Longitudinal analysis of cigar use patterns among US youth and adults, 2013-2019.

BACKGROUND: Cigars are available in a range of pack quantities, which contrasts regulations requiring cigarettes to be sold in packs of 20 or greater. Smaller packages may be associated with increases in initiation while larger packs may lead consumers to smoke more. The purpose of this study was to inform pack quantity regulations by examining whether usual cigar pack quantity purchased was associated with use, initiation, and discontinuation among youth and adults for four cigar types: premium cigars, large cigars, cigarillos, and filtered cigars. METHODS: We analyzed waves 1-5 (2013-2019) of the adult and waves 2-5 (2014-2019) of the youth Population Assessment of Tobacco and Health (PATH) Study. Samples included those responding to the item on pack quantity and providing data at all waves (adults: premium cigars [N = 536], large cigars [N = 1,272], cigarillos [N = 3,504], filtered cigars [N = 1,281]; youth: premium cigars [N = 55], large cigars [N = 217], cigarillos [N = 1514], filtered cigars [N = 266]). Generalized estimating equation models examined the population-averaged effects of pack quantity on cigar use, initiation, and discontinuation. RESULTS: Adult pack quantity was positively associated with the days used per month for premium cigars (b: 0.23, 95% CI: 0.11, 0.34), large cigars (b: 0.17, 95% CI: 0.08, 0.25), cigarillos (b: 0.12, 95% CI: 0.003, 0.24), and filtered cigars (b: 0.07, 95% CI: 0.04, 0.10), and positively associated with amount smoked per day for all cigar types. Youth pack quantity was positively associated with days used per month for premium cigars (b: 0.88, 95% CI: 0.33, 1.43), large cigars (b: 0.79, 95% CI: 0.43, 1.15), and cigarillos (b: 0.17, 95% CI: 0.01, 0.34). Adult initiation was associated with pack quantity for filtered cigars (b: -2.22, 95% CI: -4.29, -0.13), as those who initiated purchased smaller pack quantities compared to those who did not initiate that wave. Pack quantity was not associated with discontinuation for adults or youth. CONCLUSIONS: Cigar use increased as usual pack quantity purchased increased across cigar types for youth and adults. Small increases in pack quantity (e.g., one additional cigar) are likely to result in consuming less than one additional day per month, though larger increases (e.g., 10 additional cigars per pack) may result in greater use.

Evaluation of a Brief, Tailored Skin Cancer Risk Assessment and Referral Intervention for Community-Based Health Educators: Brief Report.

Skin cancer rates are rising and earlier detection through screening leads to better outcomes. Health educators in community centers are well-situated to assess skin cancer risk, deliver tailored health information, and refer high-risk patients to a dermatologist for a screening. This study describes the evaluation of a brief, tailored skin cancer risk assessment, and referral intervention training. The training was developed as part of a pilot feasibility study and seven health educators were trained in an interactive session. Knowledge, attitudes, and efficacy were assessed before and after training. Health educators showed overall improvements of 22% in skin cancer risk knowledge, 50% improvement in positive attitudes toward assessment and referral, and a 40% increase in efficacy to intervene with patients. Community-based health educators that completed the training were able to successfully assess their patients for skin cancer risk and refer high-risk patients for a screening with a healthcare provider.

Price, convenience, the buying experience, and other motivations for purchasing tobacco and e-cigarettes online.

