Exploring the Association Between Trauma, Instability, and Youth Cardiometabolic Health Outcomes Over Three Years.

PURPOSE: Childhood adversity plays a fundamental role in predicting youth cardiometabolic health. Our understanding of how adverse experiences in childhood should best be conceptualized remains elusive, based on one-dimensional measures of adversity. The present study fills a major gap in existing research by examining two distinct forms of threat and instability-related exposures that may impact cardiometabolic risk (CMR) in adolescence. METHODS: We explore two specific subtypes of adversity: trauma (e.g., badly hurt, victim of crime, loss of close person) and instability (e.g., moving, change of schools, change in household structure) as differential influences that can accumulate to impact early childhood onset of CMR (body mass index, high-density lipoprotein (HDL), low-density lipoprotein, diastolic and systolic blood pressure, triglycerides, C-reactive protein, insulin sensitivity). Secondary data were drawn from a randomized control behavioral trial of youth recruited during sixth grade from urban Cleveland (Ohio) schools beginning in 2012-2014 (n = 360) and followed for 3 years. Participants reported on 12 adverse experiences, six trauma- and six instability-specific. Multiple regression assessed effects of prospective and accumulative indices of trauma and instability with 3-year trajectories of eight objective CMR markers. RESULTS: Instability was associated with increased body mass index, decreased high-density lipoprotein, and increased C-reactive protein slopes. Trauma was associated with trends in triglyceride levels but not with any other CMR outcomes. DISCUSSION: Experiences with instability distinctly impacted adolescent CMR. Future research is needed to examine factors that can enhance stability for families in marginalized communities.

Study design and protocol for Nourishing Beginnings, an integrated service delivery model addressing food insecurity and social needs of low-income pregnant individuals.

BACKGROUND: Nourishing Beginnings is an integrated referral and service delivery model supporting Medicaid-eligible pregnant individuals by providing increased nutritional food access throughout pregnancy up to three months postpartum, through community health workers (CHW), who simultaneously address and provide support for social service needs of the client. METHODS: To study the impact of possible interventions on food security, the program includes two distinct interventions each paired with traditional CHW services, nutrition educational materials, and provision of basic essential cooking tools. Interventions consist of either bi-weekly home food delivery from the local food bank or bi-weekly financial assistance with healthy food access navigation. The study population consists of 160 pregnant individuals (18 or older,<22 weeks pregnant; 80 per intervention arm) who were referred to a countywide Pathways Community HUB (HUB), a community-based care coordination network that uses an evidence-based model to connect at-risk individuals to resources that address medical, social, economic, and behavioral health needs. Key data collection occurs at baseline, eight weeks after intervention begins, near delivery (36-38 weeks gestation), and three months postpartum. Intervention groups are compared to each other as well as against HUB historical controls and a concurrent matched sample from local Medicaid data. CONCLUSION: The goal of Nourishing Beginnings is to improve long-term health outcomes (i.e., maternal and infant) both directly and mediated through a set of proximal outcomes, including prenatal care, food security, diet and nutrition, reported race discrimination and psychosocial factors including depression, stress, healthy eating self-efficacy, and social support. Clinical Trials #: NCT05341960.

Neighborhood Racial Segregation Predict the Spatial Distribution of Supermarkets and Grocery Stores Better than Socioeconomic Factors in Cleveland, Ohio: a Bayesian Spatial Approach.

INTRODUCTION: The food environment influences the availability and affordability of food options for consumers in a given neighborhood. However, disparities in access to healthy food options exist, affecting Black and low-income communities disproportionately. This study investigated whether racial segregation predicted the spatial distribution of supermarkets and grocery stores better than socioeconomic factors or vice versa in Cleveland, Ohio. METHOD: The outcome measure was the count of supermarket and grocery stores in each census tract in Cleveland. They were combined with US census bureau data as covariates. We fitted four Bayesian spatial models. The first model was a baseline model with no covariates. The second model accounted for racial segregation alone. The third model looked at only socioeconomic factors, and the final model combined both racial and socioeconomic factors. RESULTS: Overall model performance was better in the model that considered only racial segregation as a predictor of supermarkets and grocery stores (DIC = 476.29). There was 13% decrease in the number of stores for a census tract with a higher majority of Black people compared to areas with a lower number of Black people. Model 3 that considered only socioeconomic factors was less predictive of the retail outlets (DIC = 484.80). CONCLUSIONS: These findings lead to the conclusion that structural racism evidenced in policies like residential segregation has a significant influence on the spatial distribution of food retail in the city of Cleveland.

