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Objective: In this study, we examined small food store retailers' perspectives on tobacco company agreements specifying tobacco product display and promotion. Methods: We interviewed owners/managers of small food stores (N = 63) in lower-income neighborhoods in 4 US cities using open-and closed-ended questions between October 2013 and July 2014. We coded qualitative interview data and calculated descriptive statistics. Results: Most retailers had a formal contract with a tobacco company (87%). Retailers perceived that tobacco products generated low profits, but were important to attract customers. Nearly 95% with contracts reported receiving an incentive, including marketing materials (86.8%), displays (79%), and free/discounted products (50.9%). Contract requirements included placing branded displays and marketing materials in prime locations and setting cigarette prices. Retailers in urban, African-American neighborhoods felt pressure to maintain menthol cigarette contracts to stay in business. Conclusion: Contracts with tobacco companies were common among the small food stores in this study, and retailers felt they needed the contracts to keep prices competitive. Given the reliance of retailers on tobacco industry contracts, states and localities may need to adopt measures to counter their effects, especially the financial incentives that lead to lower cigarette prices and more prominent displays of promotions and marketing materials.

OBJECTIVES: The fit of measured variables into a social-ecological model of correlates of physical activity is rarely tested. In this study, we examined the factor structure of correlates of moderate/vigorous physical activity (MVPA) within a hypothesized social-ecological model. METHODS: We measured 46 possible personal, social and environmental correlates of MVPA in 2779 adolescents participating in the Project EAT-2010 study. Confirmatory (CFA) and exploratory factor analyses (EFA) were used to determine the factor structure. Associations of factor scores with self-reported MVPA were calculated with linear regression. RESULTS: A 6-factor CFA model did not show adequate fit. Eight factors were identified using EFA (Root Mean Square Error [RMSEA] 90% CI: 0.053 to 0.055; CFI = 0.82). A factor representing the mix of personal and social correlates showed the strongest association with MVPA. CONCLUSIONS: The 8-factor model supports independent clustering of possible environmental correlates of MVPA, but indicates that social and personal correlates may not cluster independently. The factor most strongly correlated with MVPA represented a mix of personal and social correlates. Future work will be needed to better understand how mechanisms for developing physical activity work within and across levels of the social-ecological framework.

Small food stores are common in low-income settings.1–9 These stores typically, though not always,10 offer limited healthy options5–8,11–15 and are associated with overconsumption of high-fat, high-sugar foods12,13,16–19 and higher rates of obesity and chronic disease.15,20–25 In recent years, researchers and public health practitioners have increasingly sought to improve the food environment and purchasing of healthy foods in small stores.26–30 Federal programs such as the American Reinvestment and Recovery Act of 2009, the Patient Protection and Affordable Care Act, and the Healthy Food Financing Initiative have bolstered healthy corner store efforts by providing $650 million, $100 million, and $50 million in funding, respectively, to support efforts to increase access to healthy, affordable food. Improving access to healthy foods has been identified as a key strategy for obesity prevention and control by many national organizations including the Institute of Medicine, the Centers for Disease Control and Prevention, and the American Heart Association. It is part of a comprehensive approach to prevention and control, particularly in low-income and underserved communities where access is limited, and compliments other prevention and control strategies that involve individual and family change efforts.31-33. This multi-level approach (individual-family-community) is consistent with public health theories that support the use of an ecological framework for health promotion and which emphasize policy-oriented and environmental interventions to maximize reach and sustainability of our health behavior change efforts.34,35 In a recent review of small store interventions designed to promote healthy eating, common intervention strategies included increasing availability of healthier foods, particularly produce, utilizing point of purchase promotions and engaging the community. Less common strategies included business training and nutrition education. Significant impacts were found in terms of increased healthy food availability, improvements in store-owner reported sales of healthy foods, and improved customer knowledge and dietary behaviors.36 Yet, despite this growing body of evidence, little has been written on the process and many logistical challenges of designing, implementing and evaluating small store interventions. To address these gaps, 2 questions were posed: What are the main challenges affecting the feasibility, acceptability and success of small store interventions? How have previous small store interventions addressed these challenges? To answer these questions, the authors drew from experiences implementing such interventions in 4 different regions of the US. Each of the studies described intervened to improve the food environment, and were evaluated at the store and (usually) consumer levels. We chose to use a qualitative case study approach due to the paucity of evidence on the experience of developing, implementing and evaluating small store intervention programs. Qualitative research approaches are especially suited to explorative, formative investigation.37 Case studies are a strategy within qualitative research which focus on exploring bounded systems in depth and over time, using multiple sources of information.38 This paper sought to inform practitioners, researchers, and others about how to address the challenges of small store interventions to maximize efficiency and improve potential effectiveness.

