Packaging as a marketing tool: Adolescents’ perceptions of branded and plain tobacco packaging

Plain packaging first appeared on the UK policy agenda in the Department of Health’s 2008 ‘Consultation on the Future of Tobacco Control’. Since then, plain (or standardised) packaging has been framed through the potential benefit to young people. Within the period of this thesis, plain packaging has been actively debated and draft plain packaging regulations were published in June 2014. An extended literature review of academic and practitioner marketing literature, internal tobacco company documents and public health packaging research, establishes that the research informing the policy debate, while consistent in its approach and findings, fails to recognise the strategic nature of pack design, the full extent of the influence that branded design can have on consumer responses, and the importance of product design as a marketing tool. This thesis attempts to address these gaps in the plain packaging evidence base. It explores if, and how, adolescents engage with different styles of packaging and product design, whether or not an association between tobacco packaging and adolescent smoking exists, and whether it is possible to observe cognitive, affective and behavioural responses to packaging. The study uses a sequential exploratory mixed methodology design with two stages of research. First, focus groups were conducted with 15 year olds (n=48) to explore adolescent responses to tobacco packaging and product design. The findings show that adolescents are most appreciative of ‘novelty’ pack designs. These ‘novelty’ packs, for instance with innovative structures or distinctive designs and colours, generated positive user imagery and influenced affective feelings among participants. Cigarettes with slim diameters, white tips and decorative designs increased appeal and communicated a weaker tasting and less harmful product. Conversely, a plain pack eliminated positive perceptions and feelings, and exposed tobacco as harmful, dirty and not for young people. The qualitative findings were used to develop measures and hypotheses which were tested in a quantitative survey.The second stage of research utilised a cross-sectional in-home survey (n=1373) with 11 to 16 year olds. Respondents were asked to rate three different pack styles - ‘novelty’, ‘regular’ and ‘plain’ - on 11 pack ratings items and four pack feelings items. The findings show adolescents hold ‘novelty’ packaging in higher regard than ‘regular’ packaging across pack ratings items. There were fewer differences between ‘novelty’ and ‘regular’ packaging for the pack feelings items. Plain packaging was consistently rated most negatively across all survey items. Logistic regressions, controlling for factors known to influence youth smoking, showed that susceptibility to smoke was associated with positive appraisal and also receptivity for ‘novelty’ packaging. There was no association with pack appraisal or receptivity for the plain pack. While susceptibility is not a direct behavioural response it is a reasonable predictor of future tobacco use. Collectively the findings show that ‘novelty’ packaging and product design holds greatest appeal for adolescents. Plain packaging limits the opportunity for tobacco companies to communicate with, mislead and influence consumers. Based upon the role of packaging for consumer goods in general, and tobacco in particular, plain packaging would effectively reduce the promotional role of packaging

Seroprevalence of Bordetella pertussis antibodies in mothers and their newborn infants.

BACKGROUND: Pertussis is a highly communicable, vaccine-preventable respiratory disease. Although the largest number of reported cases is among young infants, the most rapidly increasing incidence in the USA is in adolescents and young adults. Importantly, adult family members are the likely major reservoir, infecting susceptible infants before completion of childhood vaccination. We studied maternal-neonatal paired blood samples for the presence of pertussis-related antibodies to assess level of immunity and passive transplacental antibody passage. METHODS. Unselected maternal-neonatal cord blood samples were collected from 101 term deliveries in a single urban uninsured/underinsured hospital setting. Sera were analyzed for anti-pertussis toxin (PT), filamentous hemagglutinin (FHA) and pertactin (PRN) IgG antibodies by enzyme-linked immunosorbent assay (ELISA). Antibody titers were calculated using reference line methodology. Antibody values were log-transformed to establish geometric mean titers (GMT) for analysis. Student's t-test, Mann-Whitney, Pearson correlation and chi square were used for statistical comparisons as appropriate. RESULTS. Mean (SD) maternal age, gestational age and birth weight were 26.8 (6.8) years, 38.9 (1.4) weeks and 3239 (501) g, respectively. Detectable maternal levels of anti-PT, FHA and PRN were found in 34.7%, 95.0% and 80.2%, respectively. Maternal GMT (SD) for PT, FHA and PRN were 4.4 (2.6), 26.6 (3.1) and 12.3 (2.9), respectively. There was no significant relationship between PT, FHA or PRN detection or antibody GMT and maternal age. Maternal anti-PT, FHA and PRN were highly correlated with neonatal cord blood values. CONCLUSION: Despite previous childhood immunization, a large number of parous women have low or undetectable pertussis-related antibody levels, suggesting susceptibility to infection. Even with efficient transplacental passage of these antibodies, neonates similarly have limited measurable protection as detected by cord blood sampling. These data support the need for adolescent or adult vaccination against Bordetella pertussis. Healthcare providers and their clients should be aware of the risk for infant infection via family member transmission

Diabète gestationnel--quelles sont les approches non médicales [Gestational diabetes--what are the non-medical approaches?].

