Visual Attention to Health Warning Labels on Waterpipe Venue Menus in Immersive Virtual Reality.

INTRODUCTION: This study examined how health warning labels (HWL) on a waterpipe venue menu captured and held the attention of consumers and influenced waterpipe tobacco smoking (WTS) attitudes, beliefs, and behaviors. AIMS AND METHODS: A randomized experiment (N = 96) of young adult waterpipe smokers was conducted in an immersive virtual reality laboratory. Participants viewed one of two virtual reality scenarios, a menu with an HWL and nicotine concentration or menu without an HWL and nicotine concentration. Eye-tracking metrics were collected, and participants completed posttest questionnaires on demographics, tobacco use history, and WTS attitudes, beliefs, and behaviors. T-tests were used to assess group differences, and a mediation analysis conducted to examine the relationship between the HWL and intention to quit WTS. RESULTS: Participants in the HWL group demonstrated greater visual attention to the warning and nicotine areas and less visual attention to the flavor and ingredients areas of the menu compared to the control group. The HWL group demonstrated greater negative attitudes toward WTS (p = .002), greater perceived risk of decreased lung function (p = .026), and greater intention to quit WTS (p = 0.003). The mediation model indicated the relationship between the HWL on a menu and intention to quit WTS was mediated by an increase in negative attitudes toward WTS. CONCLUSIONS: The HWLs on a menu captured and held the attention of consumers and increased negative attitudes, perceptions of health risk, and intention to quit WTS indicating potential benefit of including a warning label or nicotine concentration on menus to correct misperceptions of WTS. IMPLICATIONS: The study contributes to the broader literature on communicating the harms and risks of WTS. The findings suggest that HWL and nicotine concentration on waterpipe venue menus attract attention from consumers in environments comparable to the real world and the strategy warrants further exploration as a targeted policy intervention to educate the public and reduce the health burden of WTS.

Health Information on Waterpipe Lounge Menus to Educate Young Adults: Pilot Study Findings.

BACKGROUND: For years, tobacco risk communication has largely focused on cigarette smoking. New strategies must be developed to adapt to emerging tobacco products, such as waterpipe tobacco smoking (WTS). AIMS: The purpose of this pilot study was to determine the preliminary effects of health information on waterpipe lounge menus on the perceptions of harm and risk from WTS and inform future efficacy interventions for health communication (i.e., educating populations on the risks, harms, and health consequences of WTS). METHOD: Participants aged 18 to 24 years (n = 213) who smoked waterpipe at least monthly were randomized to one of four waterpipe lounge menu groups using a two-by-two experimental design with "warning message" and "nicotine content" as factors. RESULTS: Those who viewed waterpipe lounge menus that included a warning message had greater perceived relative harm to health and perceived risk of decreased lung function from WTS. Those who viewed waterpipe lounge menus that included nicotine content had greater perceived risk of heart attack from WTS. DISCUSSION: Participants who were exposed to health warnings of WTS and information on the nicotine content of waterpipe tobacco increased on measures of perceived relative harm and risk of health consequences. CONCLUSION: The pilot test results indicate promise for providing health information on waterpipe lounge menus to educate young adults on the harms and risks of WTS.

Workplace Smoking Cessation in Costa Rica: Pilot Study Findings.

Background: In Costa Rica, the leading cause of preventable death is smoking. Adults spend one third of their lives at work making the workplace an optimal site for smoking cessation interventions. Therefore, we developed a workplace smoking cessation pilot program among Costa Rican Justice Department government employees based on key Costa Rican values and best practices. Methods: First, focus groups were conducted among exsmokers and smokers. Participants in the focus groups and in the subsequent smoking cessation pilot study were invited to take part in the study through flyers, information sheets, and announcements from the Justice Department. The focus groups revealed that social factors were fundamental to quitting. Therefore, based on these results two programs (14 participants) were conducted consisting of seven sessions encouraging employees to utilize their family and exsmokers. Data were collected before and after the seven sessions on smoking behavior, social influence, and other factors. Findings: Five of 14 (36%) quit smoking. None of the quitters lived with a smoker, as compared with 56% of nonquitters who lived with a smoker. Also, quitters were less likely to have friends (40% vs. 67%) and coworkers (20% vs. 33%) who smoked compared with nonquitters. Conclusion/Application to Practice: Workplace smoking cessation programs should help smokers to increase their social contacts with nonsmokers/exsmokers. Smoking cessation programs should assess not only smoking patterns, but also social contacts, such as family, friends, and coworkers. Based on these assessments, smokers should be encouraged to seek-out nonsmokers/exsmokers to assist them in quitting.

