This study describes a cross-sectional analysis of 1,734 U.S. 15- to 20-year-old underage drinkers, recruited for a national study of media and substance use. Subjects were queried about a number of alcohol marketing variables including TV time, Internet time, favorite alcohol ad, ownership of alcohol-branded merchandise (ABM), and exposure to alcohol brands in movies. The relation between these exposures and current (30-day) binge drinking was assessed, as were proposed mediators of this relation, including marketing-specific cognitions (drinker identity and favorite brand to drink), favorable alcohol expectancies, and alcohol norms. Paths were tested in a structural equation model that controlled for sociodemographics, personality, and peer drinking. RESULTS: Almost one-third of this sample of ever drinkers had engaged in 30-day binge drinking. Correlations between mediators were all statistically significant (range 0.16 to 0.47), and all were significantly associated with binge drinking. Statistically significant mediation was found for the association between ABM ownership and binge drinking through both drinker identity and having a favorite brand to drink, which also mediated the path between movie brand exposure and binge drinking. Peer drinking and sensation seeking were associated with binge drinking in paths through all mediators. CONCLUSIONS: Associations between alcohol marketing and binge drinking were mediated through marketing-specific cognitions that assess drinker identity and brand allegiance, cognitions that marketers aim to cultivate in the consumer.

Detection of secondhand cigarette smoke via nicotine using conductive polymer films.

INTRODUCTION: The 2006 U.S. Surgeon General's Report found that there is no safe level of exposure to secondhand smoke (SHS). Many smokers attempt to protect others from exposure to SHS; however, it is difficult to assess effectiveness of these behavior changes. There is a need for personal monitoring devices that provide real-time SHS exposure data; at present, there is no device that measures ambient nicotine levels in real time. The development of such a sensor is the objective of this research. METHODS: A nicotine sensing film comprising the conductive polymer polyaniline was linked with a reporting layer, recording changes in chemiresistance due to adsorption of nicotine. Experiments were carried out in a microprocessor-controlled smoking chamber using sidestream smoke from standard reference cigarettes; up to 10 cigarettes were smoked simultaneously. The exposure chamber was calibrated for total suspended particle, carbon monoxide, and nicotine concentrations. RESULTS: We found significant real-time increases in the resistance of films upon exposure to SHS. The sensors were shown to be sensitive to the number of cigarettes consumed and ambient nicotine and demonstrated reasonable recovery between measurements. The sensors have sufficient sensitivity to detect off-gassing of nicotine or "thirdhand smoke." CONCLUSIONS: A sensing element has been developed that can reliably detect secondhand and thirdhand tobacco smoke in real time through the adsorption of ambient nicotine vapor. The device was calibrated to the number of smoked cigarettes and to nicotine concentration. Development of integrated personal sensors to record exposure to SHS using this technology is currently underway.

Association between tobacco product use and asthma among US adults from the Population Assessment of Tobacco and Health (PATH) Study waves 2-4.

BACKGROUND: Research on cigarettes and adult asthma offers mixed findings, perhaps due to overlap with chronic obstructive pulmonary disease (COPD) and inadequate adjustment for other smoke exposures. Associations between other tobacco products, including e-cigarettes, and asthma are also understudied. RESEARCH QUESTION: Using Population Assessment of Tobacco and Health Study waves 2-4 (2014/2015-2016/2017) data, we assessed the relation between tobacco product use and asthma in persons unlikely to have COPD. STUDY DESIGN AND METHODS: Prospective study of 10 267 adults aged 18-39 years without COPD diagnoses. Past-month tobacco use at wave 2 was modelled first as combustible versus non-combustible use and second as specific product categories (former, cigarettes, e-cigarettes, cigars, hookah, smokeless tobacco). Outcomes included lifetime asthma prevalence at wave 2, incidence (waves 3 and 4) and Asthma Control Test score (lower=worse). Multivariable regressions adjusted for predictors of asthma, including other smoke exposures: cigarette pack-years, secondhand smoke and marijuana use. Sensitivity analyses examined findings when persons >39 years and those with both COPD and asthma were added, and when smoke exposure adjustments were removed. RESULTS: No product, including cigarettes and e-cigarettes, was associated with prevalence or incidence of asthma. Among people with asthma at wave 2, combustible tobacco (beta=-0.86, 95% CI (-1.32 to -0.39)) and cigarettes (beta=-1.14, 95% CI (-1.66 to -0.62)) were associated with worse asthma control. No tobacco product was associated with asthma control over time. In sensitivity analyses, tobacco use became associated with incident asthma as adults >39 years and those with asthma+COPD were added, and as adjustments for other smoke exposures were omitted. INTERPRETATION: Although cigarette use was associated with worse asthma control, there were no longitudinal associations between combustible tobacco or e-cigarette use and new onset or worsening asthma in these preliminary analyses. Research on tobacco and asthma should exclude COPD and adjust for smoking history and other smoke exposures.