Young adulthood is a unique developmental period during which many health behaviors are formed.1 Unfortunately, young adults exhibit some of the poorest dietary patterns of all age groups, marked by low consumption of fruits and vegetables2 and high consumption of fast food and sugar-sweetened beverages.3-5 These behaviors, together with declining rates of physical activity, put young adults at increased risk of unhealthy weight gain.1 Few nutrition- and weight-related interventions are tailored to the needs of young adults6; thus, research is needed on the factors that contribute to dietary behaviors during this period. Growing evidence indicates that adolescents and young adults tend to have similar dietary patterns as their peers.7-10 In addition, descriptive social norms, or perceptions of peer behavior, are theorized to influence behavioral intentions and health behaviors,11-14 particularly among children, adolescents, and young adults.14 Regardless of whether perceptions are accurate representations of peer behavior,15-17 studying the relationship between descriptive social norms and dietary behaviors can provide insight on a potentially modifiable contributor to young adults’ diet. Understanding the nature of social norms can inform the design of dietary interventions that specifically target young adults’ perceptions as a means of influencing behavior. Although these types of norms-based interventions have been used to address alcohol consumption among young adults,18-22 this approach has not yet been applied to dietary behaviors among this age group. Studies of adults (mean age 34-52 years) and adolescents have found descriptive social norms to be associated with several weight-related health behaviors, including consumption of fast food, sugar-sweetened beverages, and fruit and vegetables15,16,23,24; overall dietary intake13,25; and physical activity.13,23 In contrast, little research has investigated the role of descriptive social norms in shaping young adults’ weight-related behaviors, with most research on social norms in this age group focusing on alcohol use.12,26-28 The few studies that have examined weight-related behaviors in young adults found that peer social norms significantly predicted strenuous leisure-time exercise,29 fruit intake,30 and intention to engage in physical activity and healthy eating,31 and that parents continue to shape young adults’ diet and exercise behaviors years after they leave the home.9,32 Berge et al also found that perceptions of significant others’ weight-related behaviors and attitudes were associated with young adult females’ diet, physical activity, and weight status and young adult males’ physical activity.33 This study adds to the literature on social norms and weight-related behaviors among young adults in 2 ways. First, this study uses data on descriptive social norms for 3 types of social contacts (ie, family, friends, and significant other) and proximity (ie, whether young adults live with each type of social contact) to enable comparisons between different sources of social norms and the strength of the association in more versus less proximal relationships. Second, this study broadly examines dietary intake, including both unhealthy behaviors (consumption of sugar-sweetened beverages and fast food) and healthy behaviors (fruit and vegetable consumption and preparation of meals at home) to examine whether the relationship with social norms is similar across dietary behaviors. All of these behaviors have been consistently linked to overall diet quality and/or health outcomes, particularly among adolescents and young adults.34-38 The study hypothesis was that social norms would be significantly associated with young adults’ dietary behaviors and that this association would be stronger for young adults who live with their social contacts (ie, the effect of family social norms would be stronger for young adults who live with their family).31 In addition, friend and significant other social norms were hypothesized to be more strongly associated with young adult dietary behaviors than family social norms, based on findings for social norms related to alcohol use.26

