Barriers and Facilitators to the Online Delivery of a School-Based Intervention to Reduce Racial Trauma.

Students of color face disproportionate rates of adverse childhood experiences, including racial discrimination in school settings. Effective interventions strategies are needed to address school-based racial trauma. Link for Equity was designed to be a culturally-responsive trauma-informed intervention that includes universal cultural humility training for teachers. As a result of the COVID-19 pandemic, the in-person trauma-informed cultural humility training was adapted for online delivery. The purpose of this study was to assess barriers and facilitators that impacted online delivery of the training. We conducted semi-structured interviews with 25 high school teachers from three public school districts in the Midwestern United States who participated in the online training. Interview transcripts were coded by two team members, and thematic analysis was utilized. Barriers and facilitators to online delivery were identified across five domains: receptivity, logistics, engagement, comfort, and application. The implications of these barriers and facilitators are discussed and tailored recommendations for the virtual delivery of culturally-responsive trauma-informed interventions to reduce racial discrimination in schools are provided.

Structure and integration of specialty palliative care in three NCI-designated cancer centers: a mixed methods case study.

INTRODUCTION: Early access to specialty palliative care is associated with better quality of life, less intensive end-of-life treatment and improved outcomes for patients with advanced cancer. However, significant variation exists in implementation and integration of palliative care. This study compares the organizational, sociocultural, and clinical factors that support or hinder palliative care integration across three U.S. cancer centers using an in-depth mixed methods case study design and proposes a middle range theory to further characterize specialty palliative care integration. METHODS: Mixed methods data collection included document review, semi-structured interviews, direct clinical observation, and context data related to site characteristics and patient demographics. A mixed inductive and deductive approach and triangulation was used to analyze and compare sites' palliative care delivery models, organizational structures, social norms, and clinician beliefs and practices. RESULTS: Sites included an urban center in the Midwest and two in the Southeast. Data included 62 clinician and 27 leader interviews, observations of 410 inpatient and outpatient encounters and seven non-encounter-based meetings, and multiple documents. Two sites had high levels of "favorable" organizational influences for specialty palliative care integration, including screening, policies, and other structures facilitating integration of specialty palliative care into advanced cancer care. The third site lacked formal organizational policies and structures for specialty palliative care, had a small specialty palliative care team, espoused an organizational identity linked to treatment innovation, and demonstrated strong social norms for oncologist primacy in decision making. This combination led to low levels of specialty palliative care integration and greater reliance on individual clinicians to initiate palliative care. CONCLUSION: Integration of specialty palliative care services in advanced cancer care was associated with a complex interaction of organization-level factors, social norms, and individual clinician orientation. The resulting middle range theory suggests that formal structures and policies for specialty palliative care combined with supportive social norms are associated with greater palliative care integration in advanced cancer care, and less influence of individual clinician preferences or tendencies to continue treatment. These results suggest multi-faceted efforts at different levels, including social norms, may be needed to improve specialty palliative care integration for advanced cancer patients.

Anti-Racist Violence Prevention: Partnering With Black Youth to Identify Intervention Priorities.

In this study, academic researchers partnered with Black youth to engage in critical analysis of the intersection between racism and community violence to promote anti-racist social action that advances health equity. Through youth participatory action research, we examined perspectives and experiences of Black youth to develop a shared understanding of how to approach community violence prevention with an anti-racist lens. Thirteen youth from Kansas City and Atlanta who identified as Black or African American participated in a photovoice project to explore the intersection of racism and community violence. Youth generated photo assignments, took photos that reflected the assignment, shared their photos as a group, and chose one photo to explore in depth each week using a structured method to guide photo-discussion. Qualitative analysis of youth photo-discussions identified themes related to Black youth's experiences of racism at multiple levels and identified suggestions for anti-racist interventions, including promoting Black history knowledge and nurturing Black mentoring relationships. Grounded in these findings, we propose an anti-racist approach to community violence prevention among Black youth that engages Black youth as equitable partners to build from their expertise and strengths in developing comprehensive solutions.

Youth Empowered Advocating for Health (YEAH): Facilitating Partnerships Between Prevention Scientists and Black Youth to Promote Health Equity.

