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Introduction Exposure to green spaces is beneficial to mental health in a variety of ways, ranging from stress reduction to increased attentiveness and elevated selfesteem. The impact of views of greenness, as opposed to direct exposure, has been examined, but the association between self-reported views and depressive symptoms is not known. The purpose of this study is to examine the relationship between views of greenness and Patient Health Questionnaire–9 (PHQ-9) score. Methods Questionnaire responses from 191 participants in the Health, Environment, and Action in Louisville (HEAL) study were examined. Univariate statistical analyses included Mann-Whitney U, Kruskal-Wallis, and Spearman rank tests. Inferential statistical analysis was linear regression. Results Participant satisfaction with residential greenness was significantly associated with reduced PHQ-9 score (partially adjusted: linear coefficient = -0.42; 95% CI: -0.70 – -0.14; fully adjusted: linear coefficient = -0.21; 95% CI: -0.44 – 0.02). Additionally, being satisfied with local greenness was significantly associated with having views of greenness from home (linear coefficient = 1.97; 95% CI: 1.23–2.68). Conclusions Though views of greenness were not directly associated with depression, satisfaction with local greenness was associated with reduced PHQ-9 score, and having views of greenness from home was crudely associated with increased greenness satisfaction. The findings suggest urban greening interventions that focus on greenness satisfaction may be a strategy to reduce depression. Further research is necessary to better understand these relationships.

Introduction E-cigarettes are the most popular tobacco product among youth. Although harm perceptions have been linked to youth e-cigarette use, little research focuses on vulnerable populations, such as Appalachian youth. This study examines associations between e-cigarette harm perceptions and tobacco use among a sample of Appalachian youth. Methods Using data from the 2014–2016 Youth Appalachian Tobacco Study (n=1074), distributions of six e-cigarette harm perceptions by tobacco use (never, ever non-e-cigarette, ever e-cigarette) were examined, and multivariable multinomial logistic regression was used. Results Nearly one-fourth (23.4%) of the sample were ever e-cigarette users. More e-cigarette users were male (53.4%) and in high school (57.0%). Fewer e-cigarette users strongly agreed that e-cigarettes cause health problems (15.1%), breathing problems (20.3%), and oral health problems (18.7%) and that e-cigarettes are addictive (25.1%), compared to never and non-e-cigarette users. More e-cigarette users strongly agreed (32.3%) that e-cigarettes are healthier alternatives to cigarettes compared to never (24.1%) and non-e-cigarette (25.7%) users. Regression models indicate that e-cigarette users had greater odds of strongly disagreeing with e-cigarettes being harmful or addictive, compared to never users. E-cigarette users had approximately six-fold odds of strongly disagreeing with e-cigarettes causing health problems (OR=6.12; 95% CI: 3.16–11.90) and two times greater odds of disagreeing with e-cigarettes being addictive (OR=2.09; 95% CI: 1.07–4.08) compared to never users. Conclusions Appalachian youth ever e-cigarette users perceive e-cigarettes as less harmful and less addictive compared to never users. Better informing youth, especially youth tobacco users, of the harms associated with e-cigarettes is vital.

Objective: The current study examined group differences in college students' views on e-cigarettes in terms of safety, popularity, health risks, social acceptability, efficacy as a cessation aid, and promoting combustible cigarette use. Participants: 337 undergraduates (M[subscript age] = 20.84, SD = 3.79; 72.1% female; 68.5% White) divided into three groups: Never Users (n = 178), Ever Users (n = 108), and Current Users (n = 51). Methods: Participants completed questionnaires for course credit. Results: Compared to Ever and Never Users, Current Users believed e-cigarettes were safer, healthier, a useful tool to quit smoking, did not lead to combustible cigarette smoking, and that nicotine was less dangerous. Current Users also were less likely to endorse boosting social image as a motive for use. Conclusions: Public health campaigns could benefit from targeting current users' positive beliefs about e-cigarettes to reduce the prevalence of e-cigarette use among college students.

