E-cigarette Marketing Expenditures in the United States From 2016 to 2021: Targeted Media Outlets Geared Toward People Who Are at Increased Risk for Tobacco Use.

INTRODUCTION: E-cigarette advertising exposure is linked to e-cigarette initiation and use. Thus, monitoring trends in e-cigarette advertising practices is important to understand e-cigarette use patterns observed over recent years. AIMS AND METHODS: E-cigarette advertising expenditures (January 2016-July 2021; Numerator Ad Intel) for 154 U.S. market areas were harmonized with U.S. Census sociodemographic data through Nielsen zip code designations by market area. Descriptive statistics and multivariable linear regressions were used to examine trends in e-cigarette advertising expenditures across media outlets and associations between sociodemographic characteristics and e-cigarette advertising over time. RESULTS: E-cigarette advertising expenditures peaked in 2018/2019, followed by a sharp decline in 2020. Expenditures were concentrated primarily on print (58.9%), TV (20.6%), and radio (14.4%). Major print outlets were Sports Illustrated, Rolling Stone, and Star magazines. Top TV channels were AMC, Investigation Discovery, and TBS. TV advertisements were purchased commonly during popular movies and TV series (eg King of Queens, Everybody Loves Raymond, The Walking Dead). Higher expenditures were associated with U.S. market areas that had (1) a larger percentage of non-rural zip codes (radio), (2) smaller male populations (radio), and (3) larger White or Caucasian, Black or African American, American Indian or Alaska Native, Asian, and Other or Multiracial populations (radio, print, online display, and online video). CONCLUSIONS: E-cigarette companies advertised in print magazines geared toward males and youth and young adults, radio commercials focused in urban areas with smaller male populations, and nationwide TV commercials. Declines in e-cigarette advertising expenditures in 2020 demonstrate the potential impact that federal policies may have on protecting populations who are at higher risk for tobacco use from predatory advertising practices. IMPLICATIONS: E-cigarette advertising exposure is associated with the initiation and use of e-cigarettes. This study shows how e-cigarette marketing expenditures in the United States may have targeted specific consumers (eg youth and young adults) between 2016 and 2021. The precipitous drop in advertising expenditures across all outlets during early 2020 corresponds with the implementation of the Tobacco 21 federal policy, the federal enforcement policy to remove most unauthorized flavored e-cigarette cartridges from the U.S. market, preparations for FDA's premarket review of e-cigarette products, and the decision by several TV broadcast companies to stop showing e-cigarette ads. The potential impact of federal policies may have far-reaching implications for protecting populations who are at high risk for tobacco use and its health consequences.

Alcohol Compliance Checks and Underage Alcohol-Involved Crashes: Evaluation of a Statewide Enforcement Program in South Carolina from 2006 to 2016.

OBJECTIVE: This research evaluated the South Carolina Alcohol Enforcement Team impact for reducing retail alcohol access to underage persons to decrease drinking and driving crashes among that population. METHODS: The natural research experiment used interrupted time-series (ITS) analyses of drinking and driving crashes involving under 21-year-old drivers from July 2006 through December 2016 (126-month period = 4,782 Driving Under Influence [DUI] crashes for under 21-year-old drivers, µ = 38 crashes per month). Additional data analyzed included the monthly total number of retail compliance checks (total during 126-month period = 64,954 compliance checks completed, µ = 515.5 checks per month), the average percentage of underage alcohol purchases (total completed during 126-month period = 8,814 purchases, µ = 70 purchases per month), and a calculated measure of the percent of the population under 21 years old exposed to compliance checks each month. We used drinking and driving crashes for 21-year-old and over drivers as a control time series (total number over a 126-month period = 52,180 DUI crashes for 21 and older drivers, µ = 414.1 crashes per month). RESULTS: The results show a decline in drinking and driving crashes for drivers under 21 when compliance checks increase, and when compliance checks decline, traffic crashes increase. Stable Alcohol Enforcement Team implementation over 78 months produced an overall 18 to 29% decline in such crashes. A visual examination of the crash time series demonstrated that under-21-age-driver crashes declined during the first wave of implementation and increased following a lag when enforcement declined, which provided additional empirical support for a South Carolina Alcohol Enforcement Team impact on retail alcohol availability. An ITS analysis of the prestable period compared to the stable period was statistically significant (T = -3.78, p < 0.001). A cross-check of these results using single-vehicle nighttime crashes using identical Autoregressive Integrated Moving Average models was also statistically significant (T = -8.18, p < 0.001). CONCLUSIONS: This longitudinal study provides strong evidence of sustained reductions in alcohol availability to underage youth can subsequently reduce alcohol-related traffic crashes. Reductions found in this study continued over several years, considerably longer than any previous equivalent research has shown.