INTRODUCTION: Consumers have shifted to online purchases for many products, including tobacco and e-cigarettes. These shifts have occurred alongside internet tobacco purchasing restrictions being proposed and enacted across the US. The aim of this study was to identify motivations for and against purchasing tobacco and e-cigarettes online, to better understand potential impacts or loopholes. METHODS: We surveyed 463 US adults who reported ever purchasing tobacco or e-cigarettes in April 2021, using Amazon's Mechanical Turk. Participants who reported purchasing tobacco or e-cigarettes online were asked to describe their reasons for doing so. Those who reported never purchasing online were asked to describe their reasons. Responses were triple-coded and thematically analyzed. RESULTS: Most respondents (n=330; 71.3%) had purchased tobacco or e-cigarettes online. We identified 14 reasons for purchasing tobacco or e-cigarettes online across four themes: price (cheaper online, discounts, bulk purchases, avoiding taxes), product characteristics (availability, quality), buying experience (convenience, time, COVID-19 concerns, avoiding shame, discretion, avoiding salespersons, reading reviews), and curiosity. We identified 13 reasons for not purchasing tobacco or e-cigarette products online across seven themes: buying experience (convenience, time, discretion, seeing the product), concerns (legality, safety, quality), consumption, price, supporting local, unaware, and uninterested. CONCLUSIONS: Both online and offline purchasers stated price and convenience motivated their choice to purchase tobacco or e-cigarettes online. Though few participants mentioned purchasing illicit products, concerns about legality and quality of online purchases were raised, and there was some awareness that online purchases attracted lower taxation.

A synthesis of local cigar pack policies in the US.

Communities have adopted cigar pack policies to eliminate inexpensive, small packs from being sold and reduce youth use. Still, it is unclear how widespread these policies are and whether they differ based on specific policy components. This study identified and measured local cigar pack size and price policies in the US. We used a systematic 14-step process to identify, obtain, and code local cigar pack policies, including pack size and pricing. Between January and July 2021, we identified 299 local cigar pack policies in the US. Policies were (1) identified through municipal code review and requests to state tobacco control representatives, (2) obtained online or from municipality representatives, and (3) double-coded for minimum pack size, minimum price, adopted/effective/enforcement dates, cigar definitions, differences in pack size/price by cigar type, price adjustments, whether the price is before discounts, policy exclusions, and enforcement. We identified 259 municipalities with cigar pack policies, 40 of which amended the pack size or price requirements after initial adoption, resulting in 299 policies. Policies specified eight different pack size requirements ranging from 2 to 25; most prevalent were minimums of 2 (n = 116, 39.2%) and 4 (n = 67, 22.6%). Minimum prices ranged from $0.35 to $10.00 per cigar. Exclusions included cigars priced above a specified amount (n = 225, 76.0%; $2.01-$10.00) and cigars sold at adult-only or tobacco retailers (n = 45, 15.2%). This is the first comprehensive synthesis of cigar pack size and price policies within the US. Policies vary widely both between and within states.

Exploring life stressors, depression, and coping strategies in college students.

Objective: College students experience a variety of stressors that can increase the risk for mental health concerns, like depression. It is crucial for practitioners working on college campuses to understand the relationship among stressful life events, depression, and coping strategies. The purpose of this study was to explore life stressors' impact on reported depressive symptoms and how adaptive and maladaptive coping strategies moderate that relationship in college students. Participants: Data was used from a comprehensive health behavior survey. Participants included 969 college students. Methods: Multivariable logistic models were used to examine the association between stressful events, depression, and coping strategies. Results: Results from multiple logistic regression analyses indicated that college students who experienced life stressors and participated in more negative than positive coping strategies were 2.49 (95% CI = 1.34, 4.63) times more likely to experience depression. Conclusions: Implications and creative interventions are provided for mental health practitioners working on college campuses.

Content Analysis of Skin Cancer Screenings on Pinterest: An Exploratory Study.

Skin cancer rates are rising in the United States, yet screening rates remain low. Meanwhile, social media has evolved to become a primary source of health information, with 40% of daily users of Pinterest reporting the platform as a "go-to" source. The objective of this research paper is to examine how skin cancer screenings were portrayed on Pinterest. Using the search terms "skin cancer screening" and "skin cancer exam", researchers sampled every fifth pin to collect 274 relevant pins. Two researchers coded the pins, and interrater agreement was established at 94%. The results showed that twenty-two percent of the sample depicted skin cancer screening in a negative way, yet 41.5% noted that early detection leads to better outcomes. The pins were geared toward younger, white women with minimal depiction of people of color. Few pins included comprehensive information about skin cancer risk factors, importance of routine self-screenings, or what to expect with a medical provider. Fifty-eight percent of pins included links to personal blogs. In conclusion, social media has become a powerful source of health information, yet much of the posted information is incomplete. These findings present public health experts with an opportunity to disseminate more comprehensive skin cancer screening information on social media.

