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The North Carolina Farmworker Health Program (NCFHP) implemented an emergency program in response to North Carolina migrant and seasonal farmworkers’ urgent need for Internet access for health information, family connections, and telehealth services during COVID-19 isolation and quarantine. This article describes the NCFHP Internet Connectivity Project implementation and evaluation from June 2020 to December 2021. The project placed 448 devices across the state and provided Internet access to more than 3184 farmworkers during the 2021 peak farming season. (Am J Public Health. 2022;112(11):1551–1555. https://doi.org/10.2105/AJPH.2022.307017 )

Community health workers (CHWs) are uniquely positioned to connect migrant and seasonal farmworkers to health promotion and clinical services. However, research on CHWs' experiences, particularly related to their provision of health education to farmworkers, is limited. To explore CHWs' practices and challenges in conducting health education outreach, we conducted three focus group discussions with farmworker health CHWs (N = 28) in North Carolina in the spring of 2020. We analyzed the focus group transcripts, and we compared the code outputs, thematic code summaries, and memos maintained throughout the analytic process to examine the experiences of CHWs in acquiring and disseminating health information and resources, including use of technology. We identified three themes related to CHWs' experiences providing health information to farmworkers. First, CHWs described short-term preparation, immediately before providing health outreach, and long-term activities, devoted to maintaining and improving their capacity to provide relevant health information to farmworkers. Second, they described their use of health education delivery methods, including open-ended questions, participatory and interactive approaches, and non-verbal aids. Third, participants described their current use of technology and related challenges, as well as the technology needed to enhance health outreach, including internet access. Findings reveal opportunities to improve farmworker health education through professional development for CHWs, identification of preferred methods of health education delivery to farmworkers, and provision of technology to farmworker-serving organizations. Establishing rural internet access and equipping outreach organizations with technology would position CHWs to be maximally effective as they strive to reduce farmworkers' health inequities.

ObjectiveWe sought to conduct a systematic review and meta-analysis of evidence to inform policies that reduce density and proximity of tobacco retailers.Data sourcesTen databases were searched on 16 October 2020: MEDLINE via PubMed, PsycINFO, Global Health, LILACS, Embase, ABI/Inform, CINAHL, Business Source Complete, Web of Science and Scopus, plus grey literature searches using Google and the RAND Publication Database.Study selectionIncluded studies used inferential statistics about adult participants to examine associations between tobacco retailer density/proximity and tobacco use behaviours and health outcomes. Of 7373 studies reviewed by independent coders, 37 (0.5%) met inclusion criteria.Data extractionEffect sizes were converted to a relative risk reduction (RRR) metric, indicating the presumed reduction in tobacco use outcomes based on reducing tobacco retailer density and decreasing proximity.Data synthesisWe conducted a random effects meta-analysis and examined heterogeneity across 27 studies through subgroup analyses and meta-regression. Tobacco retailer density (RRR=2.55, 95% CI 1.91 to 3.19, k=155) and proximity (RRR=2.38, 95% CI 1.39 to 3.37, k=100) were associated with tobacco use behaviours. Pooled results including both density and proximity found an estimated 2.48% reduction in risk of tobacco use from reductions in tobacco retailer density and proximity (RRR=2.48, 95% CI 1.95 to 3.02, k=255). Results for health outcomes came from just two studies and were not significant. Considerable heterogeneity existed.ConclusionsAcross studies, lower levels of tobacco retailer density and decreased proximity are associated with lower tobacco use. Reducing tobacco supply by limiting retailer density and proximity may lead to reductions in tobacco use. Policy evaluations are needed.