Long-Term Sustainability of Evidence-Based Prevention Interventions and Community Coalitions Survival: a Five and One-Half Year Follow-up Study.

This study examines (1) coalition survival, (2) prevalence of evidence-based prevention interventions (EBPIs) to reduce substance abuse implemented as part of the Tennessee Strategic Prevention Framework (SPF) State Incentive Grant (SIG), (3) EBPI sustainability, and (4) factors that predict EBPI sustainability. Secondary data were collected on 27 SPF SIG-funded coalitions and 88 EBPI and non-EBPI implementations. Primary data were collected by a telephone interview/web survey five and one-half years after the SPF SIG ended. Results from secondary data show that 25 of the 27 coalitions survived beyond the SPF SIG for one to five and one-half years; 19 coalitions (70%) were still active five and one-half years later. Further, 88 EBPIs and non-EBPIs were implemented by 27 county SPF SIG coalitions. Twenty-one (21) of 27 coalitions (78%) implemented one to three EBPIs, totaling 37 EBPI implementations. Based on primary survey data on 29 of the 37 EBPI implementations, 28 EBPIs (97%) were sustained between two and five and one-half years while 22 EBPI implementations (76%) were sustained for five and one-half years. When controlling for variability among coalitions (nesting of EBPIs in coalitions), increases in data resources (availability of five types of prevention data) was a strong predictor of length of EBPI sustainability. Positive change in extramural funding resources and level of expertise during SPF SIG implementation, as well as level of coalition formalization at the end of the SPF SIG predicted EBPI sustainability length. One intervention attribute (trialability) also predicted length of sustainability. Implications are discussed.

Opioid overdose prevention training needs: Findings from emergency medical services providers in Baltimore County, Maryland.

Emergency Medical Services (EMS) providers are on the frontlines of the opioid response. This study explored the EMS training needs in Baltimore County, Maryland. An online survey conducted between January-June 2021 assessed knowledge, attitudes, awareness, and self-efficacy to use opioid overdose prevention strategies; burnout, compassion fatigue, stress, and wellness; and training needs among EMS providers (N = 256). Participants reported positive attitudes toward the use of opioid treatment guidelines and confidence in their ability to use the guidelines. They indicated positive attitudes toward harm reduction, but less favorable attitudes toward opioid use disorder (OUD). Although the participants understood the role of a peer recovery specialist moderately well, they were not fully comfortable with making a referral. They reported relatively low levels of burnout and compassion fatigue and good wellness practices, but indicated a moderate level of stress associated with COVID-19. Perceived training needs included: lifetime fitness and wellness, trauma-informed care, stigma awareness, stages of change, and harm reduction. Offering these trainings and enhancing EMS providers' comfort to make referrals to peer recovery support services may strengthen the referral systems and connect overdose survivors to a continuum of care.

Evaluation of a Veterans Health Administration Whole Health for Mental Health Course for Clinicians.