Structural racism inflicts a disproportionate burden of stress and trauma within Black communities, resulting in physical and mental health inequities that impact Black youth. Yet few multilevel interventions exist to address these deeply rooted inequities from a preventive standpoint, and even fewer are informed by the participatory input of the impacted communities. To bridge these gaps, we developed a community-based prevention strategy that promotes agency and active resistance to structural racism, Youth Empowered Advocating for Health (YEAH), and implemented it across various settings. We outline the development, implementation, and expansion of YEAH as a tool for promoting optimal health among Black communities. Lastly, we discuss lessons learned and offer a framework outlining key principles for prevention scientists to partner with Black youth and engage them in translational science to address structural racism. This framework is aimed at driving policies, practices, and procedures that promote equitable and sustainable change for and with Black communities.

Systemic Therapy Decision Making in Advanced Cancer: A Qualitative Analysis of Patient-Oncologist Encounters.

PURPOSE: We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM). METHODS: We performed content analysis of outpatient oncology encounters at two US National Cancer Institute-designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis. RESULTS: Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation. CONCLUSION: In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.

Actual and Missed Opportunities for End-of-Life Care Discussions With Oncology Patients: A Qualitative Study.

Importance: Early discussion of end-of-life (EOL) care preferences improves clinical outcomes and goal-concordant care. However, most EOL discussions occur approximately 1 month before death, despite most patients desiring information earlier. Objective: To describe successful navigation and missed opportunities for EOL discussions (eg, advance care planning, palliative care, discontinuation of disease-directed treatment, hospice care, and after-death wishes) between oncologists and outpatients with advanced cancer. Design, Setting, and Participants: This study is a secondary qualitative analysis of outpatient visits audio-recorded between November 2010 and September 2014 for the Studying Communication in Oncologist-Patient Encounters randomized clinical trial. The study was conducted at 2 US academic medical centers. Participants included medical, gynecological, and radiation oncologists and patients with stage IV malignant neoplasm, whom oncologists characterized as being ones whom they "…would not be surprised if they were admitted to an intensive care unit or died within one year." Data were analyzed between January 2018 and August 2020. Exposures: The parent study randomized participants to oncologist- and patient-directed interventions to facilitate discussion of emotions. Encounters were sampled across preintervention and postintervention periods and all 4 treatment conditions. Main Outcomes and Measures: Secondary qualitative analysis was done of patient-oncologist dyads with 3 consecutive visits for EOL discussions, and a random sample of 7 to 8 dyads from 4 trial groups was analyzed for missed opportunities. Results: The full sample included 141 patients (54 women [38.3%]) and 39 oncologists (8 women [19.5%]) (mean [SD] age for both patients and oncologists, 56.3 [10.0] years). Of 423 encounters, only 21 (5%) included EOL discussions. Oncologists reevaluated treatment options in response to patients' concerns, honored patients as experts on their goals, or used anticipatory guidance to frame treatment reevaluation. In the random sample of 31 dyads and 93 encounters, 35 (38%) included at least 1 missed opportunity. Oncologists responded inadequately to patient concerns over disease progression or dying, used optimistic future talk to address patient concerns, or expressed concern over treatment discontinuation. Only 4 of 23 oncologists (17.4%) had both an EOL discussion and a missed opportunity. Conclusions and Relevance: Opportunities for EOL discussions were rarely realized, whereas missed opportunities were more common, a trend that mirrored oncologists' treatment style. There remains a need to address oncologists' sensitivity to EOL discussions, to avoid unnecessary EOL treatment.

Transitions in frequency of hookah smoking among youth and adults: findings from waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) study, 2013-15.

