International Journal of Environmental Research and Public Health, 2016
To help tobacco control research better include vulnerable populations, we sought to identify eff... more To help tobacco control research better include vulnerable populations, we sought to identify effective ways to recruit diverse smokers. In 2014-2015, we recruited 2149 adult cigarette smokers in California and North Carolina, United States, to participate in a randomized trial of pictorial cigarette pack warnings. The most effective means of recruiting smokers were the classified advertising website Craigslist (28% of participants), word of mouth (23%), Facebook (16%), and flyers or postcards (14%). Low-income and African American smokers were more likely to respond to interpersonal contact (including staff in-person recruitment and word of mouth) than were high-income and non-African American smokers (all p < 0.05). Hispanic and gay, lesbian, and bisexual smokers were more likely to be recruited by Craigslist than non-Hispanic and straight smokers (both p < 0.05). Of the recruitment methods requiring cost, the cheapest was Craigslist ($3-7 per smoker). The most expensive methods were newspaper ads in California ($375 per smoker) and staff in-person recruiting in North Carolina ($180 per smoker). Successfully recruiting diverse smokers requires using multiple methods including interpersonal, online, and other media. Craigslist and word of mouth are especially useful and low-cost ways to recruit diverse smokers.
Pictorial cigarette pack warnings are a promising policy solution to increase smoking cessation a... more Pictorial cigarette pack warnings are a promising policy solution to increase smoking cessation among adults. However, little is known regarding adolescents' responses to pictorial warnings, particularly in real-world settings. Participants were 112 adolescent children, ages 13-17, whose parents received either text-only warnings on the side of their cigarette packs or pictorial warnings on the top half of the front and back of their cigarette packs for 4 weeks as part of a trial. We measured adolescents' recall and recognition of these warnings, negative emotional reactions to the warnings, perceived effectiveness of the warnings, social interactions about the warnings, and smoking risk beliefs. Adolescents accurately recalled pictorial warnings more often than text-only warnings (82% vs. 19%, p < .001). Recognition of warnings was also higher for pictorial than text-only warnings (82% vs. 34%, p < .001). Pictorial warnings drew greater attention (p < .001), elicited greater negative emotional reactions (p < .05), and sparked more social interactions (p < .01) than text-only warnings. Pictorial warnings on cigarette packs may have important effects on adolescent children of smokers. Future research should further investigate the impact of such messages on adolescents' susceptibility to smoking initiation and interest in quitting smoking, particularly as the United States and other countries work to implement pictorial warning regulations.
International journal of environmental research and public health, Jan 5, 2016
The novelty of e-cigarettes and ambiguity about their effects may foster informal sharing of info... more The novelty of e-cigarettes and ambiguity about their effects may foster informal sharing of information, such as through social interactions. We aimed to describe smokers' social interactions about e-cigarettes and their recommendations that others use e-cigarettes. Data were collected from 2149 adult smokers in North Carolina and California who participated in a study of the impact of pictorial cigarette pack warnings. In the previous month, almost half of participants (45%) reported talking to at least one person about e-cigarettes and nearly a third of participants (27%) recommended e-cigarettes to someone else. Smokers recommended e-cigarettes to cut back on smoking (57%), to quit smoking (48%), for health reasons (36%), and for fun (27%). In adjusted analyses, more frequent e-cigarette use, positive views about typical e-cigarette users, and attempting to quit smoking in the past month were associated with recommending e-cigarettes for health reasons (all p < 0.05). Soc...
Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, Jan 22, 2016
Health warnings may be less effective if they elicit reactance, a motivation to resist a threat t... more Health warnings may be less effective if they elicit reactance, a motivation to resist a threat to freedom, yet we lack a standard measure of reactance. We sought to validate a new health warning reactance scale in the context of pictorial cigarette pack warnings. A national sample of adults (n = 1413) responded to reactance survey questions while viewing randomly assigned pictorial or text warnings on images of cigarette packs. A separate longitudinal sample of adult smokers received the warnings on their own cigarette packs (n = 46). Factor analyses identified a reliable and valid 27-item Reactance to Health Warnings Scale. In our experimental study, smokers rated pictorial warnings as being able to motivate quitting more than text warnings. However, five reactance scale factors weakened the warnings' impact (anger, exaggeration, government, manipulation, and personal attack; all p < .05). The Reactance to Health Warnings Scale had good psychometric properties. Reactance we...