Child Opportunity Index and Hospital Utilization in Children With Traumatic Brain Injury Admitted to the PICU.

The need to understand how Community-based disparities impact morbidity and mortality in pediatric critical illness, such as traumatic brain injury. Test the hypothesis that ZIP code-based disparities in hospital utilization, including length of stay (LOS) and hospital costs, exist in a cohort of children with traumatic brain injury (TBI) admitted to a PICU using the Child Opportunity Index (COI). DESIGN: Multicenter retrospective cohort study. SETTING: Pediatric Health Information System (PHIS) database. PATIENTS: Children 0-18 years old admitted to a PHIS hospital with a diagnosis of TBI from January 2016 to December 2020 requiring PICU care. To identify the most severely injured children, a study-specific definition of "Complicated TBI" was created based on radiology, pharmacy, and procedure codes. INTERVENTIONS: None. Main Outcomes and Measures: Using nationally normed ZIP code-level COI data, patients were categorized into COI quintiles. A low COI ZIP code has low childhood opportunity based on weighted indicators within educational, health and environmental, and social and economic domains. Population-averaged generalized estimating equation (GEE) models, adjusted for patient and clinical characteristics examined the association between COI and study outcomes, including hospital LOS and accrued hospital costs. The median age of this cohort of 8,055 children was 58 months (interquartile range [IQR], 8-145 mo). There were differences in patient demographics and rates of Complicated TBI between COI levels. The median hospital LOS was 3.0 days (IQR, 2.0-6.0 d) and in population-averaged GEE models, children living in very low COI ZIP codes were expected to have a hospital LOS 10.2% (95% CI, 4.1-16.8%; p = 0.0142) longer than children living in very high COI ZIP codes. For the 11% of children with a Complicated TBI, the relationship between COI and LOS was lost in multivariable models. COI level was not predictive of accrued hospital costs in this study. CONCLUSIONS: Children with TBI requiring PICU care living in low-opportunity ZIP codes have higher injury severity and longer hospital LOS compared with children living in higher-opportunity ZIP codes. Additional studies are needed to understand why these differences exist.

Improving Surveillance and Epidemic Response in Ohio Childcare Settings.

At the start of the Coronavirus Disease of 2019 (COVID-19) pandemic, the risk of cases in childcare programs was unknown. Thus, a rapid-response research approach was launched in Ohio childcare settings. Passive surveillance data from a state-operated incident reporting system were evaluated to estimate the number of COVID-19 cases from 15 August 2020 to 1 January 2021. Additionally, active surveillance with self-administered reverse transcriptase-polymerase chain reaction (RT-PCR) tests were conducted among staff at 46 childcare programs. Finally, six zoom-based focus groups with program administrators were used to gain feedback. Staff and children in childcare settings contributed 0.38% and 0.15% of the COVID-19 cases in Ohio during this timeframe, respectively. RT-PCR testing identified 3 unrecognized cases (0.88% of tests), and all occurred when the statewide positivity rate was >5%. Focus groups revealed that access to affordable cleaning supplies, masks, and reliable staffing were critical. Perhaps most importantly, we conclude that expanding the incident reporting system to include a childcare census would allow for the tracking of future health problems with highly valuable incidence rate estimations.

Small Improvements in an Urban Food Environment Resulted in No Changes in Diet Among Residents.

Living in a low-income neighborhood with low access to healthy food retailers is associated with increased risk for chronic disease. The U.S. Healthy Food Financing Initiative (HFFI) provides resources to support the development of infrastructure to improve neighborhood food environments. This natural experiment examined a HFFI funded food hub that was designed to be implemented by a community development corporation in an urban neighborhood in Cleveland, Ohio. It was intended to increase access to affordable, local, and healthy foods; establish programs to increase social connections and support for healthy eating; and create job opportunities for residents. We used a quasi-experimental, longitudinal design to externally evaluate food hub implementation and its impact on changes to the built and social environment and dietary patterns among residents living in the intervention neighborhood (n = 179) versus those in a comparison (n = 150) neighborhood. Overall, many of the food hub components were not implemented fully, and dose and reach of the executed food hub components was low. There were statistically significant improvements in observed availability of healthy foods in the intervention neighborhood versus the comparison neighborhood. There were no changes over time in diet quality scores, total caloric intake, or fruit and vegetable intake in the intervention neighborhood. In conclusion, low dose implementation of a food hub led to small improvements in availability of healthy foods but not in dietary patterns. Findings highlight challenges to implementing a food hub in neighborhoods with low access to healthy food retailers.