Gestational diabetes is a multifactorial disease that increases the risk for complications for the mother and her child in the short and long term. The perinatal period represents an opportunity not only to assist the mother in improving her own health but also that of the future generation. This article focuses on lifestyle and psychological aspects that form the base for non-medical treatment approaches. Considering different risk factors separately is not sufficient for the improvement of the metabolic and mental health of women with gestational diabetes. With a multimodal interdisciplinary approach that includes physical activity, dietary advice and psychological support, an improvement of the health and well-being of both the mother and her child is expected. Future studies are necessary to confirm this proposed care approach

What are disease perceptions and subjective treatment goals of insulin treated diabetic patients?

BACKGROUND: Despite increasing importance of patient self-management, little is known about their own perceptions and treatment goals. OBJECTIVES: The aim of this explorative study was to examine what diabetic patients perceive as most concerning and what their own treatment goals are. METHODS: A 23-item anonymous questionnaire was distributed among type 1 diabetic patients treated with and without an insulin pump and insulin treated type 2 diabetic patients in the outpatient clinic of a University Hospital. 86% of the questionnaires were returned (n = 124). RESULTS: In open-ended questions, patients in all three groups together felt mostly restricted by their loss of freedom (24%), the dietary restrictions (17%) and the need to measure blood glucose (17%). Patients treated with an insulin pump worried more about hypoglycaemia and less about dietary restrictions. In closed-ended questions, patients were mostly concerned about hypoglycaemia and developing complications. However, the main treatment goal of both groups together was long-term good blood glucose control (63%). Further patient goals were the prevention of complications (27%) and the preservation of a good quality of life. Quality of life was a more important goal for type 1 diabetic patients (29%) than for type 2 diabetic patients (0%). Patients thought that blood glucose control was more important for their physicians (main treatment goal for 86%) than for themselves. CONCLUSION: Insulin treated patients with diabetes spontaneously express concerns about their actual quality of life and daily hassles and mention long-term worries after explicit questioning. For their main treatment goals they choose mainly long-term goals. According to the patients, physicians tend to overestimate blood glucose control

Reduced cardiorespiratory fitness, low physical activity and an urban environment are independently associated with increased cardiovascular risk in children

Aims/hypothesis: To assist in the development of preventive strategies, we studied whether the neighbourhood environment or modifiable behavioural parameters, including cardiorespiratory fitness (CRF) and physical activity (PA), are independently associated with obesity and metabolic risk markers in children. Methods: We carried out a cross-sectional analysis of 502 randomly selected first and fifth grade urban and rural Swiss schoolchildren with regard to CRF, PA and the neighbourhood (rural vs urban) environment. Outcome measures included BMI, sum of four skinfold thicknesses, homeostasis model assessment of insulin resistance (HOMA-IR) and a standardised clustered metabolic risk score. Results: CRF and PA (especially total PA, but also the time spent engaged in light and in moderate and vigorous intensity PA) were inversely associated with measures of obesity, HOMA-IR and the metabolic risk score, independently of each other, and of sociodemographic and nutritional parameters, media use, sleep duration, BMI and the neighbourhood environment (all p < 0.05). Children living in a rural environment were more physically active and had higher CRF values and reduced HOMA-IR and metabolic risk scores compared with children living in an urban environment (all p < 0.05). These differences in cardiovascular risk factors persisted after adjustment for CRF, total PA and BMI. Conclusions/interpretation: Reduced CRF, low PA and an urban environment are independently associated with an increase in metabolic risk markers in children. Trial registration: isrctn.org 15360785 Funding: The study was funded by the Federal office of Sports (Magglingen, Switzerland), the Swiss National Science Foundation (grant nos 3234-069271 and PMPDB-114401) and the Diabetes Foundation of the Region of Base

Validation of computerized wheeze detection in young infants during the first months of life