To evaluate the inter-rater reliability of a data collection instrument to assess the tobacco ret... more To evaluate the inter-rater reliability of a data collection instrument to assess the tobacco retail environment in Mexico, after major marketing regulations were implemented. In 2013, two data collectors independently evaluated 21 stores in two census tracts, through a data collection instrument that assessed the presence of price promotions, whether single cigarettes were sold, the number of visible advertisements, the presence of signage prohibiting the sale of cigarettes to minors, and characteristics of cigarette pack displays. We evaluated the inter-rater reliability of the collected data, through the calculation of metrics such as intraclass correlation coefficient, percent agreement, Cohen's kappa and Krippendorff's alpha. Most measures demonstrated substantial or perfect inter-rater reliability. Our results indicate the potential utility of the data collection instrument for future point-of-sale research.
Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effe... more Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain. To assess the effect of adding pictorial warnings to the front and back of cigarette packs. This 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events. We randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs). The primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s warning. Of the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting. Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking. clinicaltrials.gov Identifier: NCT02247908.
This paper aims to (1) assess whether promotion of tax-free sales among Internet cigarette vendor... more This paper aims to (1) assess whether promotion of tax-free sales among Internet cigarette vendors (ICVs) changed between 2009 and 2011, (2) determine which types of ICVs are most likely to promote tax-free sales (eg, US-based, international or mixed location ICVs), and (3) compare the price of cigarettes advertised in ICVs to prices at brick-and-mortar retail outlets. We analysed data from the 200 most popular ICVs in 2009, 2010 and 2011 to assess promotion of tax-free sales and the price of Marlboro cigarette cartons. We used Nielsen scanner data from 2009, 2010 and 2011 to measure the price of Marlboro cartons in US grocery stores. The odds of ICVs claiming tax-free status were higher in 2011 than in 2009 (OR=1.58, p<0.01). Mixed location and international vendors had higher odds of promoting tax-free sales than US-based ICVs (OR=4.95 and 6.23, respectively, both p<0.001). In 2011, the average price of one Marlboro carton was $35.27 online, compared to $52.73 in US grocery ...
International Journal of Environmental Research and Public Health, 2015
The Message Impact Framework suggests that social interactions may offer smokers the opportunity ... more The Message Impact Framework suggests that social interactions may offer smokers the opportunity to process pictorial warnings on cigarette packs more deeply. We aimed to describe adult smokers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; social interactions about pictorial cigarette pack warnings in two longitudinal pilot studies. In Pilot Study 1, 30 smokers used cigarette packs with one of nine pictorial warnings for two weeks. In Pilot Study 2, 46 smokers used cigarette packs with one of five pictorial warnings for four weeks. Nearly all smokers (97%/96% in Pilot Study 1/2) talked about the warnings with other people, with the most common people being friends (67%/87%) and spouses/significant others (34%/42%). Pilot Study 2 found that 26% of smokers talked about the warnings with strangers. Discussions about the health effects of smoking and quitting smoking were more frequent during the first week of exposure to pictorial warnings than in the week prior to beginning the study (both p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Pictorial warnings sparked social interactions about the warnings, the health effects of smoking, and quitting smoking, indicating that pictorial warnings may act as a social intervention reaching beyond the individual. Future research should examine social interactions as a potential mediator of the impact of pictorial warnings on smoking behavior.
To inform international research and policy, we conducted a meta-analysis of the experimental lit... more To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33 613) met criteria. Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.
Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the associ... more Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the association between neighbourhood access to singles and cessation behaviour among adult Mexican smokers. We analysed data from Wave 4 (2010), Wave 5 (2011) and Wave 6 (2012) of the Mexican International Tobacco Control Policy Evaluation Survey. We used data from all three waves to examine time trends in singles availability and purchasing. To explore the association between neighbourhood access to singles and cessation behaviour, we used data from participants who were smokers at Wave 5 and followed up at Wave 6 (n=1272). The percentage of participants who saw singles sold daily (45.2% in 2010; 51.4% in 2011; 64.9% in 2012), who bought singles at least once a week (22.3% in 2010; 29.1% in 2011; 29.1% in 2012) and whose last cigarette purchase was a single (16.6% in 2010; 20.7% in 2011; 25.8% in 2012) increased significantly from 2010 to 2012 (all p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). The average percentage of residents who reported seeing singles sold daily in their neighbourhood in 2012 was 60% (SD=25%). In adjusted analyses, smokers living in neighbourhoods with higher access to singles were less likely to make a quit attempt (risk ratio (RR)=0.72; 95% CI 0.46 to 1.12), and more likely to relapse (RR=1.30; CI 0.94 to 1.82), but these results were not statistically significant. Single cigarettes appear widely accessible in Mexico and growing in availability. Future research should explore potential explanations, consequences and effective methods for reducing the availability of single cigarettes.