Moderation of the association between media exposure and youth smoking onset: race/ethnicity, and parent smoking.

This study of youth smoking onset aims to replicate previously published media moderation effects for race/ethnicity in a national longitudinal multiethnic sample of U.S. adolescents. Previous research has demonstrated that associations between media and smoking during adolescence are greater for Whites than Hispanics or Blacks, and for youth living in non-smoking families. In this study, changes in smoking status over 24 months were assessed among 4,511 baseline never-smokers. The incidence of smoking onset was 14.3% by 24 months with no differences by race/ethnicity. Blacks had higher exposure to movie smoking and overall television viewing compared with Whites and Hispanics. Whites responded to movie smoking regardless of parent smoking but more strongly if their parents were non-smokers. In contrast, Black adolescents showed little behavioral response to any media, regardless of parent smoking. Hispanic adolescents responded only to TV viewing and only when their parents did not smoke. In an analysis assessing the influence of the race of smoking characters on smoking behavior of White and Black adolescents, Whites responded to both White and Black movie character smoking, whereas Blacks responded only to smoking by Black movie characters. Taken as a whole, the findings replicate and extend previous findings, suggesting media factors are more influential among adolescents at low to moderate overall risk for smoking. We draw analogies between these low-moderate risk adolescents and "swing voters" in national elections, suggesting that media effects are more apt to influence an adolescent in the middle of the risk spectrum, compared with his peers at either end of it.

Tobacco Product Use and Functionally Important Respiratory Symptoms Among US Adolescents/Young Adults.

OBJECTIVE: The relation between respiratory symptoms and the range of tobacco product use among US adolescents/young adults is not yet clear. This cross-sectional analysis examines tobacco product use and respiratory symptoms in a nationally representative sample of 21,057 adolescents/young adults aged 12-24 years from Wave 4 (2016-17) of the Population Assessment of Tobacco and Health Study. METHODS: Presence of functionally important respiratory symptoms was defined by questions regarding wheezing and nighttime cough at a cutoff score associated with poorer functional health status. Past-30-day tobacco use was analyzed 2 ways: never-tobacco users (reference) versus combustible users, noncombustible-only users, and former users; or frequency of use of cigarettes and/or e-cigarettes. Weighted Poisson regression adjusted for past-30-day marijuana use, secondhand smoke exposure, and asthma. RESULTS: Functionally important respiratory symptoms were present in 10.0% overall: 13.8% of combustible users, 9.0% of noncombustible users, 8.2% of noncurrent users and 9.7% of never users. Functionally important respiratory symptoms were associated with combustible tobacco use (relative risk [RR] = 1.52[95% CI 1.29, 1.80]), marijuana use (RR = 1.54[1.34, 1.77]) and secondhand smoke exposure (RR = 1.04[1.03, 1.05]). Higher cigarette smoking frequency was also associated with functionally important respiratory symptoms for frequency categories >14 days/month (eg, RR = 1.93[1.50, 2.49] for 15-29 days/month). Frequency of e-cigarette use was not associated with functionally important respiratory symptoms. CONCLUSIONS: During 2016-17, smoking cigarettes, marijuana use, and secondhand smoke exposure were cross-sectionally associated with functionally important respiratory symptoms in adolescents/young adults. Risk increased with increased frequency of cigarette use but not e-cigarette use. Given changes to contemporary e-cigarettes and use, findings may not generalize to newer products.

Cross-sectional association between smoking depictions in films and adolescent tobacco use nested in a British cohort study.

OBJECTIVE: To assess associations between exposure to smoking depictions in films and adolescent tobacco use in a British population cohort. METHODS: Data on exposure to smoking in films and smoking behaviour were collected from 5166 15-year-old adolescents in the UK. Main outcome measures were smoking initiation (ever tried a cigarette) and current smoking status. Social, family and behavioural factors were adjusted for, together with alcohol use and peer smoking as potential mediators. Data from all existing cross-sectional studies examining the effects of exposure to smoking in films were summarised in a meta-analysis. RESULTS: Higher exposure to smoking in films was associated with a dose-response increase in the risk of smoking initiation even after adjusting for confounders. Adolescents in the highest exposure quartile were 1.73 (95% CI 1.55 to 1.93) times (RR) more likely to initiate smoking than those in the lowest quartile. They were more likely to report current smoking after adjusting for social and familial factors (RR 1.47 (95% CI 1.07 to 2.02)), but the association attenuated after including behavioural factors (RR 1.34 (95% CI 0.95 to 1.87)). The meta-analysis shows that, after aggregation of all relevant data, viewing smoking in films increases the risk of smoking onset by over 100% (combined RR 2.13 (95% CI 1.76 to 2.57)) and the risk of current or established smoking behaviour by 68% (combined RR 1.68 (95% CI 0.40 to 2.01)). CONCLUSIONS: This study provides evidence that adolescents in the UK and elsewhere who are exposed to smoking depictions in films are more likely to initiate smoking. Given the association between smoking and poor health outcomes, these data justify a review of film ratings.

