Adolescents' perceptions of flavored tobacco products, including E-cigarettes: A qualitative study to inform FDA tobacco education efforts through videogames.

INTRODUCTION: Flavored tobacco products have been shown to appeal to youth, however tobacco control strategies have traditionally not focused on these products. To inform the adaptation of an existing videogame to focus on the prevention of flavored tobacco product use, this study explored adolescents' perceptions, beliefs, and social norms surrounding these products, including flavored e-cigarettes. METHODS: We conducted and analyzed transcripts from seven focus groups with 11-17-year-old adolescents (n = 33) from after-school programs in CT and CA in 2016. Participants discussed flavored tobacco product beliefs and experiences, and how these compared to traditional cigarettes. RESULTS: Thematic analysis of transcripts revealed that participants could name flavors in tobacco products, even though few discussed first-hand experience with the products. Most groups perceived that flavored tobacco product and flavored e-cigarette use facilitated peer approval and acceptance. All groups discussed how youth could easily access flavored tobacco products, including e-cigarettes. Flavoring was a salient aspect of e-cigarette advertisements; however the groups did not recall exposure to other types of flavored tobacco product counter-marketing. CONCLUSIONS: These data can help inform the development of tobacco control strategies, novel interventions (such as videogames), and future FDA efforts to prevent adolescent tobacco product use through education and risk communication.

A systematic review of built environment factors related to physical activity and obesity risk: implications for smart growth urban planning.

Smart growth is an approach to urban planning that provides a framework for making community development decisions. Despite its growing use, it is not known whether smart growth can impact physical activity. This review utilizes existing built environment research on factors that have been used in smart growth planning to determine whether they are associated with physical activity or body mass. Searching the MEDLINE, Psycinfo and Web-of-Knowledge databases, 204 articles were identified for descriptive review, and 44 for a more in-depth review of studies that evaluated four or more smart growth planning principles. Five smart growth factors (diverse housing types, mixed land use, housing density, compact development patterns and levels of open space) were associated with increased levels of physical activity, primarily walking. Associations with other forms of physical activity were less common. Results varied by gender and method of environmental assessment. Body mass was largely unaffected. This review suggests that several features of the built environment associated with smart growth planning may promote important forms of physical activity. Future smart growth community planning could focus more directly on health, and future research should explore whether combinations or a critical mass of smart growth features is associated with better population health outcomes.

Longitudinal relationship between the alcohol warning label and alcohol consumption.

OBJECTIVE: The present study reports the longitudinal relationship between alcohol warning label exposure and alcohol consumption among adolescents. METHOD: In-school surveys assessed adolescents at three annual time points beginning in tenth grade. There were 649 participants measured at all three time points; 51% were female. Four effects were the focus of the covariance structure, latent growth analysis of these data: (1) an exposure effect, whereby earlier alcohol use leads to more exposure to the warning label; (2) a deterrent effect, whereby earlier alcohol warning label exposure reduces subsequent alcohol consumption; (3) a harmful effect, corresponding to a positive relationship between early exposure and subsequent consumption; and (4) both exposure and deterrent effects operating at the same time. RESULTS: There was a statistically significant exposure effect such that earlier alcohol use was associated with later exposure to the warning. The association between earlier alcohol warning label exposure and subsequent alcohol use was generally negative but not statistically significant, suggesting that the warning did not affect alcohol consumption. CONCLUSIONS: These results suggest that the alcohol warning label is having the intended effect as described in the law requiring the warning. That is, it is informing and reminding persons of the risks associated with alcohol use. The warning does not appear to significantly increase or decrease alcohol consumption.

From early to late adolescence: alcohol use and anger relationships.