Measuring quality and outcomes of research collaborations: An integrative review.

INTRODUCTION: Although the science of team science is no longer a new field, the measurement of team science and its standardization remain in relatively early stages of development. To describe the current state of team science assessment, we conducted an integrative review of measures of research collaboration quality and outcomes. METHODS: Collaboration measures were identified using both a literature review based on specific keywords and an environmental scan. Raters abstracted details about the measures using a standard tool. Measures related to collaborations with clinical care, education, and program delivery were excluded from this review. RESULTS: We identified 44 measures of research collaboration quality, which included 35 measures with reliability and some form of statistical validity reported. Most scales focused on group dynamics. We identified 89 measures of research collaboration outcomes; 16 had reliability and 15 had a validity statistic. Outcome measures often only included simple counts of products; publications rarely defined how counts were delimited, obtained, or assessed for reliability. Most measures were tested in only one venue. CONCLUSIONS: Although models of collaboration have been developed, in general, strong, reliable, and valid measurements of such collaborations have not been conducted or accepted into practice. This limitation makes it difficult to compare the characteristics and impacts of research teams across studies or to identify the most important areas for intervention. To advance the science of team science, we provide recommendations regarding the development and psychometric testing of measures of collaboration quality and outcomes that can be replicated and broadly applied across studies.

Two Family Interventions to Reduce BMI in Low-Income Urban Youth: A Randomized Trial.

BACKGROUND: Our primary aim was to evaluate the effects of 2 family-based obesity management interventions compared with a control group on BMI in low-income adolescents with overweight or obesity. METHODS: In this randomized clinical trial, 360 urban-residing youth and a parent were randomly assigned to 1 of 2 behaviorally distinct family interventions or an education-only control group. Eligible children were entering the sixth grade with a BMI ≥85th percentile. Interventions were 3 years in length; data were collected annually for 3 years. Effects of the interventions on BMI slope (primary outcome) over 3 years and a set of secondary outcomes were assessed. RESULTS: Participants were primarily African American (77%), had a family income of <25 000 per year, and obese at enrollment (68%). BMI increased over time in all study groups, with group increases ranging from 0.95 to 1.08. In an intent-to-treat analysis, no significant differences were found in adjusted BMI slopes between either of the family-based interventions and the control group (P = .35). No differences were found between the experimental and control groups on secondary outcomes of diet, physical activity, sleep, perceived stress, or cardiometabolic factors. No evidence of effect modification of the study arms by sex, race and/or ethnicity, household income, baseline levels of child and parent obesity, or exposure to a school fitness program were found. CONCLUSIONS: In this low-income, adolescent population, neither of the family-based interventions improved BMI or health-related secondary outcomes. Future interventions should more fully address poverty and other social issues contributing to childhood obesity.

Socioecological Path Analytic Model of Diet Quality among Residents in Two Urban Food Deserts.

BACKGROUND: Diet is critical to chronic disease prevention, yet there are persistent disparities in diet quality among Americans. The socioecological model suggests multiple factors, operating at multiple levels, influence diet quality. OBJECTIVE: The goal was to model direct and indirect relationships among healthy eating identity, perceived control of healthy eating, social support for healthy eating, food retail choice block scores, perceptions of healthy food availability, and food shopping behaviors and diet quality measured using Healthy Eating Index-2010 scores (HEI-2010) for residents living in two urban communities defined as food deserts. DESIGN: A cross-sectional design was used including data collected via self-reported surveys, 24-dietary recalls, and through objective observations of food retail environments. PARTICIPANTS/SETTING: Data collection occurred in 2015-2016 in two low-income communities in Cleveland (n=243) and Columbus (n=244), OH. MAIN OUTCOME MEASURE: HEI-2010 scores were calculated based on the average of three 24-hour dietary recalls using the Nutrition Data System for Research. ANALYSIS: Separate path models, controlled for income, were run for each community. Analysis was guided by a conceptual model with 15 hypothesized direct and indirect effects on HEI-2010 scores. Associations were considered statistically significant at P<0.05 and P<0.10 because of modest sample sizes in each community. RESULTS: Across both models, significant direct effects on HEI-2010 scores included healthy eating identity (ß=.295, Cleveland; ß=.297, Columbus, P<0.05) and distance traveled to primary food store (ß=.111, Cleveland, P<0.10; ß=.175, Columbus, P<0.05). Perceptions of healthy food availability had a significant, inverse effect in the Columbus model (ß=-.125, P<0.05). The models explained greater variance in HEI-2010 scores for the Columbus community compared with Cleveland (R2=.282 and R2=.152, respectively). CONCLUSIONS: Findings highlight the need for tailored dietary intervention approaches even within demographically comparable communities. Interventions aimed at improving diet quality among residents living in food deserts may need to focus on enhancing healthy eating identity using culturally relevant approaches while at the same time addressing the need for transportation supports to access healthy food retailers located farther away.