BACKGROUND AND AIMS: The prevalence of hookah smoking has increased in the United States since at least 2010, especially among youth and young adults. This study assessed self-reported reasons for hookah smoking cessation and transition to or maintenance of high-frequency hookah smoking among current hookah smokers. DESIGN: Separately analyzed data from the Population Assessment of Tobacco and Health (PATH) study, a longitudinal cohort study. Frequency of and reasons for hookah smoking were ascertained at wave 1 (2013-14); frequency of hookah smoking and past-year cessation were ascertained at wave 2 (2014-15). Weighted multivariable logistic and ordinal logistic regression models were fitted to predict hookah smoking cessation and frequency of hookah smoking at wave 2, respectively, accounting for demographic and behavioral risk factors, reasons for hookah smoking and frequency of hookah smoking at wave 1. SETTING: United States. PARTICIPANTS: A total of 693 youth and 4400 adult past-year hookah smokers. MEASUREMENTS: Self-reported tobacco-use patterns and associated health behaviors were measured via audio computer-assisted self-interviews (ACASI). FINDINGS: At wave 1, 5.9% of youth and 7.5% of adults were past-year hookah smokers. Among all age groups, the leading reasons for hookah smoking were enjoyment of socializing while smoking, the availability of appealing flavors and believing that it was less harmful than cigarette smoking. The odds of cessation were lower for adults who liked hookah flavors [adjusted odds ratio (aOR) = 0.40; 95% confidence interval (CI) = 0.26-0.62] compared with adults who did not like hookah flavors. The odds of transitioning to, or maintaining, monthly or more frequent hookah smoking at wave 2, compared with cessation or less than monthly smoking, were higher for adults who liked hookah flavors [adjusted proportional odds ratio (aPOR) = 2.10; 95% CI = 1.48-2.99 and enjoyed socializing while smoking hookah (aPOR = 1.82; 95% CI =1.13-2.94) compared with adults who did not like hookah flavors or socializing. CONCLUSION: The availability of appealing flavors, affordability and socialization while smoking hookah in the United States are associated with reduced likelihood of cessation and increased likelihood of high-frequency hookah smoking.

Role of norms in variation in cancer centers' end-of-life quality: qualitative case study protocol.

BACKGROUND: A critical barrier to improving the quality of end-of-life (EOL) cancer care is our lack of understanding of the mechanisms underlying variation in EOL treatment intensity. This study aims to fill this gap by identifying 1) organizational and provider practice norms at major US cancer centers, and 2) how these norms influence provider decision making heuristics and patient expectations for EOL care, particularly for minority patients with advanced cancer. METHODS: This is a multi-center, qualitative case study at six National Comprehensive Cancer Network (NCCN) and National Cancer Institute (NCI) Comprehensive Cancer Centers. We will theoretically sample centers based upon National Quality Forum (NQF) endorsed EOL quality metrics and demographics to ensure heterogeneity in EOL intensity and region. A multidisciplinary team of clinician and non-clinician researchers will conduct direct observations, semi-structured interviews, and artifact collection. Participants will include: 1) cancer center and clinical service line administrators; 2) providers from medical, surgical, and radiation oncology; palliative or supportive care; intensive care; hospital medicine; and emergency medicine who see patients with cancer and have high clinical practice volume or high local influence (provider interviews and observations); and 3) adult patients with metastatic solid tumors and whom the provider would not be surprised if they died in the next 12 months and their caregivers (patient and caregiver interviews). Leadership interviews will probe about EOL institutional norms and organization. We will observe inpatient and outpatient care for two weeks. Provider interviews will use vignettes to probe explicit and implicit motivations for treatment choices. Semi-structured interviews with patients near EOL, or their family members and caregivers will explore past, current, and future decisions related to their cancer care. We will import transcribed field notes and interviews into Dedoose software for qualitative data management and analysis, and we will develop and apply a deductive and inductive codebook to the data. DISCUSSION: This study aims to improve our understanding of organizational and provider practice norms pertinent to EOL care in U.S. cancer centers. This research will ultimately be used to inform a provider-oriented intervention to improve EOL care for racial and ethnic minority patients with advanced cancer. TRIAL REGISTRATION: Clinicaltrials.gov ; NCT03780816 ; December 19, 2018.

Intranasal delivery of low-dose insulin ameliorates motor dysfunction and dopaminergic cell death in a 6-OHDA rat model of Parkinson's Disease.