PURPOSE: To evaluate the longitudinal relationship of alcohol use in early adolescence to anger in late adolescence. METHODS: Data were collected in Indianapolis, Indiana, from 1987 to 1993 as part of a large drug abuse prevention trial. Fifty percent of the 1201 students were female, 75%, white, and 69%, low socioeconomic status, who were surveyed in grades 6/7, 9/10, and 11/12. Subjects were asked four anger-related questions: "When I have a problem, I get mad at people," "When I have a problem, I do bad things or cause trouble," "When I have a problem, I say or do nasty things," and "I am a hotheaded person." Two additional items asked subjects to report the number of alcoholic drinks consumed and frequency of drunkenness in the past 30 days. Odds ratios (OR) were used to assess the predictive relationship of alcohol use in early adolescence to anger in late adolescence. RESULTS: Early use of alcohol increased the odds of later anger. Specifically, alcohol use in the past month in grade 6/7 increased the odds in grade 11/12 of saying or doing nasty things (OR = 8.23, p < .01), self-reported hotheadedness (OR = 9.72, p < .01), and high anger on a composite anger scale (OR = 4.84, p < .05). Drunkenness in the past month in grade 6/7 increased the odds of self-reported hotheadedness (OR = 6.17, p <.05) and high anger on the anger scale (OR = 3.20, p < .05) in grade 9/10 and doing something bad to cause trouble in grade 11/12 (OR = 24.97, p < .01). For subjects in grade 9/10, alcohol use in the past month increased the odds in grade 11/12 of doing something bad to cause trouble (OR = 2.79, p < .05), saying or doing nasty things (OR = 2.02, p < .05), and self-reported hotheadedness (OR = 2.51, p < .05). CONCLUSIONS: The present study showed that alcohol use in early adolescence was associated with increased anger, both in middle and late adolescence, controlling for gender, age, and socioeconomic status. The findings suggest that alcohol and drug prevention programs delivered in early adolescence may have the capacity to prevent risk for later anger and related violent behavior.

Identifying trajectories of adolescent smoking: an application of latent growth mixture modeling.

The goal of the current study was to identify discrete longitudinal patterns of change in adolescent smoking using latent growth mixture modeling. Five distinct longitudinal patterns were identified. A group of early rapid escalators was characterized by early escalation (at age 13) that rapidly increased to heavy smoking. A pattern characterized by occasional puffing up until age 15, at which time smoking escalated to moderate levels was also identified (late moderate escalators). Another group included adolescents who, after age 15, began to escalate slowly in their smoking to light (0.5 cigarettes per month) levels (late slow escalators). Finally, a group of stable light smokers (those who smoked 1-2 cigarettes per month) and a group of stable puffers (those who smoked only a few puffs per month) were also identified. The stable puffer group was the largest group and represented 25% of smokers.

The alcohol warning and adolescents: 5-year effects.

OBJECTIVES: This study, a follow-up to the authors earlier report, examined the effects of the alcohol warning label on adolescents during the first 5 years that the warning was required. METHODS: Surveys were administered to 10th-grade (n = 16,661) and 12th-grade (n = 15,856) students from the 1989-1990 school year through the 1994-1995 school year. The measures were awareness of, exposure to, and recognition memory of the alcohol warning label; beliefs about the risks listed on the warning; and open-ended statements about consequences of alcohol use, alcohol consumption, and self-reported driving after drinking. RESULTS: There were increases in warning awareness, exposure, and recognition memory. These effects leveled off approximately 3.5 years after the inclusion of the warning on alcohol beverage containers. There was no beneficial change attributable to the warning in beliefs, alcohol consumption, or driving after drinking. CONCLUSIONS: The initial positive effects of the alcohol warning label on adolescents have leveled off, consistent with theories of repeated exposure to persuasive information. The alcohol warning has not affected adolescents' beliefs about alcohol or alcohol-related behaviors.

Effective prevention programs for tobacco use.

Several types of prevention programs have shown effects on delaying or reducing youth tobacco use for periods of 1-5 years or more. These are referred to as evidence-based programs. However, they are not widely used. At the same time, with few exceptions, adolescent tobacco use rates have been stable or have increased in the 1990s. The challenge for prevention is to identify critical components shared by effective prevention programs--that is, components most associated with effect, and then to evaluate factors that are most likely to promote adoption, implementation, and diffusion of effective programs across schools and communities in the United States. Effective tobacco prevention programs focus on counteracting social influences on tobacco use, include either direct training of youth in resistance and assertiveness skills or, for policy and community organization interventions, direct or indirect (through adults) training in community activism, and are mainly theory-based, with an emphasis on three levels of theory: (a) personal (attitudes, normative expectations, and beliefs); (b) social (social or group behavior); and/or (c) environmental (communications and diffusion). Program effects increase with the use of booster sessions, standardized implementor training and support, multiple program components, and multiple levels of theory. Overall, multi-component community programs that have a school program as a basis, with supportive parent, media, and community organization components, have shown the most sustained effects on tobacco use. Positive program adoption by the school or community, extent and quality of program implementation, and existence of credible networks of leaders to promote the program are critical for any effect. Research on predictors of adoption, implementation, and diffusion of evidence-based programs is scanty relative to outcome research. In addition, more research is needed on why multi-component programs appear to be most effective, whether effect is related to existing tobacco policies, whether prevention programs have differential effects on youth with different natural trajectories of tobacco use, and whether prevention programs can be used to recruit smokers into cessation programs.

Effects of a community-based prevention program on decreasing drug use in high-risk adolescents.