Despite higher rates of tobacco use and smoking-related diseases among sexual minorities, tobacco cessation treatment-seeking behaviors (e.g., medication, nicotine replacement products) remain poorly understood across sexual orientation subgroups. This study examines tobacco cessation treatment-seeking behaviors associated with Diagnostic and Statistical Manual of Mental Disorders, 5th Edition tobacco use disorder (TUD) across the three major sexual orientation dimensions (identity, attraction, behavior) in U.S. adults. Prevalence estimates reflect data collected from a 2012-2013 national sample of adults 18 years and older. More than three-fourths of U.S. adults with TUD had never engaged in tobacco cessation treatment-seeking behaviors, regardless of sexual orientation. Despite having the highest rates of TUD, bisexual men and women had some of the lowest rates of tobacco cessation treatment-seeking. Men who identified as gay, reported same-sex attraction, or reported same-sex behaviors had the highest rates of tobacco cessation treatment-seeking. In contrast, women with same-sex attraction or same-sex behavior had higher rates of TUD but were less likely to engage in tobacco cessation treatment-seeking behaviors than women with only other-sex attraction or other-sex behavior, respectively. Heterosexual women were more likely to engage in tobacco cessation treatment-seeking than heterosexual men; this sex difference was not present for sexual minorities. Medications and nicotine replacement therapy products were the most prevalent forms of treatment-seeking. There were notable differences in tobacco cessation treatment-seeking behaviors based on sex and sexual orientation. Findings highlight the underutilization of tobacco cessation treatment-seeking among all U.S. adults and point to important factors to consider when working with sexual minorities who are trying to reduce or stop using tobacco.

Emerging evidence using the concentration of same-sex couples from the U.S. Census suggests lesbian, gay, bisexual (LGB), and transgender (LGBT; i.e., sexual and gender minority [SGM]) people living as a same-sex couple are concentrated in less healthful neighborhoods. However, it is unclear if findings would be different if based on where LGBT individuals live. Thus, we sought to assess differences in neighborhood, county, and state characteristics between same-sex couples and LGBT individuals to inform population health research and policy interventions on LGBT health inequities. In 2017, we conducted a cross-sectional national, probability survey of LGBT adults in the U.S. and geocoded addresses (N = 407). We linked locations with census tract, county, and state characteristics selected based on health inequities theories. In 2019, we used weighted analysis to calculate descriptive statistics and conducted planned contrasts of location characteristics by both cohabitation status and gender. Many location characteristics were similar by cohabitation status and gender. However, the tract proportion of Black residents and county crime rate were lower for cohabitating than non-cohabitating men. State smoke-free air score was weaker for cohabitating than non-cohabitating women. The use of same-sex couples to determine the geographical clustering of LGBT lives in the U.S. may give a reasonable indication of overall spatial characteristics but can underestimate some important determinants of health. Care should be taken using same-sex couples as a proxy for LGBT concentration when racial segregation is a potential confounder.

BackgroundAudits of tobacco retail stores can identify marketing patterns as newer tobacco products are introduced in the US. Our study examined store and neighborhood correlates of availability of nicotine pouches and disposable e-cigarettes in four US sites.MethodsWe conducted standardized store audits of n=242 tobacco retailers in 2021 in different states: New Jersey, Kentucky, North Carolina, and New York. Store audits focused on availability of nicotine pouches and disposable e-cigarettes. We geocoded stores linking them with census tract demographics. We conducted unadjusted and adjusted Poisson regression of availability of each product with correlates of the proportion of Non-Hispanic White residents, households under poverty, proximity to schools, site, and store type.ResultsNicotine pouches and disposable e-cigarettes were each available in around half the stores, but availability differed across sites. In adjusted analyses, nicotine pouches were less likely to be available in each store type vs. chain convenience and more likely in stores in census tracts with more non-Hispanic White residents. In contrast, disposable e-cigarettes were more likely to be available in tobacco store/vape shops than convenience stores and less likely in non-specialty store types like groceries.ConclusionsThe availability of newer tobacco products like nicotine pouches and disposable e-cigarettes were widely available in stores across sites, but retail marketing patterns appear to differ. As these product types become subject to increased regulation as they go through the FDA pre-market authorization process, understanding changes in their retail environment is critical to inform potential policies regulating their sale and marketing.