People and places shaping food procurement among recipients of Supplemental Nutrition Assistance Program (SNAP).

A key gap in existing food environment research is a more complex understanding of the interplay between physical and social contexts, including the influence of social networks on food habits. This mixed methods research examined the nature of social connections at food procurement places among a sample of 30 people receiving Supplemental Nutrition Assistance Program (SNAP) benefits in an urban setting. Results highlight the significance of social connections as motivators to use food places, the value of access to information and other resources at food places, and the role of weak ties with actors within food places to facilitate utilization and interaction. Social connections at the varied places individuals procure food may be leveraged to disseminate information and resources to further healthy food access.

We Run This City: Impact of a Community-School Fitness Program on Obesity, Health, and Fitness.

INTRODUCTION: The We Run This City (WRTC) Youth Marathon Program is a community-supported, school-based fitness program designed to increase physical activity in a large, urban school district by engaging middle school youth to train 12 to 14 weeks to run or walk 1.2 miles, 6.2 miles, or 13.1 miles of the Rite Aid Cleveland Marathon. The objective of our study was to evaluate the effect of the intervention on adolescent health. METHODS: We assessed changes in obesity, health, and fitness, measured before training and postintervention, among 1,419 sixth- to eighth-grade students participating in WRTC for the first time, with particular interest in the program's effect on overweight (85th-94th body mass index percentile) or obese (≥95th percentile) students. We collected data from 2009 through 2012, and analyzed it in 2016 and 2017. Outcomes of interest were body mass index (BMI), waist-to-hip ratio (WHR), elevated blood pressure, and fitness levels evaluated by using the Progressive Aerobic Cardiovascular Endurance Run (PACER) test and the sit-to-stand test. RESULTS: We saw significant improvements overall in fitness and blood pressure. Controlling for demographics, program event, and training dosage, BMI percentile increased among normal weight participants and decreased among overweight and obese participants (P < .001). WHR increased among obese participants, whereas reductions in blood pressure among those with elevated blood pressure were associated with higher amounts of training and lower baseline BMI. CONCLUSION: Even small amounts of regular physical activity can affect the health and fitness of urban youths. School-community partnerships offer a promising approach to increasing physical activity by supporting schools and making a school-based activity inclusive, fun, and connected to the broader fitness community.

Predictors of Farmers' Market Shopping among People Receiving Supplemental Nutrition Assistance Program Benefits.

Promoting use of farmers' markets (FMs) is a promising community-level strategy to increase access to nutritious foods such as fruits and vegetables. Yet, FM shopping among people with Supplemental Nutrition Assistance Program (SNAP) benefits remains low. This research examined predictors of FM shopping among SNAP recipients living within 1 mile of a FM. A cross-sectional survey of SNAP participants (N = 270) was conducted in 2015 in Cleveland and East Cleveland, OH, USA. Multinomial regression and zero-truncated Poisson regression analyses were conducted to examine factors associated with FM shopping. Results indicate 48% reported shopping at a FM at least once in the past year, 26% had shopped at a FM before, but not in the last year, and 26% had never shopped at a FM. The multivariable analyses found awareness of FMs and a healthy food incentive program, and four dimensions of healthy food access are significantly associated with FM shopping among SNAP recipients. The food access dimensions included service delivery, spatial-temporal, personal, and social access. Findings highlight modifiable leverage points for improving the reach of FMs among low-income populations.

Development of the Systems Thinking Scale for Adolescent Behavior Change.

This report describes the development and psychometric testing of the Systems Thinking Scale for Adolescent Behavior Change (STS-AB). Following item development, initial assessments of understandability and stability of the STS-AB were conducted in a sample of nine adolescents enrolled in a weight management program. Exploratory factor analysis of the 16-item STS-AB and internal consistency assessments were then done with 359 adolescents enrolled in a weight management program. Test-retest reliability of the STS-AB was .71, p = .03; internal consistency reliability was .87. Factor analysis of the 16-item STS-AB indicated a one-factor solution with good factor loadings, ranging from .40 to .67. Evidence of construct validity was supported by significant correlations with established measures of variables associated with health behavior change. We provide beginning evidence of the reliability and validity of the STS-AB to measure systems thinking for health behavior change in young adolescents.