Lab experiments on cigarette warnings typically use a brief one-time exposure that is not paired ... more Lab experiments on cigarette warnings typically use a brief one-time exposure that is not paired with the cigarette packs smokers use every day, leaving open the question of how repeated warning exposure over several weeks may affect smokers. This proof of principle study sought to develop a new protocol for testing cigarette warnings that better reflects real-world exposure by presenting them on cigarette smokers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; own packs. We tested a cigarette pack labelling protocol with 76 US smokers ages 18 and older. We applied graphic warnings to the front and back of smokers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; cigarette packs. Most smokers reported that at least 75% of the packs of cigarettes they smoked during the study had our warnings. Nearly all said they would participate in the study again. Using cigarette packs with the study warnings increased quit intentions (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). Our findings suggest a feasible pack labelling protocol with six steps: (1) schedule appointments at brief intervals; (2) determine typical cigarette consumption; (3) ask smokers to bring a supply of cigarette packs to study appointments; (4) apply labels to smokers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; cigarette packs; (5) provide participation incentives at the end of appointments; and (6) refer smokers to cessation services at end of the study. When used in randomised controlled trials in settings with real-world message exposure over time, this protocol may help identify the true impact of warnings and thus better inform tobacco product labelling policy. NCT02247908.
ABSTRACT We applaud Monárrez-Espino et al.(1) for conducting a timely systematic review on pictor... more ABSTRACT We applaud Monárrez-Espino et al.(1) for conducting a timely systematic review on pictorial cigarette pack warnings&#39; impact on cigarette use. We have some concerns, however, about the dissimilarity of studies included in the review. We are also concerned that readers may be unaware of other evidence that supports the efficacy of pictorial warnings. (Am J Public Health. Published online ahead of print January 20, 2015: e1. doi:10.2105/AJPH.2014.302510).
The Institute of Medicine recommends that public health agencies restrict the number and regulate... more The Institute of Medicine recommends that public health agencies restrict the number and regulate the location of tobacco retailers as a means of reducing tobacco use. However, the best policy strategy for tobacco retailer reduction is unknown. The purpose of this study is to test the percent reduction in the number and density of tobacco retailers in North Carolina resulting from three policies: (1) prohibiting sales of tobacco products in pharmacies or stores with a pharmacy counter, (2) restricting sales of tobacco products within 1000ft of schools, and (3) regulating to 500ft the minimum allowable distance between tobacco outlets. This study uses data from two lists of tobacco retailers gathered in 2012, one at the statewide level, and another &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;gold standard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; three-county list. Retailers near schools were identified using point and parcel boundaries in ArcMap. Python programming language generated a random lottery system to remove retailers within 500ft of each other. Analyses were conducted in 2014. A minimum allowable distance policy had the single greatest impact and would reduce density by 22.1% at the state level, or 20.8% at the county level (range 16.6% to 27.9%). Both a pharmacy and near-schools ban together would reduce density by 29.3% at the state level, or 29.7% at the county level (range 26.3 to 35.6%). The implementation of policies restricting tobacco sales in pharmacies, near schools, and/or in close proximity to another tobacco retailer would substantially reduce the number and density of tobacco retail outlets.
In order to bolster the public mental health safety net, we must first understand how these syste... more In order to bolster the public mental health safety net, we must first understand how these systems function on a day-to-day basis. This study explored how individual attributes and organizational interdependencies within one predominantly urban US county affected responses to individuals&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; needs during psychiatric crises. We interviewed clinicians and managers within the crisis response network about people at immediate risk of psychiatric hospitalization, what had happened to them during their crises, and factors affecting services provided (N = 94 individuals and 9 agencies). Social network diagrams depicted patterns of referrals between agencies. Iterative coding of interview transcripts was used to contextualize the social network findings. Often, agencies saw crises through to resolution. However, providers also limited the types of people they served, leaving many people in crisis in limbo. This study illustrates how attributes of individuals with mental illness, service providers and their interactions, and state and federal policies intersect to shape the trajectories of individuals during psychiatric crises. Understanding both the structures of current local systems and their contexts may support continued evolution toward a more humane and robust safety net for some of our society&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s most vulnerable members.