Community health workers (CHWs) bridge the gap in health and social services delivery for marginalized communities, providing critical health information to those with limited access to health resources.The purpose of our study was to understand CHWs' approaches to identifying salient and credible health information for migrant and seasonal farmworkers in rural North Carolina (NC).Two focus group discussions were held with CHWs in eastern NC and one in western NC in February 2020.CHWs seek health information on chronic health conditions disproportionately experienced by farmworkers such as diabetes and high blood pressure. They search for information from existing resources in their possession, via the internet, and through consultation with health professionals. CHWs also verify the information and transform the content into resources that are accessible to farmworkers.Our findings suggest that CHWs possess a strong set of information literacy skills that could be enhanced through additional training in crediting sources, creating new materials, and organization and storage.This study adds to the very limited body of knowledge about how CHWs seek and transmit information to their communities and sheds light on their information need and literacy abilities.

Purpose To use the loneliness model in examining the influence of loneliness on the number cigarettes smoked per day and the different intensity levels of physical activity among community-dwelling older Americans in the United States. Design, setting, sample This study analyzed a nationally representative sample of older adults aged 65+ in two waves (2010 and 2012) of data from the Health and Retirement Study. Response rates for the two waves were 81% and 89.1%. The sample size for smoking model was 199, and for physical activity models was 3018. Measures Outcomes included number of cigarettes smoked per day and physical activity at three intensity levels: light, moderate, and vigorous. Independent variable was the UCLA loneliness scale. Analysis A lagged dependent approach for modeling longitudinal data was adopted. Models controlled for outcomes at the first timepoint (Wave 1), health/physical functioning, and demographic variables. Results Loneliness was associated with an increased number of cigarettes smoked per day (β = 2.93, P < .05) and decreased engagement in moderate and vigorous physical activity for older adults (β = .12, P < .05; β = .12, P Conclusion The findings call for smoking reduction and physical activity enhancement interventions targeting older adults who have high levels of loneliness. Efforts to enhance social support will be crucial to eradicating the harmful health impact of loneliness. Critical limitations include self-reported measures and unobserved confounders.

Menthol cigarette use is disproportionately higher among sexual- and gender-minoritized (SGM; 36%) individuals compared to cisgender, heterosexual (29%), individuals. The FDA has announced intentions to ban menthol in cigarettes, citing these use and health disparities as partial motivation. This study identified potential outcomes of a menthol cigarette ban among SGM individuals who smoke menthol cigarettes (N = 72). Potential outcomes were identified via concept mapping using the prompt: “If menthol in cigarettes was banned, a specific action I would take related to my tobacco use is…” Participants generated 82 response statements, sorted them, and rated them on personal relevance. Eight thematic clusters were identified: (1) Thoughtful Consideration of the Ban, (2) Negative Reactions to the Ban, (3) Positive Aspects of the Ban, (4) Strategies to Reduce Cravings, (5) Intent to Quit and Cessation Strategies, (6) Support-Seeking and Engagement in Positive Behaviors, (7) Strategies to Maintain Menthol-Flavored Product Use, and (8) Substance Use Alternatives to Menthol Cigarettes. Cluster differences based on sociodemographic factors, smoking behavior, and quitting interest were identified. Results provide insight into potential responses to a menthol cigarette ban and can contribute to public health prevention and intervention efforts, messaging campaigns, and support services for SGM people who smoke menthol cigarettes, specifically.

Introduction. Ineffective health communication can drive health disparities and limit the effectiveness of interventions to reduce them. Stock photo libraries are a critical tool for developers of patient education, health education, and intervention materials. It is not clear how well stock photo libraries represent communities bearing disproportionate burdens of disease. Method. We conducted a search using five popular stock image libraries (Adobe Stock Images, Canva, Getty Images, Microsoft Office Image Library, and Pixabay) in November 2021 to evaluate diversity and representation in health-related stock photos. We searched for the following five key preventive health topics: healthy eating, exercising, quitting smoking, vaccination, and pregnancy. The images (N = 495) were coded for age, gender presentation, representation of perceived minoritized racial/ethnic identity, skin color using the Massey–Martin skin color scale, markers of high socioeconomic status (SES), and access costs. Results. The representation of perceived minoritized people, darker skin color, and inclusion of markers of high SES varied greatly by the search term and library. Images predominately portrayed young adults and adults, with limited representation of other age groups. Images in libraries with any paywall were significantly more likely to depict a person of perceived minoritized racial/ethnic identity and depict darker skin colors, and were significantly less likely to contain markers of high SES identity than images in libraries that were free to use. Discussion. We found that it costs more to develop culturally relevant health education materials for minoritized populations and groups that do not represent high SES populations. This may hinder the development of effective communication interventions.