Promoting Smoking Cessation in Costa Rica: A Focus Group Study of Smokers and Ex-Smokers.

In developing worksite smoking cessation programs in Costa Rica, it is necessary to gain an understanding of smokers and ex-smokers. For smokers, it was necessary to know the barriers to quitting and what they thought may help them. For ex-smokers, we wanted to identify the main factors that helped them to successfully quit. Two separate focus groups were conducted of smokers (n = 6) and ex-smokers (n = 9) who worked at the Department of Justice. Results indicated that the key factors for both ex-smokers and smokers were social factors-family and coworkers. Participants viewed family support as fundamental to successful quitting. Smokers mentioned that the Justice Department could help them stop smoking by eliciting the support of ex-smoking coworkers. Major barriers to quitting were workplace stress and the presence of other smokers. In conclusion, family members and ex-smoking coworkers can play an important role in worksite smoking cessation programs in Costa Rica.

Flavored cigar smoking among African American young adult dual users: An ecological momentary assessment.

BACKGROUND: Flavored cigar sales have increased in recent years in the U.S. African American young adults (AAYAs) have high prevalence of smoking flavored cigars and dual use with cigarettes, but the predictors of use are unclear. We examined the predictors of flavored cigar smoking among AAYA dual users. METHODS: We analyzed data from an Ecological Momentary Assessment (EMA) study that captured near real-time affect, smoking cues, and tobacco smoking from eight text-messaging surveys per day over two weeks. Sixty-three AAYA (ages 18-29) dual users of cigarettes and cigars recorded 1205 cigar smoking moments. Multivariable Generalized Estimating Equations were used to assess the predictors of smoking cigars with flavors and specific flavor types. RESULTS: Half of the participants were women (49.2%) and aged between 18-24 (46.7%). Over the two-weeks, almost all (98.4%) participants smoked flavored cigars, and 64.2% of the cigars smoked were flavored. Alcohol (34.4%) was the most frequently smoked flavor type followed by sweet (23.4%) and mint (5.7%). Feeling stressed (AOR = 1.07) and bored (AOR = 1.10) predicted smoking alcohol flavors. Blunt smoking positively predicted smoking sweet flavors (AOR = 4.79), but negatively predicted smoking alcohol flavors (AOR = 0.40). CONCLUSIONS: Smoking flavored cigars, especially alcohol-flavored cigars, was prevalent among AAYA dual users in this study. This group might use specific flavors for different purposes including smoking blunts and boosting mood. Efforts to reduce cigar use need to tackle these risk factors and the increased marketing and low-cost pricing of cigars. A federal ban of cigar flavors might reduce the appeal of cigar products.

Beyond blunts: Reasons for cigarette and cigar use among African American young adult dual users.

BACKGROUND: African American young adults are at high risk for dual use of cigarettes and cigars. Limited work has explored and characterized the reasons for use in this population and their relative importance for initiation and current smoking of these products. METHOD: Reasons for cigarette and cigar use were systematically explored and categorized using a mixed methods participatory approach called concept mapping. A series of in-person group sessions were held with 30 African American young adult (ages 18-29) current smokers of both cigarettes and cigars in Prince George's County, MD and Washington, DC. Participants brainstormed, sorted, rated, and interpreted their reasons for initiation and past 30-day use of cigarettes and cigars. A cluster map was generated using multi-dimensional scaling, and t-tests were used to explore differences in ratings by background characteristics. RESULTS: Participants generated 64 reasons for smoking cigarettes and cigars, and categorized these reasons into six groups: emotions, urges, access, product characteristics, lifestyle, and outside pressure. Emotions and urges were the most important motivations for initiation and current smoking of both products. Product characteristics were significantly more important for cigar initiation and smoking than for cigarettes, and outside pressure was more important for current smoking of cigars than cigarettes. Ratings differed by gender, socioeconomic status, and smoking characteristics. CONCLUSIONS: Cigarette and cigar smoking have several overlapping motivations, but key differences were also found, most notably for product characteristics. The FDA's regulation of cigars and cigarettes should focus on addressing key characteristics appealing to young adults to curb dual use.