Little attention has been devoted to understanding the language surrounding e-cigarette use. Researchers employ terms such as users of e-cigarettes or ENDS, but language employed outside scholarly writing is relatively unexamined. Thus, this study examined the language used by college students to refer to people who use e-cigarettes. College students (N = 1037; Mage= 20.67, SD = 3.81; 72.1% female; 69.6% White) at a southern U.S. university responded to the open-ended question: “What do you call a person who uses e-cigarettes?” Of 1086 responses, e-cigarette users’ (n = 591) and nonusers’ (n = 495) responses were examined separately. Although users and nonusers had the same two top terms (“vaper” and “smoker”), a clearer consensus existed among users where “vaper” was most common (51.3%) followed by “smoker” (21.0%). These same terms were endorsed by 37.0% and 31.5% of nonusers, respectively. The third most popular responses of users related to addiction (e.g., “addict”, “fiend”; 8.46%), whereas nonusers’ responses indicated they did not know what to call an e-cigarette user (e.g., “I don’t know”; 7.1%). Users were equally likely to use positive (e.g., “Vape God”) and negative (e.g., “fool”) terms, whereas nonusers were nearly six times more likely to use negative terms. Therefore, it may be useful to capitalize on these language trends in health campaigns as well as develop separate messaging for users vs. nonusers.

Introduction Associations between exposure to nature and positive mental health outcomes have been established. Although the Internet is a popular source of accessing mental health information, little is known about the readability of such online information. Thus, the goal of this study was to assess the readability of online information regarding the association between exposure to nature and mental health. Methods A search of webpages was conducted using the following search terms: ‘mental health and urban greening’, ‘stress and urban greening’, ‘mental health and nature’, ‘stress and nature’, ‘mental health and outdoors’, and ‘stress and outdoors’. Readability of the 255 webpages identified was determined by the Flesch-Kincaid Grade Level measure. Results On average, webpage content was written at an 11th grade reading level (Flesch-Kincaid Grade Level mean=11.95, SD=2.68), and fewer than 2% of webpages met readability guidelines (i.e. ≤6th grade reading level). Conclusions Most online content related to nature and mental health should be written at a more appropriate level for general audiences. Web content developers should prioritize adherence to readability guidelines.

Introduction Given the growing awareness of the health risks associated with e-cigarettes, many users will access information about how to effectively quit using e-cigarettes, and the internet likely will be a popular source of information. However, little is known about the readability of online e-cigarette cessation information. Therefore, the goal of the current study was to assess the readability of webpage information about e-cigarette cessation. Methods A search of webpages was conducted using the following search terms: vaping addiction, quit vaping, quit Juul, stop vaping, stop Juul, and vaping cessation. The 464 webpages identified were coded for target audience, message valence, and source, and then assessed for reading level with the Flesch-Kincaid Grade Level assessment. Results On average, webpage content was written at a 7th grade reading level (Flesch-Kincaid Grade Level Mean=7.34, SD=2.22) and less than 25% of webpages met readability guidelines (i.e. ≤6th grade reading level). There were no differences in readability by target audience, message valence, or webpage source. Conclusions The results suggest that most online content related to e-cigarette cessation is not written at a level that is easily understood by general audiences. Thus, tobacco control advocates should assess the reading level of their messaging to ensure wide accessibility of information.

Background Although the effects of psychological health and optimism have been extensively investigated, data from community‐based cohorts assessing the association between psychological health and cardiovascular disease risk factors are sparse, and the concurrent relationship between subjective well‐being and cardiovascular health has not been studied. Methods and Results The current cross‐sectional study examined the association between well‐being and cardiovascular risk factors among 719 individuals living in a middle‐ to low‐income neighborhood. After adjusting for age, sex, race, body mass index, education, smoking status, and exercise status, we found that higher levels of well‐being were significantly associated with lower odds of dyslipidemia (odds ratio [OR], 0.7 [95% CI, 0.55–0.85]) and hypertension (OR, 0.8 [95% CI, 0.63–0.92]). Greater well‐being was also significantly associated with lower triglyceride levels (mean difference [Mdiff], 7.6 [−14.31 to −0.78]), very low‐density lipoprotein (Mdiff, 0.9 [−1.71 to −0.16]), total cholesterol to high‐density lipoprotein ratio (Mdiff, 3.9 [−6.07 to −1.73]), higher high‐density lipoprotein levels (Mdiff, 1.6 [0.46–2.75]), and lower Framingham Risk Scores (Mdiff, −7.1% [−10.84% to −3.16%]). Well‐being also moderated the association between age and arterial stiffness. The strongest association between arterial stiffness and age was found for those with the lowest well‐being scores; there was no association between age and arterial stiffness at high levels of well‐being. Conclusions In a community‐based cohort, individuals reporting higher levels of well‐being have lower odds of hypertension and dyslipidemia as well as lower rates of age‐dependent increase in vascular stiffness. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03670524.