The quality of patient education materials is an important issue for health educators, clinicians, and community health workers. We describe a challenge achieving reliable scores between coders when using the Patient Educational Materials Assessment Tool (PEMAT) to evaluate farmworker health materials in spring 2020. Four coders were unable to achieve reliability after three attempts at coding calibration. Further investigation identified improvements to the PEMAT codebook and evidence of the difficulty of achieving traditional interrater reliability in the form of Krippendorff’s alpha. Our solution was to use multiple raters and average ratings to achieve an acceptable score with an intraclass correlation coefficient. Practitioners using the PEMAT to evaluate materials should consider averaging the scores of multiple raters as PEMAT results otherwise may be highly sensitive to who is doing the rating. Not doing so may inadvertently result in the use of suboptimal patient education materials.

Perceptions of the importance of health problems can drive advocacy, policy change, resource distribution, and individual behaviors. However, little is known about how lesbian, gay, bisexual, and transgender (LGBT), that is, sexual and gender minority (SGM) adults view the health problems facing SGM populations. In a 2017 national, probability-based survey of U.S. SGM adults ( N = 453), we asked respondents to identify the most serious health problem facing SGM people today. Participants also rated the seriousness of five specific health problems (HIV/AIDS, suicide, hate crimes, harmful alcohol use, tobacco use). Analyses accounted for the complex sampling design and were stratified by gender identity. One quarter of U.S. SGM adults identified the most serious health problem facing SGM people to be HIV/AIDS (95% confidence interval [20.3, 31.2]). More respondents stated there were no serious LGBT health differences compared with straight/cisgender adults (4.2%, confidence interval [2.6, 5.9]) than identified tobacco use, hate crimes, chronic diseases, cancer, or suicide as the most serious. Importance ratings differed by gender and tobacco/alcohol use were perceived as less serious compared with HIV/AIDS, suicide, and hate crimes. Attention paid to HIV/AIDS by the SGM public, while important, may hinder efforts to address chronic diseases and other health issues affecting SGM people.

Background. There are well-documented inequities in smoking between sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, and transgender [LGBT]) and straight and cisgender people. However, there is less information about risk for and resilience against smoking among SGM people. Such information is critical for understanding etiology and developing interventions. Aims. To conduct a within-group assessment of risks and resiliencies relating to smoking status. Method. In 2017, we conducted a cross-sectional telephone survey with a national, probability-based sample of SGM adults ( N = 453). We assessed theory-informed risks (adverse childhood events, substance use–oriented social environment, mental distress, stigma, discrimination, social isolation, and identity concealment) and resiliencies (advertising skepticism, identity centrality, social support, and SGM community participation). We applied survey weights, standardized predictor variables, and fit logistic regression models predicting smoking status. We stratified by age and SGM identity. Results. Patterns of risk and resilience differ by age and identity. Effects were consistently in the same direction for all groups for participating in substance use–oriented social environments, pointing to a potential risk factor for all groups. Advertising skepticism and having people you can talk to about being LGBTQ were potential protective factors. Discussion. Intervention development should address risk and resilience that differs by SGM identity. Additionally, our findings suggest interventionists should consider theoretical frameworks beyond minority stress. Conclusion. While much of the literature has focused on the role of stress from stigma and discrimination in tobacco use, addressing social norms and bolstering protective factors may also be important in SGM-targeted interventions.