Cancer Risk Perceptions Among People Who Check Their Skin for Skin Cancer: Results from the 2017 U.S. Health Information National Trends Survey (HINTS).

When detected early, melanoma is highly treatable and rarely fatal. Self-skin checks can identify changes in moles that could be an indicator of melanoma. Cancer risk perceptions may influence the uptake of important preventive health behaviors such as self-skin checks. The purpose of this study is to examine cancer risk perception factors associated with those who have checked their skin for signs of skin cancer using the 2017 HINTS data. Retrospective cross-sectional analysis of a nationally representative sample of U.S. adults using the Health Information National Trends Survey (HINTS). Logistic regressions were performed to identify associations between having checked skin for signs of skin cancer, risk perceptions, and demographic variables. White women over the age of 45 with a college degree and annual incomes greater than $75,000 were more likely to check their skin for signs of skin cancer. More than a third reported they would rather not know if they had cancer and more than 60% had some level of worry about having cancer. Those with a personal or family history of cancer were more likely to check. HINTS is a cross-sectional survey which provides only a glimpse of behavioral predictors. Self-skin checks are simple and cost-effective to detect melanoma early and improve outcomes. Fear and worry about cancer were significant factors in the likelihood of checking skin for signs of skin cancer. Population-based strategies could be developed to reduce concerns about early detection.

Testing Multi-Theory Model (MTM) in Explaining Sunscreen Use among Florida Residents: An Integrative Approach for Sun Protection.

Florida residents have the second highest incidence of skin cancer in the nation. Sunscreen usage was found to be the one of the most effective integrative health approaches for reducing risk of skin cancer. Given the limited information on the likelihood of adopting and continuing sunscreen usage behavior, this cross-sectional study aimed to examine the correlates of initiating and sustaining sunscreen usage behavior among Florida dwellers, using the fourth-generation, multi-theory model (MTM) of behavior change. A web-based survey containing 51 questions was emailed to Florida residents aged 18 years or above, who were randomly selected from the state voter file. Psychometric validity of the survey instrument was established using structural equation modeling, and Cronbach's alpha values were calculated for assessing the internal consistency. An independent-samples-t-test and hierarchical multiple regression tests were used to analyze the data. The results indicated that participants who engaged in sunscreen usage behavior, participatory dialogue (ß = 0.062, p < 0.05), behavioral confidence (ß = 0.636, p < 0.001), and changes in the physical environment (ß = 0.210, p < 0.001) were statistically significant and accounted for 73.6% of the variance in initiating sunscreen usage behavior. In addition, the constructs of emotional transformation (ß = 0.486, p < 0.001) and practice for change (ß = 0.211, p < 0.001), as well as changes in the social environment (ß = 0.148, p < 0.001) were significant predictors of maintaining sunscreen usage behavior and contributed to 59% of variance in sustenance. These findings offer a valuable insight regarding the applicability of MTM models to guiding public health interventions promoting sunscreen usage and preventing UV radiation risk and related skin cancer.

Reasons for Pack Size Purchase among US Adults Who Purchase Cigars.