Introduction Despite decreases in the overall US smoking rate, tobacco use remains more common in some areas and by some groups. Deeper understanding of group differences is needed in order to tailor public health campaigns to the interests, perceptions and experiences of targeted audiences. Although some differences have been identified across African American and Caucasian smokers in the United States, additional insight is needed regarding factors that differentiate these groups. This study examined tobacco related perceptions and practices, with an emphasis on identifying differences across African American and Caucasian smokers. Toward this goal, we examined key demographic variables of race and age, and tobacco use characteristics. Methods The sample consisted of 284 people from the Jackson, Mississippi area who participated in focus groups and completed surveys addressing a variety of tobacco related topics, including knowledge and perceptions of products as well as use and health information seeking behavior. The selection criteria and recruitment approach ensured a balance across race (black, white), age (18–34, >35 years), sex, and cigarette smoking status (current, former, never). Statistical analyses were performed using SAS (v.9.4). Results Differences were observed across demographic subgroups regarding type and pattern of tobacco products used (e.g. mentholated, markers of nicotine dependence, hookah). Differences in preferred sources of health information based on age as well as perceptions of risk as a function of age, smoking status and race were also noted. Exposure to secondhand smoke and perceptions of its risks, quitting efforts and cessation methods differed by race. Conclusions Study findings suggest key differences across important subgroups. Knowledge of such differences has the potential to improve strategic public health messaging, allowing health campaigns to more effectively prevent tobacco product uptake as well as promote interest in quitting tobacco.

Appalachian youth tobacco use rates exceed the national average. Additional inquiry is needed to better understand youth product perceptions and use patterns. This study examined tobacco harm perceptions and their relationship with tobacco use among Appalachian youth. From 2014 to 2016, a survey of Appalachian middle and high school students (N = 1,136) was conducted. Tobacco harm perceptions were assessed by tobacco use status, categorized as never user, cigarette only user, smokeless only user, e-cigarette only user, or polytobacco user. Descriptive characteristics were compared by tobacco use status and harm perceptions. Adjusted multivariable logistic regression models assessed the relationship between tobacco use status and harm perceptions. Over one-third of participants were tobacco users (34.6%; 4.7% cigarette only users, 3.3% smokeless only users, 5.6% e-cigarette only users, and 21.0% polytobacco users). Approximately half agreed that e-cigarettes cause health problems (54.4%), and 64.7% agreed that e-cigarettes are addictive. Most participants (83.4–92.3%) agreed that smoking and smokeless tobacco cause health problems and are addictive. Tobacco users more often disagreed that tobacco products cause health problems than did never users. Compared to never users, e-cigarette only users were more likely to disagree that smoking (AOR: 2.99, 95% CI: 1.30–6.90) and e-cigarettes cause health problems (AOR: 2.79, 95% CI: 1.64–4.75) and that e-cigarettes cause addiction (AOR: 2.48, 95% CI: 1.48–4.16). Most youth were aware of health dangers associated with smoking, but perceptions were split on whether e-cigarettes were associated with health problems or addiction.The findings indicate the need for additional youth tobacco use prevention efforts.

Purpose: The purpose of this study was to explore an association between e-cigarette use and Quality of Life (QOL) among college students. Methods: During February 2016, 1,132 students completed an online survey that included measures of tobacco use and the WHOQOL-BREF instrument. Differences were tested using Chi-square, Fisher’s exact test, and ANOVA, and regression was used to assess possible relationships. Results: E-cigarettes were used by 6.97% of the participants, either solo or along with traditional cigarettes. Bivariate analyses suggest that male college students are more likely than females to use e-cigarettes, either solo or in combination with traditional cigarettes (χ2 =19.4, P < .01). Lesbian, gay, and bisexual students are more likely than heterosexual students to use traditional cigarettes, either solo or in combination with e-cigarettes (χ2 = 32.9, P < .01). Multivariate models suggest that for every 10-unit increase in overall QOL, psychological well-being, social relations or environmental health the adjusted odds of being a sole cigarette user were significantly lower (all, P < .01), respectively. For every 10-unit increase in psychological well-being the adjusted odds of being a dual user was significantly lower (OR = .83, P = .026). Conclusions: Findings indicate that lower quality of life appears to be connected to tobacco use.