Emerging evidence continues to demonstrate that disrupted insulin signaling and altered energy metabolism may play a key role underpinning pathology in neurodegenerative conditions. Intranasally administered insulin has already shown promise as a memory-enhancing therapy in patients with Alzheimer's and animal models of the disease. Intranasal drug delivery allows for direct targeting of insulin to the brain, bypassing the blood brain barrier and minimizing systemic adverse effects. In this study, we sought to expand upon previous results that show intranasal insulin may also have promise as a Parkinson's therapy. We treated 6-OHDA parkinsonian rats with a low dose (3 IU/day) of insulin and assessed apomorphine induced rotational turns, motor deficits via a horizontal ladder test, and dopaminergic cell survival via stereological counting. We found that insulin therapy substantially reduced motor dysfunction and dopaminergic cell death induced by unilateral injection of 6-OHDA. These results confirm insulin's efficacy within this model, and do so over a longer period after model induction which more closely resembles Parkinson's disease. This study also employed a lower dose than previous studies and utilizes a delivery device, which could lead to an easier transition into human clinical trials as a therapeutic for Parkinson's disease.

Reasons for engagement with online tobacco marketing among US adolescents and young adults.

INTRODUCTION: Engagement with online tobacco marketing among US adolescents increased from nearly 9% (2013-2014) to 21% (2014-2015). Such engagement increases the risk of tobacco use initiation. Despite the increase in the prevalence of and risks associated with engagement, the reasons why adolescents and young adults engage are not known. METHODS: A sample of 2619 adolescents (13-17 years) and 2625 young adults (18-24 years) living in the US participated in an online survey in July-August 2017. Engagement with online tobacco marketing was assessed through five forms of engagement (e.g. watched a video online promoting tobacco products). Reasons for engagement were assessed through an open-ended survey question. Prevalence of reasons for engagement was calculated overall, by tobacco use status, and by age group (adolescents and young adults). Multivariable logistic regression models were fit with engagement as the outcome (overall and specific reasons) and sociodemographics (including age, gender, and race/ethnicity) and tobacco use status (non-susceptible and susceptible never tobacco users; ever, but not past 30-day tobacco users; and past 30-day tobacco users) as covariates. RESULTS: Across all tobacco use statuses, the leading reasons for engagement were curiosity or desire for general knowledge about tobacco products (3.9%); incidental, unintended or forced exposure to tobacco ad (3.8%); and seeking discounts, coupons, incentives, or contests (2.9%). Susceptible never tobacco users were more likely to engage because of curiosity or general knowledge than non-susceptible never tobacco users (adjusted odds ratio, AOR=6.81; p<0.01). Past 30-day tobacco users were more likely to engage because of discounts, coupons, incentives, or contests and product appeal than ever, but not past 30-day tobacco users (AOR=7.10; p<0.01). CONCLUSIONS: Stricter state and federal regulation of tobacco marketing, specifically tobacco ads and coupons, and stronger self-regulation by social networking sites could reduce youth engagement with online tobacco marketing.

Online tobacco marketing among US adolescent sexual, gender, racial, and ethnic minorities.

INTRODUCTION: The tobacco industry has previously targeted sexual/gender and racial/ethnic minorities with focused campaigns in traditional, offline marketing. We assess whether these populations report more engagement with online tobacco marketing compared with heterosexual and non-Hispanic white youth. METHODS: Data were from 8015 adolescents sampled between 2014 and 2015 in the nationally-representative Population Assessment for Tobacco and Health (PATH) Study. Engagement with online tobacco marketing within the past year was assessed through eight forms of engagement. A weighted logistic regression model was fit with engagement as outcome and socio-demographic and psychosocial characteristics, internet-related and substance use behavior, tobacco-related risk factors, tobacco use status, and prior engagement with online tobacco marketing as covariates. RESULTS: Accounting for other covariates including tobacco use status and prior engagement with online tobacco marketing, the odds of past-year engagement were higher for sexual minority males (aOR = 1.57; 95% CI: 1.05-2.35) compared to straight males and higher for sexual minority females (aOR = 1.45; 95% CI: 1.13-1.87) compared to straight females. The odds of past-year engagement were also higher for Hispanics (aOR = 1.31; 95% CI: 1.11-1.56) and non-Hispanic Blacks (aOR = 1.42; 95% CI: 1.14-1.77) compared to non-Hispanic Whites. CONCLUSIONS: Sexual/gender and and racial/ethnic minority youth reported higher engagement with online tobacco marketing than their heterosexual and non-Hispanic white peers, respectively.

Use of Flavored E-Cigarettes Among Adolescents, Young Adults, and Older Adults: Findings From the Population Assessment for Tobacco and Health Study.

