Changing Cigarette Consumption Patterns and their Relationship to Tobacco Control Policies in a Population of Low-Intensity Smokers

Tobacco use is the single most preventable cause of premature death and disability in the world. Every year six million people will die from tobacco-related diseases. To curb the growing tobacco epidemic, World Health Organization (WHO) adopted its first-ever global public health treaty, Framework Convention on Tobacco Control (FCTC) that obligates ratifying countries to implement a range of tobacco control policies. Most of the evidence for the effectiveness of the WHO’s FCTC recommended tobacco control policies comes from high-income countries (HICs). This evidence suggests that as smoking prevalence declines in response to tobacco control policies and programs, the proportion of smokers who smoke less than daily increases and the number of cigarettes smoked by daily smokers decrease. There have been far fewer studies from low- and middle-income countries (LMICs) evaluating tobacco control policies, particularly from LMICs where non-daily smoking and light intensity smoking patterns have been dominant since before the implementation of FCTC-recommended tobacco control policies. This dissertation uses data from the 2008 – 2012 Mexico administration of the International Tobacco Control Policy Evaluation (ITC) project and the 2012 – 2014 Mexico administration of the Warning Wearout project 1) to examine the changes in cigarette consumption patterns of non-daily, daily-light (\u3c=5 cigarettes per day (CPD)) and daily-heavy smokers (\u3e5 CPD) during the rapid implementation of tobacco control policies and identifying factors that are associated with changes in cigarette consumption (paper-I),2) to evaluate the impact of lack of secondhand smoke exposure at workplaces and hospitality industry venues on cessation behaviors and whether this association differs across smoking intensity groups(paper-II), and 3) to identify the correlates of responses to health warning labels (HWLs) (paper-III). In paper-I, we found that across the three smoking intensity groups, non-daily smokers were more likely to achieve abstinence at the follow-up, about a quarter of non-daily smokers continued to smoke at the same levels across follow-up periods, and reducing smoking intensity can be a stepping stone towards cessation for daily-heavy smokers. Perceived addiction was consistently important factor associated with changes in smoking consumption for all the three smoking intensity groups. For non-daily smokers only, anti-smoking social norms promoted smoking cessation. Paper-II findings suggest that lack of secondhand smoke exposure in workplaces and hospitality industry venues was unassociated with quit behaviors across the three smoking intensity groups. The smoke-free workplace and hospitality industry policies were limited in reach since only about a third of the study sample was exposed to these policies. In paper-III, we found that after a few years of implementing pictorial HWLs in Mexico, attention to HWLs declined over the study period while cessation-related responses to HWLs continued to increase over time. Also, HWLs in Mexico appear to be equally effective across socio-economic groups (SES) and for, some measures, slightly more effective among low SES groups than high SES groups. Taken together, results from this dissertation highlight the need to design and study interventions that specifically target non-daily smokers who, despite not smoking every day, find it hard to quit. Also, it is recommended that the Mexican government should take additional actions to increase compliance to smoke-free policies and expand the policies to places where Mexicans continue to be exposed to SHS. Finally, LMICs that have limited resources should consider pictorial HWLs as a priority and rotate the content frequently to prevent wearout of HWLs

Features and amenities of school playgrounds: A direct observation study of utilization and physical activity levels outside of school time

<p>Abstract</p> <p>Background</p> <p>A significant amount of research has examined whether park or playground availability is associated with physical activity. However, little research has examined whether specific features or amenities of parks or playgrounds, such as the number of unique types of playground equipment or the safety of the equipment is associated with utilization of the facility or physical activity levels while at the facility. There are no studies that use direct observation and a detailed park assessment to examine these associations.</p> <p>Methods</p> <p>Twenty urban schoolyards in the Midwest, ten of which were renovated, were included in this study. Using a detailed environmental assessment tool (i.e., Environmental Assessment of Public Recreation Spaces), information on a variety of playground attributes was collected. Using direct observation (i.e., System for Observing Play and Leisure Activity in Youth), the number of adults, girls and boys attending each schoolyard and their physical activity levels were recorded. Each schoolyard was observed ten times for 90 minutes each time outside of school hours. Clustered multivariable negative binomial regressions and linear regressions were completed to examine the association between playground attributes and utilization of the schoolyard and the proportion active on the playground, respectively. Effect modification by renovation status was also examined.</p> <p>Results</p> <p>At renovated schoolyards, the total number of play features was significantly associated with greater utilization in adults and girls; overall cleanliness was significantly associated with less utilization in girls and boys; and coverage/shade for resting features was significantly associated with greater utilization in adults and boys. At unrenovated schoolyards, overall safety was significantly associated with greater utilization in boys. No playground attribute was associated with the proportion active on the playground after adjusting for all other significant playground attributes.</p> <p>Conclusions</p> <p>Having a large quantity of play features and shade at renovated playgrounds were positively associated with utilization of the schoolyard. Modifying playgrounds to have these features may increase the utilization of these facilities outside of school time. Additional research should explore what features and amenities are associated with increased physical activity levels of children and adults who utilize the facilities.</p

Which type of tobacco product warning imagery is more effective and sustainable over time?