Food Melt in Consumer Food Environments in Low-income Urban Neighborhoods.

OBJECTIVES: We systematically evaluated changes in availability, price, and quality of perishable food items from the beginning to the end of the month in lowincome, urban neighborhoods. METHODS: The sample included grocery stores or supermarkets in Cleveland, Ohio, within neighborhoods with >30% of population receiving food assistance. We collected data for 2 sequential months during the first and fourth weeks of each month. Two coders evaluated stores, collecting measures of availability, price, and quality for 50 items. We examined difference in number and proportion of items available at the beginning of the month (BOM) to items remaining available at the end of the month (EOM), as well as quality and price of those items. RESULTS: Across 48 stores, availability at EOM was lower than BOM; as store size increased, reduction in availability (ie, food melt) was significantly (p < .01) less pronounced. Overall, items became less expensive at the EOM whereas quality remained consistent; we noted no statistically significant differences by store type for price or quality. CONCLUSIONS: Food melt differentially affects individuals in neighborhoods without grocery stores. Findings reveal composition of food environments is dynamic rather than static, influencing food-purchasing choices among lowincome consumers.

Developing multidimensional measures of healthy food access among low-income adults in Cleveland, Ohio, USA.

OBJECTIVE: Access to nutritious foods is key to achieving health promotion goals. While there is evidence that nutritious food access is complex, measures assessing multiple domains of access, including spatial-temporal, economic, social, service delivery and personal, are lacking. The current study evaluates psychometric properties of scales designed to measure perceptions of multiple domains of nutritious food access among low-income populations. DESIGN: A cross-sectional survey was conducted in 2015. Eighty-one items were selected or developed to represent five domains of nutritious food access for food shopping overall and specific to shopping at farmers' markets. Evaluation of the items included exploratory factor analysis within each domain and internal consistency reliability for each of the sub-scales. SETTING: Data were collected in seventeen urban neighbourhoods in Greater Cleveland, Ohio, USA that have high levels of poverty. All participants had access to at least one farmers' market within 1·6 km (1 mile) of their home to standardize spatial access to nutritious foods. SUBJECTS: Adults (n 304) receiving Supplemental Nutrition Assistance Program benefits. RESULTS: Each domain included multiple sub-domains: spatial-temporal (four), service delivery (two), economic (two), social (three) and personal (three), for a total of fourteen subdomains. The internal consistency reliability for one of the sub-domains was outstanding (>0·90), seven were excellent (0·80-0·89), five were very good (0·70-0·79) and one scale had poor reliability (0·58). CONCLUSIONS: Multiple sub-domains of nutritious food access can be assessed using short measures that have been tested for internal consistency. These measures are suitable for assessing the complex phenomena of nutritious food access among low-income populations.

The Hawthorne effect in direct observation research with physicians and patients.

RATIONALE, AIMS, AND OBJECTIVES: This study examines the degree to which a "Hawthorne effect" alters outpatient-visit content. METHODS: Trained research nurses directly observed 4454 visits to 138 family physicians. Multiple data sources were used to examine the Hawthorne effect including differences in medical record documentation for observed visits and the prior visit by the same patient, time use during visits on the first versus the second observation day of each physician, and report by the patient, physician, and observer of the effect of observation. RESULTS: Visits on the first versus the second observation day were longer by an average of 1 minute (P < .001); there were time-use differences for 4 of 20 behaviour categories evaluated. No effect of the observer on the interaction was reported by 74% of patients and 55% of physicians. Most of those that reported an affect indicated it was slight. Patients with non-White race, lower-educational level, and poorer health were more likely to report being affected by the observer. CONCLUSIONS: In a study that was designed to minimize the Hawthorne effect, the presence of an observer had little effect on most patient-physician visits but appeared to at least slightly effect a subgroup of vulnerable patients.

Farmers' Market Use Patterns Among Supplemental Nutrition Assistance Program Recipients With High Access to Farmers' Markets.