We examine the effects of the COVID-19 pandemic on a community-based research project. This clinical trial investigates whether increased neighborhood greenness lowers the risk of cardiovascular diseases through reduction of air pollution. Facilitating the project involves considerable community engagement, and the project relies on successful collaboration across a multidisciplinary team. As concerns surrounding SARS-CoV-2 increased, adjustments to our research were needed. When cases of COVID-19 escalated, clinical trials were halted. In this analysis, we employ a dialectical approach to examine the competing tensions evidenced in community work during the pandemic. From the vantage point of dialectical theory, competing feelings can occur simultaneously (such as concurrent experiences of dissatisfaction/satisfaction or need for progress/safety) and influence experience. This analysis considers the dialectical tensions created by the pandemic as well as the means of reconciling some tensions and wrestling with others.

Introduction Cardiovascular disease (CVD) is a critical public health issue, with tobacco smoking the leading preventable cause. Perceptions of CVD risk in specific populations may differ by tobacco use status, potentially necessitating customized tobacco prevention measures. Methods Using data from the Youth Appalachian Tobacco Study (n=1104), CVD risk perceptions were defined by responses to three statements: ‘smoking causes heart disease’, ‘smoking causes strokes’ and ‘smoking causes high blood pressure’. Tobacco use status was characterized as never users, ever cigarette users, and ever non-cigarette users. Sociodemographic differences in CVD risk perceptions and tobacco use status were evaluated. Logistic regression analyses, adjusted for gender, race/ethnicity, and household tobacco use, were conducted. Results Among the sample, 24.1% were ever cigarette users and 10.1% were ever non-cigarette users. Compared to never users, ever cigarette users had higher odds of disagreeing that smoking causes heart disease (AOR=1.83; 95% CI: 1.23–2.73), stroke (AOR=1.54; 95% CI: 1.08–2.18) and hypertension (AOR=1.41; 95% CI: 1.00–1.99). White youth (vs racial/ethnic minorities) had fewer odds of disagreeing that smoking causes hypertension (AOR=0.44; 95% CI: 0.29– 0.68), and females (vs males) had fewer odds of disagreeing that smoking causes heart disease (AOR=0.69; 95% CI: 0.48–0.99). Conclusions Among Appalachian youth, CVD risk perceptions differed by tobacco use status and sociodemographic groups, such as race/ethnicity and gender. Findings from this study may be helpful in development of tobacco prevention efforts, such as health messaging for Appalachian youth.

Introduction Sleep deficiency is associated with health risks, and time outdoors is related to health benefits. This study assessed time outdoors and its association with sleep normality. Methods As part of a health study in Louisville, Kentucky, 735 participants completed questionnaires on their health status, behaviors, neighborhoods, and demographics in 2018–2019. The measures included information on sleep, time outdoors, and mental and physical health. Participant characteristics were assessed by dichotomized sleep normality (N=728), and logistic regression (N=709) examined potential associations between time outdoors and sleep. Results As time spent outdoors increased from ≤4 hours to >4 – ≤8 hours (OR=1.04; 95% CI: 0.65–1.64) and >8 – ≤12 hours (OR=1.17; 95% CI: 0.63–2.17), odds of normal sleep increased; however, those who spent >12 – ≤16 hours (OR=0.63; 95% CI: 0.31–1.27) or >16 hours (OR=0.83; 95% CI: 0.45–1.53) outdoors had a lower likelihood of normal sleep. No associations between time outdoors and sleep were significant. There was a significant trend of less bodily pain associated with normal sleep (p

Studies reporting clinical symptoms related to electronic nicotine delivery systems (ENDS) usage, especially types of devices and e-liquids, are sparse. The sample included 1,432 current ENDS users, ages 18–64, from a nationwide online survey conducted in 2016. ENDS use included device types, nicotine content, flavors, and e-liquid used. Outcomes included any e-cigarette, or vaping, product use-associated lung injury (EVALI)-like symptoms (e.g., cough, shortness of breath, nausea) as well as any clinical symptoms. Of the sample, 50% were female, 23% non-Hispanic (NH) White, 23% NH Black, 54% Hispanic, 18% aged 18–24, 17% LGBTQ, 41% with