Legislation requires the U.S. Food and Drug Administration (FDA) to release information to the pu... more Legislation requires the U.S. Food and Drug Administration (FDA) to release information to the public about harmful constituents in tobacco and tobacco smoke. To inform these efforts, we sought to better understand how smokers and nonsmokers think about tobacco constituents. In October 2012, 300 U.S. adults aged 18-66 years completed a cross-sectional Internet survey. The questions focused on 20 harmful tobacco constituents that the FDA has prioritized for communicating with the public. Most participants had heard of 7 tobacco constituents (ammonia, arsenic, benzene, cadmium, carbon monoxide, formaldehyde, and nicotine), but few participants had heard of the others (e.g., acrolein). Few participants correctly understood that many constituents were naturally present in tobacco. Substances that companies add to cigarette tobacco discouraged people from wanting to smoke more than substances that naturally occur in cigarette smoke (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Ammonia, arsenic, carbon monoxide, and formaldehyde being in cigarettes elicited the most discouragement from smoking. Constituents elicited greater discouragement from wanting to smoke if respondents were nonsmokers (β = -.34, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05), had negative images of smokers (i.e., negative smoker prototypes; β = .19, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05), believed constituents are added to tobacco (β = .14, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05), or were older (β = .16, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). Our study found low awareness of most tobacco constituents, with greater concern elicited by additives. Efforts to communicate health risks of tobacco constituents should consider focusing on ones that elicited the most discouragement from smoking.
Contraceptive use is an important determinant of unintended pregnancy, but little is known about ... more Contraceptive use is an important determinant of unintended pregnancy, but little is known about the social and structural factors that determine women&amp;amp;amp;amp;amp;amp;amp;amp;#39;s contraceptive use in rural Honduras. In this study, we aim to characterise the individual and social determinants of contraceptive use among women in rural Honduras. In 2011 and 2012, we conducted 14 interviews and 2 focus groups with women 18 years and older. In our analysis, we created a family-planning narrative for each participant and coded transcripts around key emergent themes related to these determinants. We found that social determinants--including poverty, gender dynamics and availability of family-planning methods--had a strong influence on contraceptive use among women in our sample. Study participants stated that they were faced with a difficult economic situation compounded by rising prices of basic goods and diminishing job opportunities. Paradoxically, at the same time that the economic situation led women to seek contraception, it also contributed to the structural barriers that limited their ability to obtain their method of choice and maintain continuous contraceptive use. Our findings suggest the need for multi-level efforts to create an enabling and sustainable environment for family planning among women in rural Honduras.
Understanding what people think about harmful and potentially harmful constituents in cigarettes ... more Understanding what people think about harmful and potentially harmful constituents in cigarettes and cigarette smoke has new urgency given legislation requiring FDA to disclose constituent information. Our study sought to obtain qualitative information on what people think about these constituents, and the language they use to talk about them. We conducted 6 focus groups in 2014 with 40 adults in North Carolina. Open-ended questions focused on cigarette and cigarette smoke constituents in general and on the 18 constituents on the FDA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s abbreviated list. We coded the transcripts for emergent themes, and all four coders discussed themes until we reached consensus. Participants knew that cigarette smoke contains chemicals but did not know how many chemicals nor what those chemicals are, beyond tar and nicotine. Dangers of constituents mentioned included &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;chemicals,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; physical disease, and addiction. Participants incorrectly believed harmful constituents came primarily from tobacco companies&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; additives. For unfamiliar constituents, people tried to make associations based on similar-sounding words. Recognizable constituents associated with health harms most discouraged participants from wanting to smoke. Most participants wanted to know health harms associated with constituents, how much of a particular constituent was present in cigarette smoke, and what else the chemicals were in. Participants showed enthusiasm for learning more information about constituents, and also showed substantial misunderstandings about the source of harmful constituents. Our findings contribute to the limited body of research on adults&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; knowledge and perceptions of cigarette smoke constituents and can aid the FDA as it plans to disclose constituent information to the public.
International Journal of Environmental Research and Public Health, 2016
To help tobacco control research better include vulnerable populations, we sought to identify eff... more To help tobacco control research better include vulnerable populations, we sought to identify effective ways to recruit diverse smokers. In 2014-2015, we recruited 2149 adult cigarette smokers in California and North Carolina, United States, to participate in a randomized trial of pictorial cigarette pack warnings. The most effective means of recruiting smokers were the classified advertising website Craigslist (28% of participants), word of mouth (23%), Facebook (16%), and flyers or postcards (14%). Low-income and African American smokers were more likely to respond to interpersonal contact (including staff in-person recruitment and word of mouth) than were high-income and non-African American smokers (all p &amp;amp;amp;amp;amp;amp;lt; 0.05). Hispanic and gay, lesbian, and bisexual smokers were more likely to be recruited by Craigslist than non-Hispanic and straight smokers (both p &amp;amp;amp;amp;amp;amp;lt; 0.05). Of the recruitment methods requiring cost, the cheapest was Craigslist ($3-7 per smoker). The most expensive methods were newspaper ads in California ($375 per smoker) and staff in-person recruiting in North Carolina ($180 per smoker). Successfully recruiting diverse smokers requires using multiple methods including interpersonal, online, and other media. Craigslist and word of mouth are especially useful and low-cost ways to recruit diverse smokers.