OBJECTIVES: This study investigated the secondary prevention effects of a substance abuse primary prevention program. METHODS: Logistic regression analyses were conducted on 4 waves of follow-up data from sixth- and seventh-grade baseline users of cigarettes, alcohol, and marijuana taking part in a school-based program in Indianapolis. RESULTS: The program demonstrated significant reductions in cigarette use at the initial follow-up (6 months) and alcohol use at the first 2 follow-ups (up to 1.5 years). Models considering repeated measures also showed effects on all 3 substances. CONCLUSIONS: Primary prevention programs are able to reach and influence high-risk adolescents in a nonstigmatizing manner.

Comparison of population-averaged and subject-specific approaches for analyzing repeated binary outcomes.

Several approaches have been proposed to model binary outcomes that arise from longitudinal studies. Most of the approaches can be grouped into two classes: the population-averaged and subject-specific approaches. The generalized estimating equations (GEE) method is commonly used to estimate population-averaged effects, while random-effects logistic models can be used to estimate subject-specific effects. However, it is not clear to many epidemiologists how these two methods relate to one another or how these methods relate to more traditional stratified analysis and standard logistic models. The authors address these issues in the context of a longitudinal smoking prevention trial, the Midwestern Prevention Project. In particular, the authors compare results from stratified analysis, standard logistic models, conditional logistic models, the GEE models, and random-effects models by analyzing a binary outcome from two and seven repeated measurements, respectively. In the comparison, the authors focus on the interpretation of both time-varying and time-invariant covariates under different models. Implications of these methods for epidemiologic research are discussed.

The conflict between least harm and no-use tobacco policy for youth: ethical and policy implications.

This paper examines policy and ethical implementation issues associated with local drug policies that are aimed at producing a "least harm" approach toward youth, with particular application to tobacco policy as an example of a legal, but addictive drug. Research is reviewed which shows the inconsistencies between federally mandated enforcement of zero tobacco use, the Synar Amendment and local community and school policies which appear to relax enforcement of no-use policies for the purpose of retaining youth in school. The inconsistencies are described from the perspective of a "least harm" approach, in that tobacco use may be considered less harmful than absence from school, or use of other substances. The conflict between law and intent to reduce harm is examined with implications for long-term enforcement of federal policy, and for effectiveness of tobacco and other drug abuse prevention programs and other drug policies. Several strategies for reducing the conflict are recommended. These include provision of support-orientated smoking cessation programs for youth on school campuses and in community organizations, and promoting consistent no-use norms across all drugs and across multiple channels that affect youth-mass media, school, point-of-purchase settings and public settings and events.

Implementation and process evaluation of a student "school-as-community" group. A component of a school-based drug abuse prevention program.

Little documentation exists regarding the functioning of formalized adolescent groups as drug abuse prevention agents. Two studies are described that were conducted at high schools whose students are at high risk for drug abuse. Twenty-one schools were randomly assigned to one of three conditions: (a) standard care, (b) classroom drug abuse education only, or (c) classroom plus school-as-community. Results of the first study indicated that the school-as-community component--which involved weekly meetings and periodic events at seven schools--was implemented as planned, drug abused focused, and perceived as productive in discouraging drug abuse. In the second study, staff in the classroom plus school-as-community condition self-reported involvement in the greatest number of community activities across the school year, compared with staff from the other two conditions. These two studies support the feasibility of formalized groups of high-risk youth to promote drug-free events.

Youth beliefs and knowledge about the risks of drinking while pregnant.

Because no published studies of young persons' knowledge and awareness of fetal alcohol syndrome are available, the awareness and beliefs about drinking while pregnant in several large samples of young persons ages 13-20 are examined. Approximately 81 percent of the entire sample that completed questionnaires in school surveys believe that drinking alcohol while pregnant can definitely harm the fetus, although males and younger persons are less likely to believe in this risk. A substantial proportion of respondents believe that occasional heavy use is not harmful and suggest a safe level of drinking that is higher than the Surgeon General's abstinence recommendations. Only 72 percent have heard of fetal alcohol syndrome, and more than one-third incorrectly report that it describes a baby born addicted to alcohol, that the syndrome can be inherited, and that it can be cured. As in prior studies of adults, beliefs about drinking while pregnant are inconsistent with the Surgeon General's recommendations. Implications for increasing the awareness of the risk of drinking while pregnant are discussed.

Directions for future research in drug abuse prevention.