With municipalities across the US establishing minimum cigar pack size regulations, it is critical to understand what drives pack size preference. The purpose of this exploratory study was to identify reasons for cigar pack size purchase. We used Amazon's Mechanical Turk to survey adults who had purchased cigars and reported past 30 day use. Participants responded to an open-ended item asking their reasons for purchasing their usual pack size. Responses were double-coded and categorized. Of 152 respondents, 61 used traditional cigars, 85 used cigarillos, and 36 used filtered cigars. Across all cigar types, most participants (73.7%) purchased boxes rather than singles; 5-9-packs were the most popular pack size category (19.7%), followed by 20+-packs (18.4%). We identified 16 reasons for pack size purchase across seven categories: price, consumption, social aspect, convenience, product characteristics, availability, and general preferences. Reasons varied according to whether the consumer purchased larger or smaller pack sizes. In this exploratory study to identify reasons for cigar pack size purchases, findings were consistent with those identified through tobacco industry documents and in the cigarette literature. Future research should examine the prevalence of these reasons, including as a function of demographic and use characteristics, to help inform the understanding of potential minimum cigar pack regulations.

The Impact of Varying Warning Color on E-Cigarette Advertisements: Results From an Online Experiment Among Young Adults.

INTRODUCTION: Advertisement warnings are often overlooked, which reduces the opportunity for risk communication. METHODS: We used Prolific to survey 1131 young adults (18-35) who currently used e-cigarettes or tobacco products. We randomized participants to one of four warning conditions: black text on white background (BW), white on black (WB), black on yellow (BY), and yellow on black (YB). We examined associations between condition and attention, recall, ad appeal, perceived message effectiveness (PME), and intentions to use e-cigarettes using chi-square and analysis of variance (ANOVA) where appropriate. We conducted logistic regressions by condition for attention and recall controlling for demographics and tobacco use. RESULTS: The warning was selected as the most attention-capturing area of the advertisement more often by those exposed to yellow warnings than white (59.9% vs. 46.8%), even after controlling for demographics and tobacco use (p < .05). Recall was greater among those exposed to yellow warnings than white (44.2% vs. 37.3%), which held in controlled models. There were no significant differences between yellow and white warnings for ad appeals, PME, or intentions to use. In subanalyses, WB warnings generated higher PME (10.1 vs. 9.5) and lower intentions to use e-cigarettes (3.0 vs. 3.3) than black on white (BW) (each p < .05). CONCLUSIONS: Yellow warning color increases attention and recall of the warning, but this increase in attention did not translate to differences in downstream effects. Among currently mandated warning variations, the white text on black background warning appears more effective than the BW. Future research should examine whether differences translate to behavior change. IMPLICATIONS: We tested color variations of the FDA-mandated nicotine text warning on e-cigarette advertisements. Yellow variations (yellow text on black background and BY) better-captured attention and increased warning recall compared to the mandated black and white warnings. Among the FDA-mandated BW and WB warnings, the WB variation appears more effective, generating higher perceived message effectiveness and lower intentions to use e-cigarettes. Given the difficulty in implementing pictorial warnings in the United States, color might represent an alternative to improve warning effectiveness. Findings may also be applicable to those designing tobacco-related health communications.

Who Purchases Tobacco Online? Findings from Waves 1 and 4 of the Population Assessment of Tobacco and Health Study.

Objectives: We examined the prevalence of and factors associated with usually purchasing tobacco online. Methods: We analyzed Waves 1 (2013-14) and 4 (2016-17) of the US Population Assessment of Tobacco and Health adult (18+) and youth (12-17) studies: 15,450 adults and 495 youth in 2013-14 and 15,037 adults and 465 youth in 2016-17. Z-tests compared the prevalence of usually purchasing tobacco online between waves and weighted multivariable regressions identified associations between purchasing online and sociodemographics. Results: The prevalence of usually purchasing tobacco online increased from 2.5% to 3.3% among adults (p < .05) and from 2.5% to 4.4% among youth (p < .05), generalizing to a US population of 2,000,000 adults and 35,000 youth. E-cigarettes and cigars and e-cigarettes and waterpipe tobacco were the most common products among adults and youth, respectively. Men, adults with greater education, adults with higher income, and non-Hispanic black youth had greater odds of purchasing tobacco online (p < .05). Conclusions: Usually purchasing tobacco online remains low, although ever purchasing was not assessed. Efforts should be made to expand Internet tobacco purchasing surveillance and extend and enforce restrictions broadly across tobacco products to reduce youth access.