OBJECTIVE: Evaluate farmers' market (FM) use patterns among Supplemental Nutrition Assistance Program (SNAP) recipients. DESIGN: Cross-sectional survey administered June to August, 2015. SETTING: Cleveland and East Cleveland, OH. PARTICIPANTS: A total of 304 SNAP recipients with children. Participants lived within 1 mile of 1 of 17 FMs. Most were African American (82.6%) and female (88.1%), and had received SNAP for ≥5 years (65.8%). MAIN OUTCOME MEASURES: Patterns of FM shopping, awareness of FM near home and of healthy food incentive program, use of SNAP to buy fruits and vegetables and to buy other foods at FMs, receipt of healthy food incentive program. ANALYSIS: Two-stage cluster analysis to identify segments with similar FM use patterns. Bivariate statistics including chi-square and ANOVA to evaluate main outcomes, with significance at P ≤ .05. RESULTS: A total of 42% reported FM use in the past year. Current FM shoppers (n = 129) were segmented into 4 clusters: single market, public market, multiple market, and high frequency. Clusters differed significantly in awareness of FM near home and the incentive program, use of SNAP to buy fruit and vegetables at FMs, and receipt of incentive. CONCLUSIONS AND IMPLICATIONS: Findings highlight distinct types of FM use and had implications for tailoring outreach to maximize first time and repeat use of FMs among SNAP recipients.

Use of Appreciative Inquiry To Engage Parents as Codesigners of a Weight Management Intervention for Adolescents.

BACKGROUND: Focus groups are often used to involve families as codesigners of weight management interventions. Focus groups, however, are seldom designed to elicit families' strengths and positive experiences. The purpose of this study was to describe the use of the Appreciative Inquiry process in the conduct of focus groups to engage families in the design of a weight management intervention for adolescents. METHODS: A convenience sample of 44 parents (84% female; 82% minority) of adolescent children with a BMI ≥ 85th percentile, who were in the 6th-8th grade in a large urban school, participated in focus groups designed to elicit family-positive experiences and strengths regarding healthy living. A structured set of questions based on the Appreciative Inquiry process was used in the focus groups. Analyses consisted of the constant comparative method to generate themes. RESULTS: Parent-positive perceptions regarding their family's healthy living habits were reflected in five themes: (1) Having healthy children is a joy; (2) Becoming healthy is a process; (3) Engaging in healthy habits is a family affair; (4) Good health habits can be achieved despite obstacles; and (5) School, community, and social factors contribute to their family's health habits. Parents generated ideas to improve their families' health. CONCLUSIONS: Focus groups based on the Appreciative Inquiry process were found to be a useful approach to discover features that are important to low-income, urban-living parents to include in an adolescent weight management program. Recommendations for designing and conducting focus groups based on the Appreciative Inquiry process are provided.

Individual, Parental, and Environmental Correlates of Cigar, Cigarillo, and Little Cigar Use Among Middle School Adolescents.

INTRODUCTION: Youth use of cigars, cigarillos, and little cigars (CCLC) is increasing. While correlates of cigarette smoking have been well documented, use of CCLC is not as well understood among young adolescents. This study assessed whether smoking beliefs, parenting practices, and environmental exposures were associated with CCLC use among 7th to 8th grade youth in an urban, mid-Western city. METHODS: The Cleveland Youth Risk Behavior Survey was conducted with 7th to 8th grade students in spring 2012. CCLC use was assessed by asking if students had smoked CCLC in the past 30 days. Covariates include self-reported gender, race, grade, acceptability of smoking, parental monitoring, hours of self-care, visits to corner stores, and current cigarette smoking. Bivariate and multivariate analyses were conducted to determine associations with current CCLC use. RESULTS: Overall, 14.3% of youth reported current CCLC use. Students reporting higher acceptability of smoking, lower parental monitoring, longer periods of self-care, more visits to corner stores and current cigarette smoking were more likely to report current CCLC use in both bivariate and multivariable logistic regression models. CONCLUSIONS: CCLC use is associated with multiple levels of influence, indicating that prevention of youth CCLC use must utilize a multilevel approach. Increased utilization of corner stores was associated with higher odds of CCLC use, and could indicate that youth stopping at corner stores may be exposed to increased tobacco retail advertising and tobacco products. The findings of this study have implications for FDA regulation to prevent CCLC initiation among youth. IMPLICATIONS: While correlates of cigarette smoking have been well documented, use of CCLC is not as well understood among young adolescents. This is the first study that has examined the association between individual, family, and environmental characteristics and CCLC use. The results of this study illustrate that youth attitudes, perceived parenting practices, and environmental exposure are associated with adolescent CCLC use. This is important as the tobacco control community begins to identify strategies to prevent and reduce CCLC use. The findings of this study have clear implications for FDA regulation to prevent CCLC initiation among youth.