Introduction Given that Appalachian youth tobacco use rates are higher than the US national average, it is important to understand whether sex differences shape associations between receiving and sharing product information and using tobacco. Methods Middle and high school students in rural Appalachia (n=1038) were surveyed about tobacco-related perceptions and behaviors, including ways youth receive and share conventional tobacco-related and e-cigarette-related information. Youth were characterized as tobacco users (i.e. ever or current users of cigarettes, smokeless tobacco, or e-cigarettes) or never users. Descriptive characteristics were compared by tobacco use and sex. Adjusted logistic regression models evaluated associations between communication channels and tobacco use. Models were stratified by sex to examine effect modification. Results Approximately one-third of Appalachian youth (33.8%) were tobacco users and use varied by sex (males: 54.4%; females: 45.6%). Male (OR=1.75; 95% CI: 1.18–2.60) and female (OR=2.30; 95% CI: 1.53–3.47) youth who received e-cigarette-related information through friends and family (FF) had higher odds of tobacco use. Additionally, females who received e-cigarette-related information through public displays and digital media had nearly two-fold increased odds of tobacco use. Although sharing conventional tobacco-related and e-cigarette-related information through FF was associated with increased odds of tobacco use among both sexes, these relationships were stronger among females. Conclusions Although specific communication channels were associated with tobacco use, associations involving receiving and sharing e-cigarette information were more pronounced in female tobacco users. Consideration of sex differences in how youth receive and share tobacco-related information may benefit tobacco prevention interventions.

Among youth who use electronic nicotine delivery systems (ENDS), e-cigarettes are often the first tobacco product tried. Flavor is a common reason for experimentation with e-cigarettes. This study assessed flavor preferences and the choice of ENDS as an initial product among youth by selected demographic characteristics. The analysis sample included 1549 participants who had ever tried ENDS, drawn from a national online survey of youth aged 13–18 in 2017. Fruit was the most common favorite flavor among ENDS users, followed by menthol/mint/wintergreen. Preference for flavor varied by age, sex and racial/ethnic background. ENDS were the tobacco products most likely to be tried first, particularly among participants under age 17. Those who preferred fruit flavor were twice as likely to have tried ENDS first, compared to those with other flavor preferences, while those who preferred menthol/mint/wintergreen flavor were half as likely to have tried ENDS first. Our findings support an association between flavor and ENDS use. Our research supports previous findings indicating that: 1) flavor is one of the primary reasons for experimentation with ENDS among youth; 2) fruit flavor is strongly associated with use of ENDS as the first tobacco product; and 3) preference of fruit flavor varies by age, sex and racial/ethnic background. These findings have relevance for developing targeted messages for specific youth audiences and implications for tobacco regulatory policies. In addition to January 2020 federal regulations, the authors recommend tighter restrictions, specifically that the marketing and sale of all e-cigarette flavors other than tobacco be eliminated.

Introduction As e-cigarette use increases, questions about individual and public health effects remain unanswered (e.g. cessation tool, addiction path). Despite increasing use, few studies have focused on vape shop patrons. This study examined whether vape shop patrons believe their health is affected by the use of e-cigs; more specifically, the aim was to evaluate the association between e-cig use, change in tobacco use, and perception of health. Methods A survey of e-cig users (N=78) was conducted in vape shops. Questions included e-cig and traditional tobacco use, health perceptions, and demographics. Descriptive techniques were used to characterize participants as either those who perceived e-cig use improved their health or those who perceived their health unaffected. Logistic regression assessed the association between change in tobacco use, e-cig use, and perception of health effects. Results Most reported daily e-cig (91%) and current (11.5%) or former (78.2%) combustible cigarette use. Approximately, three-fourths (76.9%) perceived better health; the remainder (23.1%) perceived unaffected health. Change in cigarette use was significantly associated with perceptions that health is better with e-cig use. Participants who decreased cigarette use by 2–3 cartons/month and more than 3 cartons/month were significantly more likely to indicate that e-cig use has improved their health compared to those who decreased tobacco use by 1.5 cartons or fewer per month (OR=4.35, 95% CI: 1.13–16.9; OR=25.67, 95% CI: 2.97–221.7, respectively). Conclusions The majority of e-cig users perceived better health. Our findings suggest that health campaign designers should carefully assess the scientific uncertainty surrounding the use of these devices and consider means to clearly convey this information. Given the lack of scientific agreement on the health effects of e-cigs and the important role that perceptions play in behavior, health campaign designers, health education practitioners, policy makers, and health care providers should err on the side of caution when advising individuals about e-cig use.