Objectives: Veterans experience mental health disorders at higher rates than their civilian counterparts and also experience multiple barriers to mental health services. The Veterans Health Administration (VA) has implemented a Whole Health approach to make health care more person-focused and oriented toward promotion of health-sustaining behavior. We conducted an evaluation to investigate the effects of a Whole Health for Mental Health (WHMH) course for clinicians that focuses on shifting the perspective to a system of care in which mental health is incorporated as a core part of whole-person care. Design: We collected surveys before the course, immediately after the course, and at a 2-month follow-up. Settings/Location: The course was implemented in non-clinical settings in two VA medical centers (one in the Northeast and one in the Mountain West). Subjects: Our sample consisted of VA staff who enrolled in WHMH and completed a pre- and post-survey (n = 100) and follow-up survey (n = 99). Intervention: The WHMH is a 2-day face-to-face course that covers multiple aspects of mental health through a Whole Health lens. The course includes evidence-based practices within each aspect of mental health. The course also emphasizes implementation of Whole Health in clinicians' lives, their practice, and the health care system. Outcome measures: Attitudes were measured at pre-, post-, and follow-up assessments. The WHMH behaviors were measured at pre- and follow-up assessments. Results: There were statistically significant, large changes toward improvement from pre-test to post-test for all attitudes examined. These changes remained significant at follow-up, and the magnitude of change remained at least medium to large. Statistically significant, medium magnitude or larger improvements were found at follow-up for four of the five WHMH behavior outcomes examined. Conclusions: Our results suggest that clinicians can increase their attitudes and use of Whole Health concepts and both conventional and complementary approaches related to mental health issues.

Acceptability of a HIV self-testing program among people who use illicit drugs.

BACKGROUND: People who use illicit drugs (PWUD) remain at significantly elevated risk for HIV infection and continue to have very low testing rates. HIV self-testing (HIVST) has been shown to be acceptable among many high-risk populations, but less is known about PWUD. METHODS: From May-June 2021, a HIVST program was implemented at a syringe services program (SSP) in Louisville, Kentucky. PWUD were given the option to privately self-test at the SSP or take the test home and follow-up with study staff. Primary outcomes were acceptability, ease of use, usability, reasons for self-testing, testing location, frequency of future testing, and preference for future testing location. RESULTS: Among 230 study participants, 77% reported high acceptability (i.e., the HIVST kits made them feel much more able to keep track of their HIV status compared to standard testing methods). Virtually all (97.4%) reported the test kits were very easy to use. Problems while using the HIVST kits were rare (range 1.3-3.0%). The most common reasons for testing were a desire to know their status (85.2%), the test was free (37%), and the short duration for results (30.9%). Testing primarily occurred onsite (87.8%). The majority (83%) reported they would use the HIVST kits at least every six months if made available through the health department and would prefer to test at home (71.7%). Multivariate analyses found that awareness of and intention to use pre-exposure prophylaxis (PrEP) were significantly associated with high acceptability and testing onsite. CONCLUSION: Study participants found HIVST to be acceptable and very easy to use. The multivariate findings suggest HIVST interventions should be packaged with PrEP interventions and harm reduction programs.

Achieving Whole Health: A Preliminary Study of TCMLH, a Group-Based Program Promoting Self-Care and Empowerment Among Veterans.

OBJECTIVE: An emerging literature suggests patients with chronic illnesses can benefit from integrated, person-centric approaches to health care, including group-based programs. However, much of the research in this area is disease specific. The objective of this study was to collect preliminary evidence on the efficacy of Taking Charge of My Life and Health (TCMLH), a Whole Health group-based program that emphasizes self-care and empowerment on the overall health and well-being of veterans, a population burdened with high rates of multiple chronic conditions. METHOD: Self-reported outcomes, including standardized survey measures, were collected at pretest, posttest, and 2-month follow-up from 77 participants across 15 groups at four VA sites. Random intercept mixed-model regressions were used to analyze data. RESULTS: Results from this initial study showed high satisfaction with the program and facilitators, and high attendance. There were significant pre-post gains in self-care attitudes and behaviors, patient motivation, meaning and purpose, mental health, perceived stress, goal progress, and goal-specific hope. Outcomes were maintained at 2-month follow-up for patient motivation, perceived stress, goal-specific hope, and goal progress. Significant gains were observed in health care empowerment and physical health from pretest to follow-up. CONCLUSIONS: Preliminary findings support the efficacy of TCMLH, a Whole Health group-based program that emphasizes patient empowerment, self-care practices, and peer support. Future research priorities include a rigorous evaluation with a larger sample size and control group to assess effectiveness.