Objective This study examined smokers’ responses to pictorial health warnings (PHWs) with different types of imagery under natural exposure conditions. Methods Adult smokers from online panels in Canada (n=2357), Australia (n=1671) and Mexico (n=2537) were surveyed every 4 months from 2012 to 2013. Participants were shown PHWs on packs in their respective countries and asked about: (1) noticing PHWs; (2) negative affects towards PHWs; (3) believability of PHWs; (4) PHW-stimulated discussions; and (5) quit motivation due to PHWs. Country-specific generalised estimating equation models regressed these outcomes on time (ie, survey wave), PHW imagery type (ie, symbolic representations of risk, suffering from smoking and graphic depictions of bodily harm) and interactions between them. Results In all countries, PHW responses did not significantly change over time, except for increased noticing PHWs in Canada and Mexico, increased negative affect in Australia and decreased negative affect in Mexico. For all outcomes, symbolic PHWs were rated lower than suffering and graphic PHWs in Canada (the only country with symbolic PHWs). Graphic PHWs were rated higher than suffering PHWs for negative affect (all countries), discussions (Canada) and quit motivation (Australia). Suffering PHWs were rated higher than graphic PHWs for noticing PHWs (Canada), believability (all countries), discussions (AustraliaandMexico) and quit motivation (Mexico). Changes in noticing, believability and discussions varied somewhat by imagery type across countries. Conclusions The different PHW imagery appears to have different pathways of influence on adult smokers. Reactions to specific PHWs are similar over 1–2 years, suggesting that wear-out of PHW effects is due to decreased attention rather than the diminishing effectiveness of content

Which type of tobacco product warning imagery is more effective and sustainable over time? A longitudinal assessment of smokers in Canada, Australia and Mexico

Objective This study examined smokers\u27 responses to pictorial health warnings (PHWs) with different types of imagery under natural exposure conditions. Methods Adult smokers from online panels in Canada (n=2357), Australia (n=1671) and Mexico (n=2537) were surveyed every 4 months from 2012 to 2013. Participants were shown PHWs on packs in their respective countries and asked about: (1) noticing PHWs; (2) negative affects towards PHWs; (3) believability of PHWs; (4) PHW-stimulated discussions; and (5) quit motivation due to PHWs. Country-specific generalised estimating equation models regressed these outcomes on time (ie, survey wave), PHW imagery type (ie, symbolic representations of risk, suffering from smoking and graphic depictions of bodily harm) and interactions between them. Results In all countries, PHW responses did not significantly change over time, except for increased noticing PHWs in Canada and Mexico, increased negative affect in Australia and decreased negative affect in Mexico. For all outcomes, symbolic PHWs were rated lower than suffering and graphic PHWs in Canada (the only country with symbolic PHWs). Graphic PHWs were rated higher than suffering PHWs for negative affect (all countries), discussions (Canada) and quit motivation (Australia). Suffering PHWs were rated higher than graphic PHWs for noticing PHWs (Canada), believability (all countries), discussions (AustraliaandMexico) and quit motivation (Mexico). Changes in noticing, believability and discussions varied somewhat by imagery type across countries. Conclusions The different PHW imagery appears to have different pathways of influence on adult smokers. Reactions to specific PHWs are similar over 1-2 years, suggesting that wear-out of PHW effects is due to decreased attention rather than the diminishing effectiveness of content

Does Reactance Against Cigarette Warning Labels Matter? Warning Label Responses and Downstream Smoking Cessation Amongst Adult Smokers in Australia, Canada, Mexico and the United States