US attitudes about banning menthol in cigarettes: results from a nationally representative survey.

Menthol is a cigarette flavoring that makes smoking more appealing to smokers. The US Food and Drug Administration (FDA) has regulatory authority to ban mentholated cigarettes to reduce youth uptake and encourage adult cessation. Survey findings indicate that more than half of all Americans (56.1%) and of Blacks alone (68.0% in one sample and 75.8% in another) support banning menthol. Endorsement of a ban-especially by Blacks, who have the highest rates of menthol cigarette use-would support FDA action to ban menthol to protect the public's health.

Improving Care for Childhood Obesity: A Quality Improvement Initiative.

Obesity affected 13.7 million children in the United States in 2015. The American Academy of Pediatrics (AAP) offers an evidence-based approach to obesity management, but adherence to recommendations is suboptimal. Our objective was to improve provider adherence to the AAP recommendations for care of patients with obesity by making systematic changes in our practice for patients of ages > 2 and younger than 19 years with a BMI > 95th percentile. METHODS: We performed a retrospective chart review of 417 qualifying encounters to assess adherence in the six months preceding the initiative. We measured adherence as a proportion of eligible patients who had (1) obesity on the problem list; (2) laboratory work offered; (3) counseling provided; (4) early follow-up recommended; (5) referral to a weight management program. In 2018, a multidisciplinary QI team conducted plan-do-study-act cycles to educate providers on the AAP recommendations and improve obesity-related care systems. The initiative lasted 18 months. RESULTS: During the initiative, we tracked 885 patient encounters via chart review. We witnessed continued improvement in 4 out of 5 measures. For early follow-up offered, we saw improvement after PDSA 1, followed by a decline after PDSA 3. Providers ordered laboratory tests in only 13% of encounters for eligible children ages younger than 6 years versus 45% for ages older than 6 years, an age-dependent disparity that persisted despite the QI initiative. CONCLUSION: Our pediatric practice sustained improvement in adherence to AAP recommendations. There is a need to assess the reasons behind the care disparity based on patient ages.

Validation of an Index for Functionally Important Respiratory Symptoms among Adults in the Nationally Representative Population Assessment of Tobacco and Health Study, 2014-2016.

The purpose of this study is to validate the seven-item wheezing module from the International Study of Asthma and Allergies in Children (ISAAC) in the nationally representative Population Assessment of Tobacco and Health Study. Adult participants with complete Wave 2-3 data were selected, including those with asthma but excluding those with COPD and other respiratory diseases (n = 16,295). We created a nine-point respiratory symptom index from the ISAAC questions, assessed the reliability of the index, and examined associations with self-reported asthma diagnosis. Threshold values were assessed for association with functional outcomes. The weighted prevalence for one or more respiratory symptom was 18.0% (SE = 0.5) for adults without asthma, 70.1% (SE = 1.3) for those with lifetime asthma, 75.7% (SE = 3.7) for adults with past-year asthma not on medications, and 92.6% (SE = 1.6) for those on medications. Cronbach's alpha for the respiratory symptom index was 0.86. Index scores of ≥2 or ≥3 yielded functionally important respiratory symptom prevalence of 7-10%, adequate sensitivity and specificity for identifying asthma, and consistent independent associations with all functional outcomes and tobacco use variables. Respiratory symptom index scores of ≥2 or ≥3 are indicative of functionally important respiratory symptoms and could be used to assess the relationship between tobacco use and respiratory health.

Alcohol retail density and demographic predictors of health disparities: a geographic analysis.

OBJECTIVES: We examined whether the geographic density of alcohol retailers was greater in geographic areas with higher levels of demographic characteristics that predict health disparities. METHODS: We obtained the locations of all alcohol retailers in the continental United States and created a map depicting alcohol retail outlet density at the US Census tract level. US Census data provided tract-level measures of poverty, education, crowding, and race/ethnicity. We used multiple linear regression to assess relationships between these variables and retail alcohol density. RESULTS: In urban areas, retail alcohol density had significant nonlinear relationships with Black race, Latino ethnicity, poverty, and education, with slopes increasing substantially throughout the highest quartile for each predictor. In high-proportion Latino communities, retail alcohol density was twice as high as the median density. Retail alcohol density had little or no relationship with the demographic factors of interest in suburban, large town, or rural census tracts. CONCLUSIONS: Greater density of alcohol retailers was associated with higher levels of poverty and with higher proportions of Blacks and Latinos in urban census tracts. These disparities could contribute to higher morbidity in these geographic areas.