This paper describes future directions for research in drug abuse prevention from six perspectives that are relevant to NIH: integrated demand and supply reduction, strategic prevention that addresses whole populations and high risk groups, comprehensive or extended prevention that includes multiple channels and periods for intervention delivery, technology transfer, prevention research methods development, and finally, the overarching perspective of interfacing basic and social science research approaches. Specific research questions are summarized that represent each perspective, with implications for NIH policy.

Measurement invariance in longitudinal clinical research assuming change from development and intervention.

Valid and reliable measures of psychological and behavioral constructs are critical to clinical research, particularly longitudinal treatment research, in which multiple groups are compared over time for possible changes within and between constructs as a result of intervention or development. Structural equation modeling (SEM) analysis is a class of statistical procedures that can be used to test multiple hypotheses about these relationships simultaneously while controlling for measurement error. The procedures have been applied primarily to testing between-construct relationships in nonexperimental studies, with relatively little emphasis on establishing whether measures are sufficiently invariant across groups and across time to permit these tests. This article uses an empirical example of a longitudinal experimental prevention study with two groups to illustrate the use of SEM, first, to systematically test measurement invariance across groups at each wave of measurement, and second, after establishing measurement invariance, to test structural invariance longitudinally.

Generality and specificity in health behavior: application to warning-label and social influence expectancies.

The authors outlined a meta-theoretical and an analytic framework for construing the predictive effects of health-behavior expectancies, or beliefs, in terms of both general and specific processes. This framework was applied empirically to the investigation of the predictive effects of outcome expectancies related to the recently mandated alcohol-warning label as well as to expectancies reflecting social influence processes. Results showed that general and specific predictive effects of expectancies on alcohol-use behaviors operated simultaneously, demonstrating the potential value of the framework. The authors summarized implications for continued theoretical development as well as for applications in prevention of alcohol abuse through warning-label and social influence interventions.

The alcohol warning label and adolescents: the first year.

Awareness of the alcohol labeling law and exposure to, beliefs about, and memory for the government-mandated alcohol warning label were measured in a sample of adolescents immediately before the label was required to appear (in the fall of 1989) and 1 year after the label was required. After the label was required, there were increases in awareness, exposure, and recognition memory, but there were not substantial changes in alcohol use or beliefs about the risks written on the warning.

Implementation issues in drug abuse prevention research.

This chapter reviews methodological issues in evaluating the quality of implementation of drug abuse prevention programs. Issues of definition (adherence, exposure, reinvention), measurement (self-report, other's report, behavioral observation), and parameters of influence (person, situation, environment) are addressed. Implementation results of recent drug prevention and health promotion studies are reviewed as they relate to these issues. A general model is then proposed that represents implementation as a multiply determined process involving the interaction of person, situation, and environmental influences. Using this model, several recommendations are offered for estimating the "true" drug abuse prevention program effect as the average of effect estimates generated from experimental program assignment and level of program implementation. Potential differences between researcher and programmer standards of quality or level of implementation are noted, using the common interpretation of the efficacy/effectiveness research trial continuum as an example.

Mediating mechanisms in a school-based drug prevention program: first-year effects of the Midwestern Prevention Project.

Describes (a) the effects of a social-influences-based drug prevention program (the Midwestern Prevention Project) on the mediating variables it was designed to change and (b) the process by which the effects on mediating variables changed use of drugs (tobacco, alcohol, and marijuana). Students in 42 middle schools and junior high schools in Kansas City, Missouri, and Kansas City, Kansas, were measured in the fall of 1984 (N = 5,065) and again 1 year later (N = 5,008) after 24 of the schools had been through the program. Compared to students in control schools, students in program schools became less likely to express belief in the positive consequences of drug use, less likely to indicate that they would use such drugs in the future, more likely to report that their friends were less tolerant of drug use, and more likely to believe that they were better able to communicate with their friends about drug or school problems. Change in perceptions of friends' tolerance of drug use was the most substantial mediator of program effects on drug use. There was evidence that intentions to use and beliefs about the positive consequences of use may also mediate program effects on drug use.

Relative effectiveness of comprehensive community programming for drug abuse prevention with high-risk and low-risk adolescents.

This article reviews major risk factors for cigarette smoking, alcohol, and other drug abuse and promising community-based approaches to primary prevention. In a longitudinal experimental study, 8 representative Kansas City communities were assigned randomly to program (school, parent, mass media, and community organization) and control (mass media and community organization only) conditions. Programs were delivered at either 6th or 7th grade, and panels were followed through Grade 9 or 10. The primary findings were (a) significant reductions at 3 years in tobacco and marijuana use and (b) equivalent reductions for youth at different levels of risk. This study provides evidence that a comprehensive community program-based approach can prevent the onset of substance abuse and that the benefits are experienced equally by youth at high and low risk.