Objective Some researchers have raised concerns that pictorial health warning labels (HWLs) on cigarette packages may lead to message rejection and reduced effectiveness of HWL messages. This study aimed to determine how state reactance (i.e., negative affect due to perceived manipulation) in response to both pictorial and text-only HWLs is associated with other types of HWL responses and with subsequent cessation attempts. Methods Survey data were collected every 4 months between September 2013 and 2014 from online panels of adult smokers in Australia, Canada, Mexico, and the US were analyzed. Participants with at least one wave of follow-up were included in the analysis (n = 4,072 smokers; 7,459 observations). Surveys assessed psychological and behavioral responses to HWLs (i.e., attention to HWLs, cognitive elaboration of risks due to HWLs, avoiding HWLs, and forgoing cigarettes because of HWLs) and cessation attempts. Participants then viewed specific HWLs from their countries and were queried about affective state reactance. Logistic and linear Generalized Estimating Equation (GEE) models regressed each of the psychological and behavioral HWL responses on reactance, while controlling for socio-demographic and smoking-related variables. Logistic GEE models also regressed having attempted to quit by the subsequent survey on reactance, each of the psychological and behavioral HWL responses (analyzed separately), adjustment variables. Data from all countries were initially pooled, with interactions between country and reactance assessed; when interactions were statistically significant, country-stratified models were estimated. Results Interactions between country and reactance were found in all models that regressed psychological and behavioral HWL responses on study variables. In the US, stronger reactance was associated with more frequent reading of HWLs and thinking about health risks. Smokers from all four countries with stronger reactance reported greater likelihood of avoiding warnings and forgoing cigarettes due to warnings, although the association appeared stronger in the US. Both stronger HWLs responses and reactance were positively associated with subsequent cessation attempts, with no significant interaction between country and reactance. Conclusions Reactance towards HWLs does not appear to interfere with quitting, which is consistent with its being an indicator of concern, not a systematic effort to avoid HWL message engagement

Does Reactance Against Cigarette Warning Labels Matter? Warning Label Responses and Downstream Smoking Cessation Amongst Adult Smokers in Australia, Canada, Mexico and the United States

Objective Some researchers have raised concerns that pictorial health warning labels (HWLs) on cigarette packages may lead to message rejection and reduced effectiveness of HWL messages. This study aimed to determine how state reactance (i.e., negative affect due to perceived manipulation) in response to both pictorial and text-only HWLs is associated with other types of HWL responses and with subsequent cessation attempts. Methods Survey data were collected every 4 months between September 2013 and 2014 from online panels of adult smokers in Australia, Canada, Mexico, and the US were analyzed. Participants with at least one wave of follow-up were included in the analysis (n = 4,072 smokers; 7,459 observations). Surveys assessed psychological and behavioral responses to HWLs (i.e., attention to HWLs, cognitive elaboration of risks due to HWLs, avoiding HWLs, and forgoing cigarettes because of HWLs) and cessation attempts. Participants then viewed specific HWLs from their countries and were queried about affective state reactance. Logistic and linear Generalized Estimating Equation (GEE) models regressed each of the psychological and behavioral HWL responses on reactance, while controlling for socio-demographic and smoking-related variables. Logistic GEE models also regressed having attempted to quit by the subsequent survey on reactance, each of the psychological and behavioral HWL responses (analyzed separately), adjustment variables. Data from all countries were initially pooled, with interactions between country and reactance assessed; when interactions were statistically significant, country-stratified models were estimated. Results Interactions between country and reactance were found in all models that regressed psychological and behavioral HWL responses on study variables. In the US, stronger reactance was associated with more frequent reading of HWLs and thinking about health risks. Smokers from all four countries with stronger reactance reported greater likelihood of avoiding warnings and forgoing cigarettes due to warnings, although the association appeared stronger in the US. Both stronger HWLs responses and reactance were positively associated with subsequent cessation attempts, with no significant interaction between country and reactance. Conclusions Reactance towards HWLs does not appear to interfere with quitting, which is consistent with its being an indicator of concern, not a systematic effort to avoid HWL message engagement

Over-Time Impacts of Pictorial Health Warning Labels and their Differences across Smoker Subgroups:Results from Adult Smokers in Canada and Australia