OBJECTIVES: The use of flavored electronic cigarettes (e-cigarettes) is common among e-cigarette users, but little is known about the potential harms of flavorings, the extent to which the concurrent use of multiple flavor types occurs, and the correlates of flavor type use. The objective of this study was to assess the types of e-cigarette flavors used by adolescent (aged 12-17), young adult (aged 18-24), and older adult (aged ≥25) e-cigarette users. METHODS: We assessed the prevalence of flavored e-cigarette use within the past month by flavor types and concurrent use of multiple flavor types among past-month e-cigarette users sampled during Wave 2 (2014-2015) of the Population Assessment for Tobacco and Health Study among 414 adolescents, 961 young adults, and 1711 older adults. We used weighted logistic regression models for the use of fruit-, candy-, mint/menthol-, tobacco-, or other-flavored e-cigarettes and concurrent use of multiple flavor types. Covariates included demographic characteristics, e-cigarette use frequency, cigarette smoking status, current use of other tobacco products, and reasons for e-cigarette use. RESULTS: The leading e-cigarette flavor types among adolescents were fruit, candy, and other flavors; among young adults were fruit, candy, and mint/menthol; and among older adults were tobacco or other flavors, fruit, and mint/menthol. Compared with older adults, adolescents and young adults were more likely to use fruit-flavored e-cigarettes (adjusted odds ratio [aOR] = 3.35; 95% confidence interval [CI], 2.56-4.38; and aOR = 2.31; 95% CI, 1.77-3.01, respectively) and candy-flavored e-cigarettes (aOR = 3.81; 95% CI, 2.74-5.28; and aOR = 2.95; 95% CI, 2.29-3.80, respectively) and concurrently use multiple flavor types (aOR = 4.58; 95% CI, 3.39-6.17; and aOR = 2.28; 95% CI, 1.78-2.91, respectively). CONCLUSIONS: Regulation of sweet e-cigarette flavors (eg, fruit and candy) may help reduce the use of e-cigarettes among young persons without substantially burdening adult e-cigarette users.

Engagement With Online Tobacco Marketing Among Adolescents in the United States: 2013-2014 to 2014-2015.

OBJECTIVE: To assess changes in engagement with online tobacco and electronic cigarette (e-cigarette) marketing (online tobacco marketing) among adolescents in the United States between 2013 and 2015. METHODS: We assessed the prevalence of six forms of engagement with online tobacco marketing, both overall and by brand, among adolescents sampled in Wave 1 (2013-2014; n = 13651) and Wave 2 (2014-2015; n = 12172) of the nationally representative Population Assessment for Tobacco and Health Study. Engagement was analyzed by tobacco use status: non-susceptible never tobacco users; susceptible never tobacco users; ever tobacco users, but not within the past year; and past-year tobacco users. RESULTS: Among all adolescents, the estimated prevalence of engagement with at least one form of online tobacco marketing increased from 8.7% in 2013-2014 to 20.9% in 2014-2015. The estimated prevalence of engagement also increased over time across all tobacco use statuses (eg, from 10.5% to 26.6% among susceptible adolescents). Brand-specific engagement increased over time for cigarette, cigar, and e-cigarette brands. CONCLUSION: Engagement with online tobacco marketing, both for tobacco and e-cigarettes, increased almost twofold over time. This increase emphasizes the dynamic nature of online tobacco marketing and its ability to reach youth. The Food and Drug Administration, in cooperation with social networking sites, should consider new approaches to regulate this novel form of marketing. IMPLICATIONS: This is the first study to estimate the national prevalence of engagement with online tobacco marketing among adolescents over time. The estimated prevalence of this engagement approximately doubled between 2013-2014 and 2014-2015 among all adolescents and, notably, among adolescents at relatively low risk to initiate tobacco use. This increase in engagement could represent public health harm if it results in increased initiation and use of tobacco products. Stronger federal regulation of online tobacco marketing and tighter control of access to tobacco-related content by social media sites could reduce adolescents' exposure to and engagement with online tobacco marketing.

Combustible and Electronic Tobacco and Marijuana Products in Hip-Hop Music Videos, 2013-2017.