The relationship between poor dietary intake and adverse health outcomes has been well established. For example, diets rich in fruits and vegetables and whole grains and low in saturated fat have been associated with a lower risk of a number of conditions including obesity, cardiovascular disease, diabetes, and some cancers.1 Low-income and minority populations are disproportionately at risk for poor dietary intake.2-5 Socioeconomic disparities in dietary quality start in early childhood, and dietary intakes of lower income children fall short of recommended levels for several food groups and nutrients including fruits and vegetables, vitamin A, vitamin E, calcium, zinc, and iron.6-9 Dietary patterns adopted in early life can provide the foundation for food habits in later childhood and adulthood. Consequently, early childhood is a critical time to improve diets among low-income populations overall and reduce related health disparities. Federal food and nutrition assistance programs play a vital role in shaping the diets of low-income children and their families. Established in 1972, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the largest nutrition assistance programs in the United States. In 2010, WIC provided supplemental foods, health care referrals, and nutrition education to 9.2 million low-income pregnant and post-partum women, infants, and children up to age 5 who were found to be at nutritional risk.10 Until 2009, the WIC food package relied heavily on dairy products (cheese and milk) and juice; it included little in the way of fruits and vegetables. Other WIC-authorized foods included infant formula, iron-fortified cereals, eggs, legumes, canned tuna, and peanut butter.11 Despite improved knowledge about nutrition, shifts in dietary deficiencies and obesity rates, and increasing racial and ethnic diversity in the WIC population, the food package had not been updated since 1980.12 In 2009, the USDA implemented new WIC food packages based on the Institute of Medicine's recommendations.12 The revisions aligned the packages with the 2005 Dietary Guidelines of Americans and infant-feeding practice guidelines of the American Academy of Pediatrics.13 They addressed dietary imbalances among young children and women, such as excessive intake of saturated fat and sodium and low intake of fiber, vitamin E, and iron.14 Fruits, vegetables, and whole grains were added; and the quantity of fruit juice was cut in half. Saturated fat and cholesterol content of the packages was lowered by reducing the amount of milk, cheese, and eggs, as well as allowing whole milk only for children under 2 years.14 State agencies were given flexibility in prescribing food packages to accommodate the cultural food preferences of WIC participants.15 For example, in addition to whole-wheat bread, states could choose to include one or more options of whole-grain tortillas, brown rice, oats, and other whole grains.15 The revision recognized that WIC participants, like the population at large, increasingly rely on convenience foods. Therefore, states could offer canned beans—in addition to dried—as well as frozen, canned, and dried varieties of fruits and vegetables.14 Poor diet among low-income populations is partially attributed to the low availability of healthy foods.16,17 Previous studies show associations between food environments and healthy eating, obesity, and chronic diseases in low-income urban populations.18-21 Changes to WIC policy have the potential to improve the food environment for low-income communities by increasing the availability of healthy foods. In most states, food packages are redeemed at authorized retailers, or “WIC vendors.” Understanding vendor perspectives on program implementation is crucial for successful outcomes and sustainability.22,23 The Institute of Medicine's report, WIC Food Packages: Time for a Change, discussed positive perspectives (eg, increased sales of high profit margin groceries, new customers) as well as negative perspectives (eg, increased costs) on what vendors may experience from the new WIC food package.12 Now that the new WIC food packages have been implemented, it is important to explore implementation successes and challenges across the United States so that additional changes can be made. We located only 2 published studies that looked at vendor perspectives on the new WIC food package, particularly among vendors operating small food stores, and only one has taken a qualitative approach.24 A recent study assessed Connecticut retailers' perspectives on the new WIC program through structured, in-person interviews before and after the change (n=68). Most retailers (71%) were happy or very happy to participate in the new WIC program because of additional sales, financial stability in economic downturns, and spillovers into non-WIC products.25 A report based on interviews of small store-owners in Colorado, New Hampshire, Pennsylvania, and Wisconsin before (n=35) and after (n=43) the WIC food package change revealed generally positive perceptions of the changes, though a number of owners reported difficulty with limited refrigeration equipment and the ability to keep foods fresh.24 Given state-level variability in the WIC program and stocking requirements, as well as the known differences in healthy food availability in small, urban corner stores across the United States,26 it is important to expand our understanding by conducting additional research across a wide array of geographic regions, focusing on the experiences of small stores. This paper sought to explore the perceptions of owners and managers of small food stores about the new WIC packages through in-depth interviews of 52 store owners/managers across 7 states.