Preliminary Impacts of an HIV-Prevention Program Targeting Out-of-School Youth in Postconflict Liberia.

Adolescents in Sub-Saharan Africa account for greater HIV/STI (human immuno defiency virus/sexually transmitted infection) burdens and difficult-to-reach populations. This study implemented a community-based HIV/STI program to reach at-risk youth aged 15 to 17 years in postconflict Liberia. Using a randomized controlled trial, community youths were assigned to an adapted version of an effective HIV/STI program, Making Proud Choices, or attention-matched comparison curriculum, General Health Program. Both programs were of similar doses, reach and coverage, and administered in classroom settings by trained health educators. The findings suggest that the adapted HIV/STI program had positive effects on knowledge, sexual refusal and condom use self-efficacy, condom negotiation self-efficacy, positive condom attitudes, parental communication about sex, and negative condom attitudes over time. Culturally adapted community-based, behavioral-driven programs can positively affect mediators of sexual behaviors in at-risk adolescents in postconflict settings. This is the first published report of an evidence-based HIV/STI program on sexual risk-taking behaviors of community youths in Liberia.

Reducing sexual risk taking behaviors among adolescents who engage in transactional sex in post-conflict Liberia.

Transactional sex (TS) has been correlated with HIV/STD infection, pregnancy, early marriage, and sexual violence in sub-Saharan Africa (SSA). Few Western-based HIV prevention programs adapted for SSA have examined intervention impacts for this group. This article examines whether an HIV prevention intervention, delivered to sixth-grade students in Liberia (age range 14-17) and found to increase condom use and other mediators for the larger sample, significantly impacted sexual behaviors and mediators for those who engaged in TS. Using an attention-matched, group-randomized controlled design, four matched pairs of elementary schools in Monrovia, Liberia, were randomly assigned to an adapted eight-module HIV prevention or a general health curriculum. Nine-month impacts of the intervention on sexual risk behaviors and mediators for those who engaged in TS, when compared with other study participants, are presented. Twelve percent of our sample of sixth graders (n = 714) ever engaged in TS. The majority of females reported being promised something in exchange for sex (52%), whereas the majority of males (52%) reported being both the giver and recipient of gifts in exchange for sex. Compared with other students, those who engaged in TS reported greater increases in the number of sex partners, reported greater frequency of sexual intercourse, were more likely to try to get pregnant or someone else pregnant, and reported greater reductions in protective sexual attitudes and HIV risk perception at the nine month follow-up, in both the intervention and the control groups. Our intervention, although successful for the general in-school adolescent sample, did not impact risk behaviors or mediators for adolescents who engaged in TS. Future research should explore the complex sexual economy in which TS is embedded and consider adapting HIV prevention interventions to the needs of this high-risk group.

Impact of school-based HIV prevention program in post-conflict Liberia.

This paper presents findings of a feasibility study to adapt and evaluate the impact of an evidence-based HIV prevention intervention on sexual risk behaviors of in-school 6th grade youth in post-conflict Liberia (n = 812). The study used an attention-matched, group randomized controlled trial. Four matched pairs of elementary/middle schools in Monrovia, Liberia, were randomly assigned to either an adapted eight-module HIV prevention or a general health curriculum. Three- and nine-month impacts of the intervention on sexual risk behaviors and on mediating variables are presented. The intervention significantly impacted protective peer norms and positive condom attitudes and increased frequency of condom use at the nine-month follow-up. The intervention did not impact sexual initiation or multiple sex partnerships. Future intervention research should address the salient pressures that are unique to post-conflict settings and include longer follow-up time periods and smaller class sizes to meaningfully impact sexual initiation and multiple sex partnerships.