Importance: Hip-hop is the leading music genre in the United States and its fan base includes a large proportion of adolescents and young adults of all racial and ethnic groups, particularly minorities. The appearance of combustible and electronic tobacco and marijuana products, especially brand placement and use by popular and influential artists, may increase the risk of tobacco and marijuana use and decrease perceptions of harm. Objective: To assess the prevalence of the appearance and use of combustible and electronic tobacco and marijuana products, including brand placement, in leading hip-hop songs. Design, Setting, and Participants: Analysis of top 50 songs from 2013 to 2017 of Billboard magazine's weekly Hot R&B/Hip-Hop Songs with videos that included the appearance or use of combustible tobacco and marijuana products (manufactured cigarettes, cigars, hookah or waterpipe, pipe, hand-rolled tobacco and marijuana products, marijuana buds); appearance of exhaled smoke or vapor without an identifiable source product; appearance or use of electronic tobacco and marijuana products (eg, electronic cigarettes); tobacco or marijuana brand placement; appearance or use of combustible and electronic tobacco and marijuana by main or featured artist. Data were collected from December 6, 2017, to June 4, 2018. Main Outcomes and Measures: Prevalence of (1) appearance or use of combustible tobacco and marijuana products, (2) appearance of smoke or vapor, (3) appearance or use of electronic tobacco and marijuana products, (4) tobacco or marijuana brand placement, and (5) appearance or use of combustible and electronic tobacco and marijuana by main or featured artist. Probability of appearance or use of combustible and electronic tobacco and marijuana products by quartile of viewership of videos. Results: The proportion of leading hip-hop videos containing combustible use, electronic use, or smoke or vapor ranged from 40.2% (76 of 189) in 2015, to 50.7% (102 of 201) in 2016. For each year, the leading category of combustible use was hand-rolled products. The appearance of branded products increased from 0% in 2013 (0 of 82) to 9.9% in 2017 (10 of 101) for combustible products, and from 25.0% in 2013 (3 of 12) to 87.5% in 2017 (14 of 16) for electronic products. The prevalence of combustible or electronic product use or exhaled smoke or vapor increased by quartile of total number of views: 41.9% (8700 to 19 million views) among songs in the first quartile of viewership and 49.7% among songs in the fourth quartile of viewership (112 million to 4 billion views). Conclusions and Relevance: Combustible and electronic tobacco and marijuana use frequently occurred in popular hip-hop music videos. The genre's broad appeal, use of branded products by influential artists, and rise of electronic product and marijuana use may contribute to a growing public health concern of tobacco and marijuana use.

Online Tobacco Marketing and Subsequent Tobacco Use.

BACKGROUND: Nearly 2.9 million US adolescents engaged with online tobacco marketing in 2013 to 2014. We assess whether engagement is a risk factor for tobacco use initiation, increased frequency of use, progression to poly-product use, and cessation. METHODS: We analyzed data from 11 996 adolescents sampled in the nationally representative, longitudinal Population Assessment for Tobacco and Health study. At baseline (2013-2014), we ascertained respondents' engagement with online tobacco marketing. At follow-up (2014-2015), we determined if respondents had initiated tobacco use, increased frequency of use, progressed to poly-product use, or quit. Accounting for known risk factors, we fit a multivariable logistic regression model among never-users who engaged at baseline to predict initiation at follow-up. We fit similar models to predict increased frequency of use, progression to poly-product use, and cessation. RESULTS: Compared with adolescents who did not engage, those who engaged reported higher incidences of initiation (19.5% vs 11.9%), increased frequency of use (10.3% vs 4.4%), and progression to poly-product use (5.8% vs 2.4%), and lower incidence of cessation at follow-up (16.1% vs 21.5%). Accounting for other risk factors, engagement was positively associated with initiation (adjusted odds ratio [aOR] = 1.26; 95% confidence interval [CI]: 1.01-1.57), increased frequency of use (aOR = 1.58; 95% CI: 1.24-2.00), progression to poly-product use (aOR = 1.70; 95% CI: 1.20-2.43), and negatively associated with cessation (aOR = 0.71; 95% CI: 0.50-1.00). CONCLUSIONS: Engagement with online tobacco marketing represents a risk factor for adolescent tobacco use. FDA marketing regulation and cooperation of social-networking sites could limit engagement.