Pictorial cigarette pack warnings are a promising policy solution to increase smoking cessation a... more Pictorial cigarette pack warnings are a promising policy solution to increase smoking cessation among adults. However, little is known regarding adolescents&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; responses to pictorial warnings, particularly in real-world settings. Participants were 112 adolescent children, ages 13-17, whose parents received either text-only warnings on the side of their cigarette packs or pictorial warnings on the top half of the front and back of their cigarette packs for 4 weeks as part of a trial. We measured adolescents&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; recall and recognition of these warnings, negative emotional reactions to the warnings, perceived effectiveness of the warnings, social interactions about the warnings, and smoking risk beliefs. Adolescents accurately recalled pictorial warnings more often than text-only warnings (82% vs. 19%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Recognition of warnings was also higher for pictorial than text-only warnings (82% vs. 34%, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Pictorial warnings drew greater attention (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001), elicited greater negative emotional reactions (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05), and sparked more social interactions (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .01) than text-only warnings. Pictorial warnings on cigarette packs may have important effects on adolescent children of smokers. Future research should further investigate the impact of such messages on adolescents&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; susceptibility to smoking initiation and interest in quitting smoking, particularly as the United States and other countries work to implement pictorial warning regulations.
International journal of environmental research and public health, Jan 5, 2016
The novelty of e-cigarettes and ambiguity about their effects may foster informal sharing of info... more The novelty of e-cigarettes and ambiguity about their effects may foster informal sharing of information, such as through social interactions. We aimed to describe smokers' social interactions about e-cigarettes and their recommendations that others use e-cigarettes. Data were collected from 2149 adult smokers in North Carolina and California who participated in a study of the impact of pictorial cigarette pack warnings. In the previous month, almost half of participants (45%) reported talking to at least one person about e-cigarettes and nearly a third of participants (27%) recommended e-cigarettes to someone else. Smokers recommended e-cigarettes to cut back on smoking (57%), to quit smoking (48%), for health reasons (36%), and for fun (27%). In adjusted analyses, more frequent e-cigarette use, positive views about typical e-cigarette users, and attempting to quit smoking in the past month were associated with recommending e-cigarettes for health reasons (all p < 0.05). Soc...
Annals of behavioral medicine : a publication of the Society of Behavioral Medicine, Jan 22, 2016
Health warnings may be less effective if they elicit reactance, a motivation to resist a threat t... more Health warnings may be less effective if they elicit reactance, a motivation to resist a threat to freedom, yet we lack a standard measure of reactance. We sought to validate a new health warning reactance scale in the context of pictorial cigarette pack warnings. A national sample of adults (n = 1413) responded to reactance survey questions while viewing randomly assigned pictorial or text warnings on images of cigarette packs. A separate longitudinal sample of adult smokers received the warnings on their own cigarette packs (n = 46). Factor analyses identified a reliable and valid 27-item Reactance to Health Warnings Scale. In our experimental study, smokers rated pictorial warnings as being able to motivate quitting more than text warnings. However, five reactance scale factors weakened the warnings' impact (anger, exaggeration, government, manipulation, and personal attack; all p < .05). The Reactance to Health Warnings Scale had good psychometric properties. Reactance we...
To evaluate the inter-rater reliability of a data collection instrument to assess the tobacco ret... more To evaluate the inter-rater reliability of a data collection instrument to assess the tobacco retail environment in Mexico, after major marketing regulations were implemented. In 2013, two data collectors independently evaluated 21 stores in two census tracts, through a data collection instrument that assessed the presence of price promotions, whether single cigarettes were sold, the number of visible advertisements, the presence of signage prohibiting the sale of cigarettes to minors, and characteristics of cigarette pack displays. We evaluated the inter-rater reliability of the collected data, through the calculation of metrics such as intraclass correlation coefficient, percent agreement, Cohen's kappa and Krippendorff's alpha. Most measures demonstrated substantial or perfect inter-rater reliability. Our results indicate the potential utility of the data collection instrument for future point-of-sale research.
Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effe... more Pictorial warnings on cigarette packs draw attention and increase quit intentions, but their effect on smoking behavior remains uncertain. To assess the effect of adding pictorial warnings to the front and back of cigarette packs. This 4-week between-participant randomized clinical trial was carried out in California and North Carolina. We recruited a convenience sample of adult cigarette smokers from the general population beginning September 2014 through August 2015. Of 2149 smokers who enrolled, 88% completed the trial. No participants withdrew owing to adverse events. We randomly assigned participants to receive on their cigarette packs for 4 weeks either text-only warnings (one of the Surgeon General&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s warnings currently in use in the United States on the side of the cigarette packs) or pictorial warnings (one of the Family Smoking Prevention and Tobacco Control Act&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s required text warnings and pictures that showed harms of smoking on the top half of the front and back of the cigarette packs). The primary trial outcome was attempting to quit smoking during the study. We hypothesized that smokers randomized to receive pictorial warnings would be more likely to report a quit attempt during the study than smokers randomized to receive a text-only Surgeon General&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s warning. Of the 2149 participants who began the trial (1039 men, 1060 women, and 34 transgender people; mean [SD] age, 39.7 [13.4] years for text-only warning, 39.8 [13.7] for pictorial warnings), 1901 completed it. In intent-to-treat analyses (n = 2149), smokers whose packs had pictorial warnings were more likely than those whose packs had text-only warnings to attempt to quit smoking during the 4-week trial (40% vs 34%; odds ratio [OR], 1.29; 95% CI, 1.09-1.54). The findings did not differ across any demographic groups. Having quit smoking for at least the 7 days prior to the end of the trial was more common among smokers who received pictorial than those who received text-only warnings (5.7% vs 3.8%; OR, 1.53; 95% CI, 1.02-2.29). Pictorial warnings also increased forgoing a cigarette, intentions to quit smoking, negative emotional reactions, thinking about the harms of smoking, and conversations about quitting. Pictorial warnings effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking over 4 weeks. Our trial findings suggest that implementing pictorial warnings on cigarette packs in the United States would discourage smoking. clinicaltrials.gov Identifier: NCT02247908.
This paper aims to (1) assess whether promotion of tax-free sales among Internet cigarette vendor... more This paper aims to (1) assess whether promotion of tax-free sales among Internet cigarette vendors (ICVs) changed between 2009 and 2011, (2) determine which types of ICVs are most likely to promote tax-free sales (eg, US-based, international or mixed location ICVs), and (3) compare the price of cigarettes advertised in ICVs to prices at brick-and-mortar retail outlets. We analysed data from the 200 most popular ICVs in 2009, 2010 and 2011 to assess promotion of tax-free sales and the price of Marlboro cigarette cartons. We used Nielsen scanner data from 2009, 2010 and 2011 to measure the price of Marlboro cartons in US grocery stores. The odds of ICVs claiming tax-free status were higher in 2011 than in 2009 (OR=1.58, p<0.01). Mixed location and international vendors had higher odds of promoting tax-free sales than US-based ICVs (OR=4.95 and 6.23, respectively, both p<0.001). In 2011, the average price of one Marlboro carton was $35.27 online, compared to $52.73 in US grocery ...
International Journal of Environmental Research and Public Health, 2015
The Message Impact Framework suggests that social interactions may offer smokers the opportunity ... more The Message Impact Framework suggests that social interactions may offer smokers the opportunity to process pictorial warnings on cigarette packs more deeply. We aimed to describe adult smokers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; social interactions about pictorial cigarette pack warnings in two longitudinal pilot studies. In Pilot Study 1, 30 smokers used cigarette packs with one of nine pictorial warnings for two weeks. In Pilot Study 2, 46 smokers used cigarette packs with one of five pictorial warnings for four weeks. Nearly all smokers (97%/96% in Pilot Study 1/2) talked about the warnings with other people, with the most common people being friends (67%/87%) and spouses/significant others (34%/42%). Pilot Study 2 found that 26% of smokers talked about the warnings with strangers. Discussions about the health effects of smoking and quitting smoking were more frequent during the first week of exposure to pictorial warnings than in the week prior to beginning the study (both p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Pictorial warnings sparked social interactions about the warnings, the health effects of smoking, and quitting smoking, indicating that pictorial warnings may act as a social intervention reaching beyond the individual. Future research should examine social interactions as a potential mediator of the impact of pictorial warnings on smoking behavior.
To inform international research and policy, we conducted a meta-analysis of the experimental lit... more To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33 613) met criteria. Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.
Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the associ... more Determine (1) trends in single cigarette availability and purchasing in Mexico and (2) the association between neighbourhood access to singles and cessation behaviour among adult Mexican smokers. We analysed data from Wave 4 (2010), Wave 5 (2011) and Wave 6 (2012) of the Mexican International Tobacco Control Policy Evaluation Survey. We used data from all three waves to examine time trends in singles availability and purchasing. To explore the association between neighbourhood access to singles and cessation behaviour, we used data from participants who were smokers at Wave 5 and followed up at Wave 6 (n=1272). The percentage of participants who saw singles sold daily (45.2% in 2010; 51.4% in 2011; 64.9% in 2012), who bought singles at least once a week (22.3% in 2010; 29.1% in 2011; 29.1% in 2012) and whose last cigarette purchase was a single (16.6% in 2010; 20.7% in 2011; 25.8% in 2012) increased significantly from 2010 to 2012 (all p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). The average percentage of residents who reported seeing singles sold daily in their neighbourhood in 2012 was 60% (SD=25%). In adjusted analyses, smokers living in neighbourhoods with higher access to singles were less likely to make a quit attempt (risk ratio (RR)=0.72; 95% CI 0.46 to 1.12), and more likely to relapse (RR=1.30; CI 0.94 to 1.82), but these results were not statistically significant. Single cigarettes appear widely accessible in Mexico and growing in availability. Future research should explore potential explanations, consequences and effective methods for reducing the availability of single cigarettes.
Lab experiments on cigarette warnings typically use a brief one-time exposure that is not paired ... more Lab experiments on cigarette warnings typically use a brief one-time exposure that is not paired with the cigarette packs smokers use every day, leaving open the question of how repeated warning exposure over several weeks may affect smokers. This proof of principle study sought to develop a new protocol for testing cigarette warnings that better reflects real-world exposure by presenting them on cigarette smokers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; own packs. We tested a cigarette pack labelling protocol with 76 US smokers ages 18 and older. We applied graphic warnings to the front and back of smokers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; cigarette packs. Most smokers reported that at least 75% of the packs of cigarettes they smoked during the study had our warnings. Nearly all said they would participate in the study again. Using cigarette packs with the study warnings increased quit intentions (p&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05). Our findings suggest a feasible pack labelling protocol with six steps: (1) schedule appointments at brief intervals; (2) determine typical cigarette consumption; (3) ask smokers to bring a supply of cigarette packs to study appointments; (4) apply labels to smokers&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; cigarette packs; (5) provide participation incentives at the end of appointments; and (6) refer smokers to cessation services at end of the study. When used in randomised controlled trials in settings with real-world message exposure over time, this protocol may help identify the true impact of warnings and thus better inform tobacco product labelling policy. NCT02247908.
ABSTRACT We applaud Monárrez-Espino et al.(1) for conducting a timely systematic review on pictor... more ABSTRACT We applaud Monárrez-Espino et al.(1) for conducting a timely systematic review on pictorial cigarette pack warnings&#39; impact on cigarette use. We have some concerns, however, about the dissimilarity of studies included in the review. We are also concerned that readers may be unaware of other evidence that supports the efficacy of pictorial warnings. (Am J Public Health. Published online ahead of print January 20, 2015: e1. doi:10.2105/AJPH.2014.302510).
The Institute of Medicine recommends that public health agencies restrict the number and regulate... more The Institute of Medicine recommends that public health agencies restrict the number and regulate the location of tobacco retailers as a means of reducing tobacco use. However, the best policy strategy for tobacco retailer reduction is unknown. The purpose of this study is to test the percent reduction in the number and density of tobacco retailers in North Carolina resulting from three policies: (1) prohibiting sales of tobacco products in pharmacies or stores with a pharmacy counter, (2) restricting sales of tobacco products within 1000ft of schools, and (3) regulating to 500ft the minimum allowable distance between tobacco outlets. This study uses data from two lists of tobacco retailers gathered in 2012, one at the statewide level, and another &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;gold standard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; three-county list. Retailers near schools were identified using point and parcel boundaries in ArcMap. Python programming language generated a random lottery system to remove retailers within 500ft of each other. Analyses were conducted in 2014. A minimum allowable distance policy had the single greatest impact and would reduce density by 22.1% at the state level, or 20.8% at the county level (range 16.6% to 27.9%). Both a pharmacy and near-schools ban together would reduce density by 29.3% at the state level, or 29.7% at the county level (range 26.3 to 35.6%). The implementation of policies restricting tobacco sales in pharmacies, near schools, and/or in close proximity to another tobacco retailer would substantially reduce the number and density of tobacco retail outlets.