Non-medical use of prescription drugs among youth in an Appalachian population: prevalence, predictors, and implications for prevention.

This article examines prevalence of non-medical use of prescription drugs (NMUPD) in a sample of elementary and high school students in an Appalachian Tennessee county. We found that lifetime prevalence of NMUPD (35%) was higher than prevalence of cigarette use (28%) and marijuana use (17%), but lower than lifetime prevalence of alcohol use (46%). We examined characteristics, as well as risk and protective factors in several domains, as predictors of NMUPD. For comparison, we also examined these characteristics and factors as predictors of alcohol, cigarette, and marijuana use. Using survey data from a sample of late elementary school and high school students (grades 5, 7, 9, and 11), logistic regression analyses showed that the risk factors of friends' non-medical use and perceived availability, and the protective factors of preceived risk, parents' disapproval, school commitment, and community norms against youth NMUPD were significant predictors of lifetime prevalence of NMUPD. Implications for prevention are discussed.

Individual and contextual predictors of inhalant use among 8th graders: a multilevel analysis.

Few studies of inhalant use have examined a large number of predictors at the individual level, including risk and protective factors and delinquent behavior, while also taking into account contextual variables (such as school size and poverty rates). This exploratory study uses 8th grade data from a large-scale survey of students in Kentucky to examine individual and contextual predictors of prevalence of inhalant use, and compares the predictors of inhalant use with factors predicting the use of marijuana and other drug use. Hierarchical Generalized Linear Modeling results using a logit link function suggest that the relationships between inhalant use and some of these factors are different than the relationships between the factors and both marijuana and other drug use. Implications for prevention of inhalant use are discussed.

Therapeutic community drug treatment success in Peru: a follow-up outcome study.

BACKGROUND: The purpose of this study was to assess the impact of drug abuse treatment in Peru that used the therapeutic community (TC) model. Program directors and several staff members from all study treatment facilities received two to eight weeks of in-country training on how to implement the TC treatment model prior to the follow-up study. METHODS: This outcome study involved 33 TC treatment facilities and 509 former clients in Lima and other cities in five providences across Peru. A retrospective pre-test (RPT) follow-up design was employed in which 30-day use of illegal drugs and alcohol to intoxication was measured at baseline retrospectively, at the same time of the six-month follow-up. In-person interview data were collected from directors of 73 percent of the eligible TC organizations in January and February 2003 and from former 58 percent of the eligible TC former clients between October 2003 and October 2004. Drug testing was conducted on a small sample of former clients to increase the accuracy of the self-reported drug use data. RESULTS: Medium to large positive treatment effects were found when comparing 30-day illegal drug and alcohol use to intoxication before and six months after receiving treatment. As a supplemental analysis, we assumed the 42 percent of the former clients who were not interviewed at the six month assessment had returned to drugs. These results showed medium treatment effects as well. Hierarchical Generalized Linear Modeling (HGLM) results showed higher implementation fidelity, less stigma after leaving treatment, and older clients, singly or in combination are key predictors of treatment success. CONCLUSION: This study found that former clients of drug and alcohol treatment in facilities using the TC model reported substantial positive change in use of illegal drugs and alcohol to intoxication at a six-month follow-up. The unique contribution of this study is that the results also suggest attention should be placed on the importance of implementing the TC drug abuse treatment model with fidelity. Further, the results strongly suggest that TC drug abuse treatment programs should incorporate follow-up activities that attempt to neutralize community negative reactions (perceived stigma) independent of other factors.