Introduction: This study examines patterns of change in different smoker subgroups' responses to new pictorial health warning labels (HWLs) over the initial, two year post-implementation period in Canada, where HWLs include package inserts with cessation messages, and Australia, where "plain" packaging (i.e., prohibition of brand imagery) was also implemented. Methods: Data were collected from online consumer panels in Canada (n(smokers) = 3153; n(observations) = 5826) and Australia (n(smokers) = 2699; n(observations) = 5818) from September 2012 to September 2014, with approximately 1000 adult smokers surveyed in each country every four months, using replenishment to maintain sample size. Data were analyzed using generalized estimating equation models where main effects and interactions among time, country, and socio-demographic factors on HWL responses (i.e., attention to HWLs; cognitive and behavioral responses to HWLs) were examined. Results: Over time, attention to HWLs declined but cognitive and forgoing responses to HWLs increased, in both Canada and Australia. In both countries, compared to smokers with low income and/or education, smokers with high income and/or education showed an increase over time in attention and cognitive responses to HWLs (p &lt; .05). In Australia only, compared to older smokers, younger smokers showed less decline over time in attention and greater increase in cognitive and forgoing responses to HWLs (p &lt; .001). Conclusions: Novel HWL policies in Canada and Australia appear effective in staving off "wear out" over the first 2 years after implementation, particularly amongst smokers who are from higher SES groups and, in Australia, who are younger. Implications: Previous research shows that the effects of health warning label (HWL) on smokers decline over time, but no studies to date have evaluated whether trends differ across socio-demographic groups. This study suggests that innovative policy configurations that combine prominent pictorial HWLs with inserts (Canada) and with "plain" packaging (Australia) may delay wear out over the first 2 years after implementation. While this study found evidence for wear out in attention to HWLs, other HWL responses (cognitive responses, forgoing cigarettes) actually increased over time, with greater increases amongst smokers with higher income and/or education

Changes in left ventricular systolic function after transcatheter patent ductus arteriosus closure in premature infants

Background : Changes in left ventricular (LV) systolic function have not been well described in premature neonates after transcatheter patent ductus arteriosus (PDA) closure. Methods and Results : We retrospectively identified all premature neonates < 3 kg who underwent a transcatheter PDA closure at our center between January 1 2015 and January 31, 2021. LV indices before and after closure were extracted and an analysis was performed. Overall, 23 neonates were included with a mean procedural weight of 1894 ± 622 g. At 24 h after closure, the median left ventricular ejection fraction (LVEF) (66% interquartile range [IQR] 12% vs. 61% IQR 12, P< 0.001) and median LV end-diastolic dimension z-score (3.3 IQR 1.8 vs. 1.4 IQR 2.6, P < 0.001) both decreased and 5 (22%) neonates had an LVEF <55%. Patients who had an LVEF <55% at 24 h had a higher preprocedure LV end-diastolic dimension z-score (4.2 IQR 1.2 vs. 2.8 IQR 1.6, P = 0.01), a higher preprocedure LV end-diastolic volume (19 mL IQR 4 mL vs. 11 mL IQR 11, P = 0.03), a higher birth weight (940 g IQR 100 g vs. 760 g IQR 140, P = 0.04), and were more likely to receive intravenous calcium during the procedure (60% vs. 11%, P = 0.04) compared to those with an LVEF ≥55% at 24 h after closure. Of those with LVEF <55% at 24 h, all normalized before discharge. Conclusion : In preterm neonates who underwent successful transcatheter PDA closure, 23% developed abnormal LVEF after closure and those with significant LV dilation before the procedure were at increased risk for the development of LVEF <55% after closure

Policy Support, Norms, and Secondhand Smoke Exposure Before and After Implementation of a Comprehensive Smoke-Free Law in Mexico City

Objectives. We assessed attitudes and beliefs about smoke-free laws, compliance, and secondhand smoke exposure before and after implementation of a comprehensive smoke-free law in Mexico City. Methods. Trends and odds of change in attitudes and beliefs were analyzed across 3 representative surveys of Mexico City inhabitants: before implementation of the policy (n = 800), 4 months after implementation (n = 961), and 8 months after implementation (n = 761). Results. Results indicated high and increasing support for 100% smoke-free policies, although support did not increase for smoke-free bars. Agreement that such policies improved health and reinforced rights was high before policy implementation and increased thereafter. Social unacceptability of smoking increased substantially, although 25% of nonsmokers and 50% of smokers agreed with smokers' rights to smoke in public places at the final survey wave. Secondhand smoke exposure declined generally as well as in venues covered by the law, although compliance was incomplete, especially in bars. Conclusions. Comprehensive smoke-free legislation in Mexico City has been relatively successful, with changes in perceptions and behavior consistent with those revealed by studies conducted in high-income countries. Normative changes may prime populations for additional tobacco control interventions

C-C3-02: Ethnic Differences in Interval Diagnosed Breast Cancers in South Carolina

Background/Aims: The incidence of breast cancer (BrCA) among African-American (AA) women is lower than European-American (EA) women, yet their mortality rate is twice as high. Numerous hypotheses have been proposed to explain this disparity ranging from the biological to factors related to access to care. The relatively under-studied area of interval-diagnosed BrCAs, tumors which arise between regular mammograms and represent one of the most aggressive types of tumors, among AA women may represent such a biological factor. The goal of this investigation was to describe and compare detection patterns of BrCAs and their related histopathology among AA and EA women in South Carolina