An Ecological Momentary Assessment of Cigarette and Cigar Dual Use Among African American Young Adults.

Introduction: The dual use of cigarettes and cigars among African American young adults is a significant public health issue. Patterns of and reasons for dual use are difficult to capture using traditional self-report methods. This study used ecological momentary assessment (EMA) to characterize patterns of dual smoking and examine the personal and environmental predictors of cigarette and cigar smoking among African American young adult dual users (ages 18-29) in real-time. Methods: For 14 days, 64 participants smoked ad libitum and were prompted four times daily to record their smoking, craving, emotions, social smoking, and environment via text message on their mobile phones. The odds of single product and dual use were examined using adjusted generalized estimating equations. Results: Participants smoked an average of 7.9 cigarettes and 4.2 cigars per day. Cigarettes and cigars were smoked as frequently during periods of dual use as they were during periods of single product use. Cigarette craving was positively associated with cigarette-only smoking (OR: 1.07), whereas cigar craving was positively associated with cigar-only smoking (OR: 1.43) and dual use (OR: 1.08). Cigars had the greatest odds of dual use when with others (OR: 4.69) and in others' homes (OR: 4.33). Cigarettes had the greatest odds of being smoked while alone (OR: 1.57). Conclusions: EMA was useful for capturing variable smoking patterns and predictors. In this study population, cigarettes and cigars appeared to be smoked additively, and cigars smoked socially. These findings can inform future interventions addressing dual use in this high priority population. Implications: This is the first study to use EMA to examine naturalistic patterns and predictors of multiple tobacco use in real-time. African American young adults smoked cigarettes and cigars during periods of dual use as frequently as during periods of single product use. This suggests that most use was additive (one product smoked in addition to another) and less often as substitution (one product smoked instead of another). Social smoking and craving were strongly associated with cigar smoking in single and dual use periods. This study suggests the need for cessation messaging specifically targeted to reduce dual use in this population.

Associations Between Orphan and Vulnerable Child Caregiving, Household Wealth Disparities, and Women's Overweight Status in Three Southern African Countries Participating in Demographic Health Surveys.

This study examines whether orphan and vulnerable children (OVC) primary caregivers are facing absolute household wealth (AWI) disparities, the association between AWI and women's overweight status, and the modifying role of OVC primary caregiving status on this relationship. Demographic Health Surveys data (2006-2007) from 20 to 49 year old women in Namibia (n = 6,305), Swaziland (n = 2,786), and Zambia (n = 4,389) were analyzed using weighted marginal means and logistic regressions. OVC primary caregivers in Namibia and Swaziland had a lower mean AWI than other women in the same country. In Zambia, OVC primary caregivers had a lower mean AWI score than non-primary caregivers living with an OVC but a higher mean AWI score than non-OVC primary caregivers. In Swaziland and Zambia, even small increases in household wealth were associated with higher odds for being overweight regardless of women's caregiving status. Only in Namibia, OVC primary caregiving modified the effect of the previous association. Among Namibian OVC primary caregivers, women who had at least medium household wealth (4 or more AWI items) were more likely to be overweight than their poorest counterparts (0 or 1 AWI items). OVC primary caregivers are facing household wealth disparities as compared to other women from their communities. Future studies/interventions should consider using population-based approaches to reach women from every household wealth level to curb overweight in Swaziland and Zambia and to focus on specific household wealth characteristics that are associated with OVC primary caregivers' overweight status in Namibia.

Barriers and facilitators to smoking cessation among Latino adults.