The Food and Drug Administration (FDA) can regulate the introduction of new tobacco products and some changes to existing products. Cigarette packs have been used as a marketing tool to target specific groups and priority populations. Research has shown that sexual and gender minority (SGM) adults are substantially more likely to use tobacco products than their straight and cisgender counterparts. However, research to inform the FDA’s regulatory decisions regarding cigarette packs targeting priority populations is nascent. To fill this gap, we conducted an online experiment in 2018, randomizing U.S. adults who reported current smoking ( N = 954, 52% were SGM) to view one of three cigarette packs. A graphic designer developed “Glacier” branded packs with three levels of SGM imagery: (1) no targeting, (2) subtle targeting, and (3) a rainbow “pride edition.” Participants viewed and rated the pack using cognitive, affective, and behavioral measures informed by theory. We used a linear model framework to compare the two SGM-targeted packs with the not targeted version and tested interactions between pack and SGM identity for the dependent variables. We stratified results by SGM status. SGM status was a significant moderator of the relationship between the pack and ratings of appeal, positive affect, feeling shocked, and intent to try with a coupon. Findings from this study revealed that packs designed for SGM populations can disproportionately change cognitive, affective, and behavioral intention responses for SGM smokers. Products entering the market should be assessed by FDA for the appeal of their packs to vulnerable populations.

We sought to examine perceived gender identity, perceived co-worker discomfort, and salary recommendations for youth counselors with transgender-related work experience. In two experiments conducted in 2016 and 2017, we randomized participants to view 1 of 2 résumés with varying work experience at a camp for transgender youth or a generic youth camp. Study 1 participants were 274 adult festivalgoers at a lesbian, gay, bisexual, and transgender pride festival. Study 2 participants were 296 employed, heterosexual adults aged 35-60 from an online survey panel. In Study 1, viewing the résumé with transgender experience resulted in a statistically significantly higher likelihood of reporting the applicant was gender minority than cisgender (adjusted odds ratio = 3.76, 95% confidence interval [1.32, 10.72], p = .01), higher but not a statistically significant level of co-worker discomfort (aOR = 1.39, 95% CI [0.83, 2.32], p = .22), and, although not statistically significant, a $2,605 higher salary (95% CI [-$604, - $5,814], p = .11). In Study 2, we found a statistically significantly greater likelihood of reporting the applicant was gender minority than cisgender (OR = 2.56, 95% CI [1.36, 4.82], p < .01), statistically significantly higher odds of reported co-worker discomfort (OR = 3.57, 95% CI [2.15, 5.92], p < .01), and, although not statistically significant, a $1,374 higher salary (95% CI [-$1,931, $4,679], p = .41). Our results indicate the potential for stigma by association for professionals working with marginalized groups and suggest potential pathways through which employment discrimination may exacerbate existing inequities for gender minority people.

Objectives: As inequities in health for sexual and gender minority (SGM; eg, lesbian, gay, bisexual, and transgender [LGBT]) populations become increasingly well documented, it is important to investigate causes of inequities to inform intervention work. One area of importance is in employment discrimination, as there are limited or no protections against sexual orientation and gender identity discrimination in approximately half of US states. We sought to assess the internal consistency and validity of a brief, adapted scale to measure SGM work-place discrimination. Methods: We modified an existing workplace age discrimination scale to assess SGM work- place discrimination. We assessed internal consistency, criterion validity, construct validity, and conducted a confirmatory factor analysis. Data came from a convenience sample of employed, SGM-identified adults (N = 124) attending a pride festival in Durham, NC, in September 2016. Results: The 5-item scale was significantly associated with poorer health, greater internalized homonegativity, reporting workplace bullying, SGM isolation, gender expression discrimination, and having filed a formal complaint of workplace discrimination. The scale had a single factor solution. Conclusions: This 5-item scale may be useful in efficiently documenting and addressing SGM workplace discrimination; it assesses material forms of discrimination (eg, pay and job tasks assigned) against SGM employees.

Objective To compare eligibility for lung cancer screening and receipt of a CT scan for lung cancer among sexual minorities. Methods Secondary data analysis of cross-sectional data from older U.S. adults in the Behavioral Risk Factor Surveillance System survey during the 2017 cycle (n = 20,685). Results Rates of eligibility for low-dose helical computed tomography (LDCT) were roughly twice as high among sexual minorities than among heterosexuals (21.1% vs. 11.7%). The odds of gay men and lesbian women indicating eligibility for LDCT screening were four to five times higher when compared to their heterosexual peers. No statistically significant differences were found between sexual minorities and heterosexuals with respect to having a CT scan for lung cancer in the past year. Conclusions There are potential sexual-identity-related disparities in the utilization of lung cancer screening among eligible smokers. Interventions are needed to increase awareness and uptake of lung cancer screening in order to detect and manage this common form of cancer in the U.S.