Cannabidiol (CBD): Perspectives from Pinterest.

BACKGROUND: Pinterest, a widely used social media platform, has shaped how people seek and share health information. Cannabidiol (CBD), a non-psychoactive component of cannabis is marketed as a treatment for many conditions and sales rose to more than 820 million in 2017. Yet CBD is mostly unregulated, legality is murky, and many of the health claims are not scientifically proven. Purpose: This content analysis examined how CBD products were portrayed on Pinterest. Methods: In 2018, using the search terms cannabidiol and CBD, researchers sampled every fifth pin to collect 226 relevant pins. A codebook was developed, pilot tested, and used to code pins. Results: The majority (91.6%) of pins positively portrayed CBD with many claiming a physical or mental benefit including anxiety, depression, pain, and inflammation relief. Most pins did not (98.2%) address potential side effects or recommend dosage. In this sample, user engagement was high with 85.2% of pins being saved and links to commercial sites selling CBD products, personal blogs, and social media accounts. Conclusions: Social media has become a powerful source of health information. This study revealed widespread acceptance of the use of CBD products with minimal information from reliable public health sources represented.

Parents Are Unaware of Their Youths' Tobacco Use: Results from the Population Assessment of Tobacco and Health Study.

BACKGROUND: In this study, we determined the prevalence of and factors associated with parent unawareness of youth tobacco use. METHODS: We used data from waves 1, 2, and 3 (2013-2016) of the Population Assessment of Tobacco and Health study, a nationally representative study of 13,650 US youth ages 12 to 17 and their parents. We conducted weighted multivariate analyses comparing parent unawareness of youth-reported ever use and associations between parents' unawareness of youth use and covariates. RESULTS: Youth ever tobacco use ranged from 21.8% in 2013-2014, to 24.1% in 2014-2015, to 23.4% in 2015-2016. Parent unawareness ranged from 57.6% in 2013-2014, to 61.9% in 2014-2015, and 64.5% in 2015-2016. Factors associated with higher parent unawareness of youth tobacco use in 2015-2016 were youth being female, black, or Hispanic (adjusted odds ratio [AOR] = 1.24-2.61; all ps < .05). Youth with lower academic performance, relatives who used tobacco, tobacco available in the home, or past 30-day use, were less likely to have parents unaware of their use (AORs 0.33-0.56; all ps < .05). CONCLUSIONS: Among youth who reported ever using tobacco, most had parents who were unaware of their use. School-based efforts targeting specific sociodemographic factors could increase parent awareness of youth tobacco use.

Cancer risk perception predictors for total body skin examinations: a cross-sectional study using Health Information National Trends Survey (HINTS) 2017 data.

BACKGROUND: Despite the lack of national skin cancer screening recommendations, a total body skin examination by a healthcare provider may detect skin cancer earlier, allowing for more effective treatment and better outcomes. OBJECTIVE: Examine prevalence, demographic, and cancer risk perceptions of adults who have had a skin examination performed by a healthcare provider. METHODS: Retrospective, cross-sectional analysis of a nationally representative sample of U.S. adults using the Health Information National Trends Survey (HINTS). Logistic regressions were performed to identify associations between having a skin examination, risk perceptions, and demographic variables. RESULTS: Approximately 46% of the sample reported having a skin examination. Females, college graduates, those with a history of skin cancer, people who check their skin for signs of skin cancer, and adults over the age of 45 were more likely to have a skin examination. The people least likely to be screened were those not wanting to know their chances of getting cancer. LIMITATIONS: HINTS is a cross-sectional survey which provides only a glimpse of predictors. CONCLUSIONS: The findings are consistent with other studies that people sometimes avoid cancer risk information. An educational intervention focused on the benefits of early cancer detection would benefit people who report not wanting to know their chances of getting cancer.