In order to bolster the public mental health safety net, we must first understand how these syste... more In order to bolster the public mental health safety net, we must first understand how these systems function on a day-to-day basis. This study explored how individual attributes and organizational interdependencies within one predominantly urban US county affected responses to individuals&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; needs during psychiatric crises. We interviewed clinicians and managers within the crisis response network about people at immediate risk of psychiatric hospitalization, what had happened to them during their crises, and factors affecting services provided (N = 94 individuals and 9 agencies). Social network diagrams depicted patterns of referrals between agencies. Iterative coding of interview transcripts was used to contextualize the social network findings. Often, agencies saw crises through to resolution. However, providers also limited the types of people they served, leaving many people in crisis in limbo. This study illustrates how attributes of individuals with mental illness, service providers and their interactions, and state and federal policies intersect to shape the trajectories of individuals during psychiatric crises. Understanding both the structures of current local systems and their contexts may support continued evolution toward a more humane and robust safety net for some of our society&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s most vulnerable members.
Legislation requires the U.S. Food and Drug Administration (FDA) to release information to the pu... more Legislation requires the U.S. Food and Drug Administration (FDA) to release information to the public about harmful constituents in tobacco and tobacco smoke. To inform these efforts, we sought to better understand how smokers and nonsmokers think about tobacco constituents. In October 2012, 300 U.S. adults aged 18-66 years completed a cross-sectional Internet survey. The questions focused on 20 harmful tobacco constituents that the FDA has prioritized for communicating with the public. Most participants had heard of 7 tobacco constituents (ammonia, arsenic, benzene, cadmium, carbon monoxide, formaldehyde, and nicotine), but few participants had heard of the others (e.g., acrolein). Few participants correctly understood that many constituents were naturally present in tobacco. Substances that companies add to cigarette tobacco discouraged people from wanting to smoke more than substances that naturally occur in cigarette smoke (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). Ammonia, arsenic, carbon monoxide, and formaldehyde being in cigarettes elicited the most discouragement from smoking. Constituents elicited greater discouragement from wanting to smoke if respondents were nonsmokers (β = -.34, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05), had negative images of smokers (i.e., negative smoker prototypes; β = .19, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05), believed constituents are added to tobacco (β = .14, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05), or were older (β = .16, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). Our study found low awareness of most tobacco constituents, with greater concern elicited by additives. Efforts to communicate health risks of tobacco constituents should consider focusing on ones that elicited the most discouragement from smoking.
Contraceptive use is an important determinant of unintended pregnancy, but little is known about ... more Contraceptive use is an important determinant of unintended pregnancy, but little is known about the social and structural factors that determine women&amp;amp;amp;amp;amp;amp;amp;amp;#39;s contraceptive use in rural Honduras. In this study, we aim to characterise the individual and social determinants of contraceptive use among women in rural Honduras. In 2011 and 2012, we conducted 14 interviews and 2 focus groups with women 18 years and older. In our analysis, we created a family-planning narrative for each participant and coded transcripts around key emergent themes related to these determinants. We found that social determinants--including poverty, gender dynamics and availability of family-planning methods--had a strong influence on contraceptive use among women in our sample. Study participants stated that they were faced with a difficult economic situation compounded by rising prices of basic goods and diminishing job opportunities. Paradoxically, at the same time that the economic situation led women to seek contraception, it also contributed to the structural barriers that limited their ability to obtain their method of choice and maintain continuous contraceptive use. Our findings suggest the need for multi-level efforts to create an enabling and sustainable environment for family planning among women in rural Honduras.
Understanding what people think about harmful and potentially harmful constituents in cigarettes ... more Understanding what people think about harmful and potentially harmful constituents in cigarettes and cigarette smoke has new urgency given legislation requiring FDA to disclose constituent information. Our study sought to obtain qualitative information on what people think about these constituents, and the language they use to talk about them. We conducted 6 focus groups in 2014 with 40 adults in North Carolina. Open-ended questions focused on cigarette and cigarette smoke constituents in general and on the 18 constituents on the FDA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s abbreviated list. We coded the transcripts for emergent themes, and all four coders discussed themes until we reached consensus. Participants knew that cigarette smoke contains chemicals but did not know how many chemicals nor what those chemicals are, beyond tar and nicotine. Dangers of constituents mentioned included &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;chemicals,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; physical disease, and addiction. Participants incorrectly believed harmful constituents came primarily from tobacco companies&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; additives. For unfamiliar constituents, people tried to make associations based on similar-sounding words. Recognizable constituents associated with health harms most discouraged participants from wanting to smoke. Most participants wanted to know health harms associated with constituents, how much of a particular constituent was present in cigarette smoke, and what else the chemicals were in. Participants showed enthusiasm for learning more information about constituents, and also showed substantial misunderstandings about the source of harmful constituents. Our findings contribute to the limited body of research on adults&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; knowledge and perceptions of cigarette smoke constituents and can aid the FDA as it plans to disclose constituent information to the public.
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Papers by Marissa Hall