Audits of tobacco retailers can identify marketing patterns as newer tobacco products are introduced in the US. Our study examined store and neighborhood correlates of availability of nicotine pouches and disposable e-cigarettes in four US sites. We conducted standardized store audits of n = 242 tobacco retailers in 2021 in different states: New Jersey, Kentucky, North Carolina, and New York. We geocoded stores linking them with census tract demographics. We conducted unadjusted and adjusted Poisson regression of availability of each product with correlates of the proportion of Non-Hispanic White residents, households under poverty, proximity to schools, site, and store type. Nicotine pouches and disposable e-cigarettes were each available in around half the stores overall, but availability differed across sites (range: 76 %-32 %). In adjusted analyses, nicotine pouches were less likely to be available in each store type vs chain convenience (IRR range 0.2-0.6) and more likely in stores in census tracts with a greater percentage of non-Hispanic White residents (IRR range 1.8-2.3). In contrast, disposable e-cigarettes were more likely to be available in tobacco/vape shops (IRR 1.9 (1.4-2.5) than convenience stores and less likely in non-specialty store types like groceries (IRR 0.2 (0.1-0.4). Newer tobacco products like nicotine pouches and disposable e-cigarettes were widely available in stores across sites, but retail marketing patterns appear to differ. As these product types become subject to increased regulation as they go through the FDA pre-market authorization process, understanding patterns and changes in the retail environment is critical to inform potential policies regulating their sale and marketing.

There are profound health inequities for agricultural workers. We sought to assess the literature on migrant and seasonal farmworker health with an eye toward health promotion interventions, special populations, use of community health workers (CHWs), and technology. We conducted a systematic mapping review by searching five databases in March 2021. Using quantitative content analysis after establishing interrater reliability, we coded titles and abstracts to assess 13 topics and six characteristics of the research such as its focus on health promotion, use of technology, and inclusion of CHWs. We identified 1,083 records. Just 8.2% of records described or evaluated a health promotion effort to intervene in farmworker well-being and even fewer (4.2%) examined unique populations of farmworkers such as indigenous farmworkers ( n = 11) or sexual minority farmworkers ( n = 1). A small body of literature focused on the role of CHWs or promotores most frequently described their role in implementing health interventions. The literature on farmworker health has gaps regarding health promotion interventions, special populations, and integration of CHWs into research projects. We offer suggestions to fill in identified gaps in the literature.

Introduction While plain packaging of tobacco products has emerged as a policy intervention to reduce smoking, regulators in the US have limited ability to implement plain packaging. We sought to identify the impact of subtle changes to cigarette packaging (Study 1) and how packaging design influenced participant choices based on appeal, harm, and style (Study 2). Methods We conducted two discrete-choice experiments with US adult smokers online in 2018. In Study 1 (n=285), we assessed participants' selections based on subtle changes to pack design features (dimensions, color saturation, logo size). In Study 2 (n=284), we assessed three choices in which participants selected packs based on appeal, harmfulness, and best match to their personal style. Study 2 packs varied by color hue, design with different levels of organic labeling and natural imagery, and color saturation. Results Pack designs influenced smokers' choices. In Study 1, pack dimensions and color saturation emerged as the most important features, and, in Study 2, design and color hue were the most influential characteristics. Conclusions Regulators should consider how the design of cigarette packages may influence consumers' perceptions and choices.