CBD (Cannabidiol) Product Attitudes, Knowledge, and Use Among Young Adults.

Background: Cannabidiol (CBD), a non-psychoactive component of cannabis is marketed as a potential treatment for many conditions and widely available to purchase as a dietary supplement. In 2017, sales of CBD exceeded 820 million dollars despite many unconfirmed health claims, murky legality, and limited product efficacy and safety testing.Purpose/Objectives: This study aims to explore cannabidiol (CBD) knowledge, attitudes, and use among young adults.Methods: The anonymous 36-item survey developed using Qualtrics was distributed via social media from November 2018 to January 2019 with 340 respondents.Results: Of the 340 respondents, 242 reported they had heard of CBD, and 135 reported using CBD products. CBD users were primarily white, female, without children, made less than $25,000 per year, and unmarried. Most commonly used CBD products were edibles (56.30%), tinctures (54.07%), and vape (38.52%). Top reasons for use included stress relief (65.39%), relaxation (54.81%), and sleep improvement (42.22%). Many respondents reported using guesswork to determine dosage, and over half of respondents reported at least one unanticipated side effect.Conclusions/Importance: This study revealed that many users are not responsibly using CBD products, many believe CBD products provide health benefits that are not yet scientifically proven, and they are not knowledgeable about legal and regulatory issues. Until CBD use is more thoroughly researched and has more comprehensive regulation, public health professionals should address alternative stress and anxiety treatment methods.

Negative health symptoms reported by youth e-cigarette users: Results from a national survey of US youth.

BACKGROUND: E-cigarettes are the most prevalent tobacco product among US youth, but little is known about the health symptoms users experience. METHODS: Between August 2016 and May 2017, we conducted a nationally representative cross-sectional telephone survey of 975 US youth ages 13-17. Respondents who reported ever trying e-cigarettes were asked whether they ever experienced six physical health symptoms they thought were caused by e-cigarette use. We examined whether symptoms varied by demographics and tobacco use. RESULTS: Approximately 12.4% of respondents (n = 141) reported ever trying e-cigarettes. Of lifetime e-cigarette users, 37.0% reported past 30-day e-cigarette use, 17.2% reported past 30-day cigarette use, and 23.7% reported past 30-day use of another tobacco product. Most (63.3%) reported a symptom, most often cough (42.3%), followed by dizziness or lightheadedness (31.5%), headache or migraine (25.4%), dry or irritated mouth or throat (14.9%), shortness of breath (13.7%), change in or loss of taste (3.5%), and other (5.7%; nausea, dry eyes, earache, and tight chest). Headaches were more common among past 30-day e-cigarette users than non-users (43.8% vs. 14.6%). Shortness of breath was more common among past 30-day cigarette (33.8% vs. 9.5%) and other tobacco users (31.6% vs. 8.2%). Past 30-day cigarette users were also more likely to report any symptom (86.0% vs. 58.6%). CONCLUSIONS: Most youth e-cigarette users attribute health symptoms to their e-cigarette use. Past 30-day users were more likely to report certain symptoms than non-users. Findings can educate health practitioners and school nurses about common symptoms youth may experience and inform prevention messages.

Pinterest Homemade Sunscreens: A Recipe for Sunburn.

Social media, specifically Pinterest with more than 175 million users, has changed the way people seek and share health information. Recent consumer interest in natural products has led to an increase of shared recipes for homemade products including sunscreen. Homemade sunscreen products are risky because they are not regulated or tested for efficacy like commercial sunscreens. With rising skin cancer rates, the use of effective broadband sunscreen is critical to reduce incidence of skin cancer. This study used directed content analysis to examine how homemade sunscreens were portrayed on Pinterest. Using the search terms, homemade sunscreen and natural sunscreen, researchers sampled every fifth pin to collect 189 relevant pins. A codebook was developed, pilot tested, and used to code pins. Two researchers coded pins and interrater reliability was established at 90%. Of the 189 pins, the majority of pins (95.2%) positively portrayed the effectiveness of homemade sunscreens and 68.3% recommended recipes for homemade sunscreens that offered insufficient UV radiation protection. Sun Protection Factor (SPF) claims were made in 33.3% of pins with a range of SPF 2 to SPF 50. In this sample of pins, 41.8% of pins had been saved by other users ranging from one to more than 21,000 times. Social media is a powerful source of health information. However, this study revealed widespread interest and acceptance of insufficient sun protection information. Pinterest and the interest in homemade recipes for sunscreen present an opportunity for public health professionals to proactively engage on social media. Abbreviations: US: United States; SPF: sun protection factor; USFDA: United states food and drug administration; UV: ultraviolet.