Background Several respiratory diseases are associated with specific respiratory sounds. In contrast to auscultation, computerized lung sound analysis is objective and can be performed continuously over an extended period. Moreover, audio recordings can be stored. Computerized lung sounds have rarely been assessed in neonates during the first year of life. This study was designed to determine and validate optimal cut-off values for computerized wheeze detection, based on the assessment by trained clinicians of stored records of lung sounds, in infants aged <1 year. Methods Lung sounds in 120 sleeping infants, of median (interquartile range) postmenstrual age of 51 (44.5–67.5) weeks, were recorded on 144 test occasions by an automatic wheeze detection device (PulmoTrack®). The records were retrospectively evaluated by three trained clinicians blinded to the results. Optimal cut-off values for the automatically determined relative durations of inspiratory and expiratory wheezing were determined by receiver operating curve analysis, and sensitivity and specificity were calculated. Results The optimal cut-off values for the automatically detected durations of inspiratory and expiratory wheezing were 2% and 3%, respectively. These cutoffs had a sensitivity and specificity of 85.7% and 80.7%, respectively, for inspiratory wheezing and 84.6% and 82.5%, respectively, for expiratory wheezing. Inter-observer reliability among the experts was moderate, with a Fleiss’ Kappa (95% confidence interval) of 0.59 (0.57-0.62) for inspiratory and 0.54 (0.52 - 0.57) for expiratory wheezing. Conclusion Computerized wheeze detection is feasible during the first year of life. This method is more objective and can be more readily standardized than subjective auscultation, providing quantitative and noninvasive information about the extent of wheezing

Effect of the MySweetheart randomized controlled trial on birth, anthropometric and psychobehavioral outcomes in offspring of women with GDM.

Gestational diabetes mellitus (GDM) may negatively affect offspring outcomes. A lifestyle intervention may therefore not only improve maternal, but also offspring outcomes. The effects of lifestyle interventions on birth, anthropometric, and psychobehavioral outcomes in offspring of women with GDM need further evidence. The MySweetheart trial is a monocentric single-blind randomized controlled trial in 211 women with GDM. It tested the effect of a pre- and postpartum multidimensional interdisciplinary lifestyle and psychosocial intervention focusing on both the mothers and their infants and its effects on maternal (primary outcomes) and offspring (secondary outcomes) metabolic and psychobehavioral outcomes compared with guidelines-based usual-care. This paper focuses on offspring's birth, anthropometric, and maternal report of psychobehavioral outcomes at singular timepoints. Women with GDM aged ≥18 years, between 24-32 weeks of gestation, speaking French or English were included and randomly allocated to either the intervention or to an active guidelines-based usual-care group using a 1:1 allocation ratio. The intervention lasted from pregnancy until 1 year postpartum and focused on improving diet, physical activity, and mental health in the mother. For the offspring it focused on supporting breastfeeding, delaying the timing of introduction of solid foods, reducing the consumption of sweetened beverages, increasing physical activity of the family, and improving parental responsiveness to infant distress, hunger, satiety and sleeping cues, and difficult behavior. Adverse birth and neonatal outcomes rarely occurred overall. There were no differences between groups in offspring birth, neonatal, anthropometric, or psychobehavioral outcomes up to one year. After adjustments for maternal age and the offspring's sex and age, there was a borderline significant between-group difference in birth length (β:-0.64, CI:-1.27; -0.01, p: 0.05), i.e., offspring of mothers in the intervention group were born 0.64 cm shorter compared to those in the usual-care group. This is the first pre- and postpartum multidimensional interdisciplinary lifestyle and psychosocial intervention in GDM focusing on both the mother and the offspring. It did not lead to a significant improvement in most birth, anthropometric, and psychobehavioral outcomes in offspring of women with GDM. ClinicalTrials.gov Identifier: NCT02890693

Weight-bearing bones are more sensitive to physical exercise in boys than in girls during pre- and early puberty: a cross-sectional study

Summary: We carried out a cross-section study of the sex-specific relationship between bone mineral content and physical activity at sites with different loading in pre- and early pubertal girls and boys. There was significant sensitivity of bone mineral content of the hip to physical exercise in boys, but not in girls. Background: Since little is known whether there are sex differences in sensitivity of bone to loading, we investigated sex differences in the cross-sectional association between measures of physical activity (PA) and bone mass and size in pre- and early pubertal children of both sexes. Methods: We measured bone mineral content/density (BMC/BMD) and fat-free mass (FFM) in 269 6- to 13-year-old children from randomly selected schools by dual-energy X-ray absorptiometry. Physical activity (PA) was measured by accelerometers and lower extremity strength by a jump-and-reach test. Results: Boys (n = 128) had higher hip and total body BMC and BMD, higher FFM, higher muscle strength and were more physically active than girls (n = 141). Total hip BMC was positively associated with time spent in total and vigorous PA in boys (r = 0.20-0.33, p < 0.01), but not in girls (r = 0.02-0.04, p=ns), even after adjusting for FFM and strength. While boys and girls in the lowest tertile of vigorous PA (22min/day) did not differ in hip BMC (15.62 vs 15.52g), boys in the highest tertile (72min/day) had significantly higher values than the corresponding girls (16.84 vs 15.71g, p < 0.05). Conclusions: Sex differences in BMC during pre- and early puberty may be related to a different sensitivity of bone to physical loading, irrespective of muscle mas

Maternal and fetal predictors of anthropometry in the first year of life in offspring of women with GDM.