BACKGROUND: Previous studies have found that Latinos who smoke are less likely than non-Latino white smokers to use pharmaceutical aids such as nicotine replacement therapies or to receive physician advice to stop smoking. This qualitative study further explored barriers and facilitators to smoking cessation among Latino adults in Maryland. METHODS: Five Spanish-language focus groups were conducted in September 2008 in Maryland with Latino current smoker and ex-smoker men and women (n = 55). Participants were recruited through flyers, information sheets, and site visits at community health clinics and Latino events, and were predominately of Central American origin. RESULTS: Personal health concerns were the main reason to quit smoking; impact on children and family health and role model pressure were frequently mentioned. Barriers to quit smoking included environmental temptation and social factors, emotional pressure, addiction, and habitual behavior. Respondents mostly relied on themselves for cessation, with little use of cessation products or other medications, or awareness of available services. CONCLUSIONS: Social influence serves both as a strong motivation for Latinos to quit smoking and as a source of temptation to continue smoking. Favored by both current smokers and ex-smokers, lay health promoters are effective agents to reach Latinos with smoking cessation interventions. In addition, the low use of cessation services could be improved by increasing awareness and availability of Spanish-language cessation services.

Does social support mediate the moderating effect of intrinsic religiosity on the relationship between physical health and depressive symptoms among Jews?

Previous research in the general population suggests that intrinsic religiosity moderates (mitigates) the effect of poor physical health on depression. However, few studies have focused specifically on the Jewish community. We therefore examined these variables in a cross-sectional sample of 89 Orthodox and 123 non-Orthodox Jews. Based on previous research suggesting that non-Orthodox Judaism values religious mental states (e.g., beliefs) less and a collectivist social religiosity more, as compared to Orthodox Judaism, we hypothesized that the moderating effect of intrinsic religiosity would mediated by social support among non-Orthodox but not Orthodox Jews. As predicted, results indicated that the relationship between physical health and depression was moderated by intrinsic religiosity in the sample as a whole. Furthermore, this effect was mediated by social support among non-Orthodox Jews, but not among the Orthodox. The importance of examining religious affiliation and potential mediators in research on spirituality and health is discussed.

EMTs' attitudes' toward death before and after a death education program.

OBJECTIVE: To test the hypothesis that emergency medical technicians' (EMTs') attitudes toward death will change after exposure to a death education program. METHODS: A convenience sample of 83 rural EMTs participated in this pretest-posttest study after exposure to an educational program related to death. Intact groups of EMTs were randomly assigned to one of three conditions. The short-intervention group received a two-hour class solely on making death notifications. The long-intervention group received a 16-hour, two-day workshop based on the Emergency Death Education and Crisis Training (EDECT(SM)) program. The control group received a program about toxicology. Each participant completed a questionnaire with items structured in a Likert five-point format with "strongly agree" and "strongly disagree" as the anchors. RESULTS: Before the training programs, most (77%) participants reported that an EMT's actions impact the family's grief. Less than half (43%) reported that an EMT's role should include making a death notification. The majority (84%) reported that their training was inadequate to make a death notification or to help the family with their grief. Most (84%) felt uncomfortable making a death notification. Those EMTs in the long-intervention group were significantly more likely (92%) to feel that their training was adequate after the intervention when compared with those EMTs in the short-intervention group (43%) or those in the control group (21%). CONCLUSION: The data showed that EMTs' attitudes toward death changed after exposure to a training program about death.

Survey of EMTs' attitudes towards death.

INTRODUCTION: The purpose of this study was to ascertain information about emergency medical technicians' (EMTs') attitudes towards their training, comfort, and roles when a patient dies on-scene. METHODS: A sample of 136 EMTs (all levels) from 14 different states participated in a survey prior to completing a continuing education program. About 40% (n = 54) of the EMTs were attending a training program related to death based on the Emergency Death Education and Crisis Training Curriculum, while 60% (n = 82) were attending an EMT training program not related to death. Each participant answered questions about their attitudes towards a death on-scene using a five-point Likert scale. The EMTs were compared by level-of training (EMT-B/EMT-I and EMT-P), and by type of educational program attended (death-related education and non-death-related education). RESULTS: Most (82%) participants reported that an EMT's actions impact the grief process of a bereaved family. About half (54%) reported that an EMT's role should include notifying the family of the death. However, three-quarters (76%) reported that they had not been trained adequately to make a death notification or help the family with their grief. Many (40%) felt uncomfortable making a death notification. Differences were present in EMTs enrolled in the death education courses as compared to those attending an educational program not related to death. Differences also were found in the levels of EMTs (EMT-B/EMT-I versus EMT-Paramedics). CONCLUSION: This study provides new insights about EMTs' attitudes towards death and the death-related training they receive.