Nature contact at school: The impact of an outdoor classroom on children's well-being.

Nature contact facilitates healthy child development and a disconnect with nature presents potential health risks. This study was designed to test a nature intervention at an elementary school among children. An experimental crossover design was implemented over six weeks; two teachers taught their respective kindergarten classes the daily language arts lesson in either the control (indoor classroom) or nature treatment (outdoor classroom) conditions. Child well-being measures were compared in the two conditions. Teachers' redirections of child behavior were significantly fewer in the nature condition (t = 2.49, p < 0.05) compared to the control. Also, fewer children were off task in the nature condition on average. There were mixed well-being results; children reported no significance difference in happiness in the two conditions, but teachers reported modest benefit in child well-being in the nature condition. The outdoor classroom is a promising method for increasing nature contact and promoting student well-being.

Lifestyle Factors Associated With Sunscreen Use Among Young Adults.

Background. Skin cancer is the most common cancer in the United States with melanoma rates increasing. Sunscreen use is an effective way to protect the skin and reduce skin cancer risk. Limited research has been conducted examining the relationship between sunscreen use and other lifestyle factors. Interventions aimed at multiple lifestyle factors have shown promise for prevention and reduced health care costs. Objective. This study explores the relationship between sunscreen use and lifestyle factors associated with mortality and morbidity among young adults. Lifestyle factors examined included physical activity, substance abuse, smoking, sexual behavior, unintentional injury, and mental well-being. Methods. A convenience sample of 747 college students was surveyed about sunscreen use and other health risks. Data were analyzed using SPSS 19. Results. White, female students older than 21 years were more likely to use sunscreen. Texting while driving, low life satisfaction, and binge drinking were associated with inadequate sunscreen use. Limitations. Convenience sampling limits generalizability and surveys are subject to recall, self-report, and self-selection bias. Conclusions. The findings provide the framework to develop multiple risk factor interventions.

Applying a Social-Ecological Framework to Factors Related to Nicotine Replacement Therapy for Adolescent Smoking Cessation.

OBJECTIVE: This systematic review synthesizes factors related to nicotine replacement therapy (NRT) use among adolescents seeking to quit smoking, using the social-ecological model as a guiding framework. DATA SOURCE: Searches of PubMED, ProQuest, EBSCOhost, and ERIC were conducted in July 2016. STUDY INCLUSION AND EXCLUSION CRITERIA: Original studies of cigarette smokers younger than 18 years that discussed NRT were included. DATA EXTRACTION: Two reviewers individually extracted study purpose, sample, design, and results. DATA SYNTHESIS: Factors were categorized by social-ecological model level and summarized. RESULTS: A total of 103 907 articles were identified during initial search. After narrowing to peer-reviewed articles in English and eliminating reviews and adult-only studies, we reviewed 51 articles. These 51 articles identified factors from studies at each level of the social-ecological model: intrapersonal ( k = 20), interpersonal ( k = 2), organizational ( k = 7), community ( k = 11), and public policy ( k = 14). CONCLUSION: Findings provide insight into the applicability of NRT for adolescent smoking cessation, and factors by social-ecological model level highlight areas for additional research. Future adolescent NRT studies should assess factors at the interpersonal, organizational, and community levels, as well as the interactions between levels.