Emerging adulthood (typically defined as ages 18-25 years) is a unique developmental period in which habits and behaviors that affect health are formed.1 This period represents a time when many individuals may be finding their independence and negotiating new responsibilities and life skills as they transition into established adults. As a result, emerging adulthood represents a unique period when the maintenance and development of health behaviors may be influenced by new factors such as management of one’s own finances and priority setting. From a health perspective, emerging adulthood is marked as a period of weight gain, decreased physical activity (PA) levels and diet quality,2-9 increased alcohol use and tobacco use,10-12 and high rates of unhealthy weight-control behaviors.13,14 There has been evidence that these behaviors (ie, weight status, PA, diet, alcohol and tobacco use, and unhealthy weight-control behaviors) may be linked among emerging adults.15 These behaviors, specifically insufficient PA, poor diet, tobacco and alcohol use, are leading behavioral causes of overall population-level mortality.16 A consequent condition of insufficient PA and poor diet is obesity, which has been on the rise over the past 3 decades among almost all populations of children, adolescents, and adults.17-19 Given the public health imperative to address overweight and obesity, insufficient PA, poor diet, and tobacco and alcohol use, emerging adulthood may be a critical period for interventions aimed at addressing the development of these risky health behaviors. Among young people in the United States, numerous health disparities exist by socioeconomic status (SES) including overweight and obesity, PA, and nutrition,8,20-22 as well as alcohol and tobacco use.20,23 For example, Nelson and colleaguesfound that in a gender-stratified analysis of nationally representative sample of 4-year college students, there were significant differences by parental educational attainment, with students whose parents did not attend college having the highest risk of overweight and obesity compared to students whose parents had attended college.8 Parental educational attainment can provide information on individuals’ general living condition during time periods when they are particularly dependent on their parents; this may be considered by some as an “inherited SES.” Therefore, parental educational attainment is often a measure of SES that is used among children, adolescents, and emerging adults in health-related research.8,21,23,24 Other common measures of SES, such as income, educational attainment, or occupation, may not be as relevant for emerging adults because they are still in a process of developing the skills and tools necessary to accomplish and establish meaningful levels of income, education, and occupation. However, among emerging adults, who are transitioning into their own independence, parental educational attainment may capture only a portion of the financial context in which emerging adults exist. Other measures, such as current financial strain, have also been used to assess SES among emerging adult populations like college students. For example, one study examining credit card debt among students at a 4-year university found that having debt over $1000 in the last month significantly predicted multiple weight-related behaviors including low PA levels and breakfast consumption and high levels of sedentary behavior, fast food consumption, unhealthy weight control, and body dissatisfaction.13 In addition, this marker of current financial strain was associated with increased levels of perceived stress. Overall, many scholars agree that SES is a complex construct that is composed of multiple dimensions.25-28 Thus, we believe that current financial strain may capture a different aspect of emerging adults’ financial context compared to the SES they inherited from their parents. More specifically, although parental educational attainment reflects the financial experiences during childhood, financial strain captures the current intrapersonal financial experience. Given the importance of weight-related behaviors, tobacco and alcohol use in the prevention of obesity and premature mortality, and the adverse changes in behaviors during emerging adulthood, it is important to understand the role that financial context and financial strain may play in influencing the behaviors of emerging adults. Furthermore, to our knowledge, no assessment of perceived financial strain and health has been undertaken in diverse populations of emerging adults, such as those attending 2-year community and technical colleges. Students attending 2-year colleges are more likely to come from racial/ethnic minority groups and low-income backgrounds in which the relationship between financial strain and context and health may be different from that of 4-year college students. With enrollment in postsecondary institutions increasing among emerging adults,29 non-traditional, 2-year colleges are an important setting for intervention delivery, particularly interventions aimed in the development and maintenance of healthy behaviors that lower risk of chronic diseases. A better understanding of financial context and financial strain as related to health behaviors in these settings may be informative in intervention development, because future interventions may need to take into account the availability of resources for young adult college students and consider the financial barriers associated with behavior change. To address these gaps in the literature, the purpose of this study was to (1) explore the weight status, weight-related behaviors, and alcohol and tobacco use behaviors among a diverse sample of both 2-year and 4-year college students by financial context (ie, parental educational attainment) and financial strain (ie, how difficult it is to live off of one’s current household income) and (2) examine the association between financial context, financial strain, and weight status, weight-related behaviors, and alcohol and tobacco use among college students whose parents had not completed high school or had experienced high financial strain.

Objective To determine if post-traumatic stress disorder (PTSD) is associated with health risk behaviors among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans attending college. Method Using 2008 Boynton College Student Health Survey data, we tested associations between self-reported PTSD diagnosis and self-reported risk behaviors (n=406). Results We found PTSD diagnosis to be significantly associated with reporting involvement in a physical fight in the past year (ARR = 3.1; 95% CI: 2.2, 4.4) and marginally associated with highrisk drinking (ARR = 1.3; 95% CI: 1.1, 1.6). However, no association was seen between PTSD and the tobacco use and other safety behaviors that we examined. Conclusion PTSD is likely a factor that contributes to the relationship between military service and certain health risk behaviors.

Objective To explore how weekday and weekend sleep patterns are related to adolescent substance use, depressive symptoms, and school truancy. Methods Selfreport surveys of 242 youth (93.4% white, mean age 16.4 years). Results Longer weekday sleep duration was inversely associated with depressive symptoms, past month alcohol use, and drunkenness. Later weekend bedtime and wake-times, compared to those of weekdays, were associated with increased substance use and truancy. Conclusions Weekday sleep duration appears to be protective for substance use, depression and school truancy for teenagers. However, inconsistent sleep patterns between weekdays and weekends were associated with a range of markers for adolescent risk.