Integrating smoking cessation into worker training among Latino immigrant workers: development of a program.

The prevalence of smoking among Latino immigrant workers needs to be addressed with culturally and linguistically appropriate smoking cessation programs. One innovative approach to reaching these workers is through worker health and safety training programs. These programs offer multiple opportunities to provide smoking cessation messages, a "teachable moment" to focus on health issues, and the likelihood that peers and family members will share these messages. A collaborative effort between an occupational health and safety training facility and a university utilizing Latino and non-Latino personnel developed a smoking cessation program integrated with worker health and safety training. Preliminary results of an evaluation of the program indicate that the program was able to reach a wide range of immigrant workers and improve their knowledge of the risks of smoking and the effectiveness of different methods of quitting smoking.

Cognitive Interviews Conducted in Spanish: A Method for Enhancing a Hispanic Infant Feeding Questionnaire.

Research indicates that using cognitive interview techniques, that are qualitative in nature, can enhance the quality of health survey instruments. This study was conducted during the formative phase of the Un Bebe Saludable: Un Regalo Muy Especial (A Healthy Baby: A Very Special Gift) program. Cognitive interviews were conducted in Spanish in an effort to improve the quality of a Hispanic infant feeding behavior survey designed to evaluate a peer education program for Latina mothers participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Results indicate that a small sample of cognitive interviews can improve the level of question comprehension and the ease at which respondents can process the information from specific survey items. Our experience suggests that adding cognitive interviewing to conventional field pre-testing and back-translation techniques during the development of Hispanic health surveys may enhance the quality of the health behavior data that are generated.

Measuring acculturation among Central American women with the use of a brief language scale.

The purpose of this study was to test the reliability and validity of a brief language usage scale as a measure of acculturation in 197 Central American immigrant women. This study presents an analysis of cross-sectional survey data collected during face-to-face interviews conducted in Spanish as part of the program evaluation of the Infant Feeding for Hispanic Supplemental Nutrition Program for Women, Infants, and Children (WIC) Populations a Peer Education Model. The Short Acculturation Scale, a four-item language usage scale exploring the participants' language preferences, was used as a measure of acculturation. The participant's age, length of time in the United States, and perceived social support for breastfeeding were used as validation measures. Results demonstrated good internal reliability for the acculturation summary scale. Consistent with previous studies, significant correlations (p < 0.01) were found between acculturation and mother's age, perceived social support for breastfeeding, and mother's length of time in the United States. The reliability and validity data from this group of Central American immigrants support the continued use of this brief measure of acculturation in diverse Latino subpopulations when multidimensional measures are neither practical nor feasible.

Factors affecting nutrition behavior among middle-class adolescents in urban area of Northern region of Brazil

O Brasil tem sido considerado um país em transiçäo nutricional em razäo dos recentes aumentos na prevalência de obesidade e doenças crônicas na classe média, sendo importante identificar os fatores que influenciam as preferências nutricionais desse grupo. Foi realizado estudo com estudantes de classe média de um colégio secundário, particular, em Manaus, AM, Brasil. Com o objetivo de determinar a disponibilidade e a acessibilidade das merendas e analisar as atitudes e preferências dos estudantes e a influência de vários fatores na escolha de merendas nutritivas. O estudo incluiu quatro fases: (a) discussäo em um grupo de especialistas em nutriçäo sobre a disponibilidade e acessibilidade das merendas em Manaus; (b) inquérito junto a um grupo dos adolescentes (n=63) sobre suas preferências e hábitos nutricionais; (c) inquérito junto a supermercado selecionado para identificar a disponibilidade e acessibilidade das merendas preferidas; (d) um grupo acompanhado de um subamostra dos adolescentes (n=55) para identificar as preferências e atitudes sobre o custo e disponibilidade das merendas. Foi constatado que os estudantes possuíam condiçöes financeiras para comprar merendas e que as merendas nutritivas näo custam mais do que as näo nutritivas. A preferência dos adolescentes foi por merendas näo nutritivas. Os fatores que, principalmente, influenciam na escolha originam-se da família e da televisäo. As implicaçöes para futuras pesquisas e programas nutricionais säo discutidos, recomendando-se campanha de educaçäo nutricional para famílias, visto a importância desta na escolha de merendas entre esses adolescentes.