Gestational Diabetes Mellitus (GDM) carries an increased risk for adverse perinatal and longer-term cardiometabolic consequences in offspring. This study evaluated the utility of maternal anthropometric, metabolic and fetal (cord blood) parameters to predict offspring anthropometry up to 1 year in pregnancies with GDM. In this prospective analysis of the MySweetheart study, we included 193/211 women with GDM that were followed up to 1 year postpartum. Maternal predictors included anthropometric (pre-pregnancy BMI, gestational weight gain (GWG), weight and fat mass at the 1 &lt;sup&gt;st&lt;/sup&gt; GDM visit), and metabolic parameters (fasting insulin and glucose, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), Quantitative insulin-sensitivity check index (QUICKI), HbA1c, triglycerides, and high-density lipoprotein (HDL) at the 1 &lt;sup&gt;st&lt;/sup&gt; visit and HbA1c at the end of pregnancy). Fetal predictors (N=46) comprised cord blood glucose and insulin, C-Peptide, HOMA-IR, triglycerides and HDL. Offspring outcomes were anthropometry at birth (weight/weight z-score, BMI, small and large for gestational age (SGA,LGA)), 6-8 weeks and 1 year (weight z-score, BMI/BMI z-score, and the sum of 4 skinfolds). In multivariate analyses, birth anthropometry (weight, weight z-score, BMI and/or LGA), was positively associated with cord blood HDL and HbA1c at the 1 &lt;sup&gt;st&lt;/sup&gt; GDM visit, and negatively with maternal QUICKI and HDL at the 1 &lt;sup&gt;st&lt;/sup&gt; GDM visit (all p ≤ 0.045). At 6-8 weeks, offspring BMI was positively associated with GWG and cord blood insulin, whereas the sum of skinfolds was negatively associated with HDL at the 1 &lt;sup&gt;st&lt;/sup&gt; GDM visit (all p ≤0.023). At 1 year, weight z-score, BMI, BMI z-score, and/or the sum of skinfolds were positively associated with pre-pregnancy BMI, maternal weight, and fat mass at the 1 &lt;sup&gt;st&lt;/sup&gt; GDM visit and 3 &lt;sup&gt;rd&lt;/sup&gt; trimester HbA1c (all p ≤ 0.043). BMI z-score and/or the sum of skinfolds were negatively associated with cord blood C-peptide, insulin and HOMA-IR (all p ≤0.041). Maternal anthropometric, metabolic, and fetal metabolic parameters independently affected offspring anthropometry during the 1 &lt;sup&gt;st&lt;/sup&gt; year of life in an age-dependent manner. These results show the complexity of pathophysiological mechanism for the developing offspring and could represent a base for future personalized follow-up of women with GDM and their offspring

Primitive Words, Free Factors and Measure Preservation

Let F_k be the free group on k generators. A word w \in F_k is called primitive if it belongs to some basis of F_k. We investigate two criteria for primitivity, and consider more generally, subgroups of F_k which are free factors. The first criterion is graph-theoretic and uses Stallings core graphs: given subgroups of finite rank H \le J \le F_k we present a simple procedure to determine whether H is a free factor of J. This yields, in particular, a procedure to determine whether a given element in F_k is primitive. Again let w \in F_k and consider the word map w:G x G x ... x G \to G (from the direct product of k copies of G to G), where G is an arbitrary finite group. We call w measure preserving if given uniform measure on G x G x ... x G, w induces uniform measure on G (for every finite G). This is the second criterion we investigate: it is not hard to see that primitivity implies measure preservation and it was conjectured that the two properties are equivalent. Our combinatorial approach to primitivity allows us to make progress on this problem and in particular prove the conjecture for k=2. It was asked whether the primitive elements of F_k form a closed set in the profinite topology of free groups. Our results provide a positive answer for F_2.Comment: This is a unified version of two manuscripts: "On Primitive words I: A New Algorithm", and "On Primitive Words II: Measure Preservation". 42 pages, 14 figures. Some parts of the paper reorganized towards publication in the Israel J. of Mat