Purpose: To examine whether social network characteristics of US-and foreign-born individuals are related to hypertension, diabetes and obesity prevalence. Design: Cross-sectional. Setting: Six San Francisco Bay Area counties. Participants: N = 1153 cohorts of young and older adults (21-30 and 50-70 years). Measures: Network structure and support measures were calculated using name elicitation and interpreter questions common in egocentric surveys. Hypertension and diabetes were self-reported, and overweight/obesity was determined using body mass index calculations. Foreign-birth status was based on country of birth. Analysis: Adjusted and unadjusted logistic regression models were used to examine associations between network characteristics and hypertension, diabetes and overweight/obesity. These relationships were tested for moderation by foreign-birth status, age and gender. Results: Higher percentages of family members (AOR = 4.16, CI: 1.61-10.76) and same-sex individuals (AOR = 3.41, CI: 1.25-9.35) in the composition of respondents’ networks were associated with overweight/obesity. Higher composition of family members (AOR = 3.54, CI: 1.09-11.48) was associated with hypertension. Respondents whose networks composed of higher numbers of advice individuals (AOR = 0.88, CI: 0.77-0.99), female respondents (AOR = 0.52, CI: 0.35-0.77) and foreign-born respondents (AOR = 0.54, CI: 0.32-0.92) were less likely to report overweight/obesity. Diabetes was associated with higher composition of individuals living within 5-minutes to respondents (AOR = 5.13, CI: 1.04-25.21). Conclusion: Family and network support members such as advice individuals could be potential targets for chronic disease prevention, particularly among older adults and immigrants.

INTRODUCTION: Sexual minorities (i.e. individuals who identify as lesbian, gay, and bisexual) are at increased risk for marijuana use. However, little is known about initiation during adulthood. This study examines: (1) sexual minority status as a risk factor for marijuana initiation, and (2) the modifying effect of sex (labeled at birth) on this relationship. METHODS: We analyzed Wave 1 (2013–2014) and Wave 2 (2014–2015) of the Population Assessment of Tobacco and Health, a nationally representative survey. Participants were n = 10,756 adult never marijuana users. A multivariable logistic regression examined the relationship between sexual minority status and initiation of marijuana use at Wave 2. Multivariable logistic regressions, stratified by sex, were used to assess for effect modification. Covariates were sex, age, race/ethnicity, income, currently attending college, and mental health well-being. RESULTS: Approximately 1.1% of adults initiated marijuana use from Wave 1 to Wave 2. Sexual minority status was associated with 1.57 (95% CI: 1.00–2.46) greater odds of marijuana initiation. In stratified analyses, sexual minority status was associated with greater odds of marijuana initiation for females (Adj OR: 1.97; 95% CI: 1.19–3.26) but not males (Adj OR: 0.84: 95% CI: 0.33–2.16). CONCLUSIONS: Sexual minority status is a risk factor for marijuana initiation during adulthood. This relationship was only consistent for females, suggesting that sex may be an effect modifier. However, research designed and powered to directly detect this effect is needed. Findings highlight a need for public health interventions that reduce disparities in marijuana use among sexual minorities.

ObjectivesTo advance understanding of how message framing can be used to maximise public support across different pricing policies for alcohol, tobacco and sugary drinks/foods that prevent consumption of cancer-causing products.DesignWe designed a 3×4×3 randomised factorial experiment to test responses to messages with three pricing policies, four message frames and three products.SettingOnline survey panel (Qualtrics) in 2019.ParticipantsAdults (N=1850) from the UK and USA.InterventionsParticipants randomly viewed one of 36 separate messages that varied by pricing policy (increasing taxes, getting rid of price discounts, getting rid of low-cost products), four frames and product (alcohol, tobacco, sugary drinks/foods).Primary and secondary outcome measuresWe assessed the relationship between the message characteristics and four dependent variables. Three were related to policy support: (1) increasing taxes on the product mentioned in the message, (2) getting rid of price discounts and special offers on the product mentioned in the message and (3) getting rid of low-cost versions of the product mentioned in the message. One was related to reactance, a psychological response to having one’s freedom limited.ResultsWe found no effect for pricing policy in the message. Frames regarding children and reducing cancer risk moderated some outcomes, showing promise for real-world use. We found differences in support by product and reactance with greatest support and least reactance for tobacco policies, less support and more reactance for alcohol policies, and the least support and most reactance for sugary drinks/foods policies.ConclusionsCancer prevention efforts using policy interventions can be informed by the message framing literature. Our results offer insights for cancer prevention advocacy efforts across the UK and USA and highlight that tax versus non-tax approaches to increasing the cost of cancer-causing products result in similar responses from consumers.

Persons with mental illness have poorer oral health and are less likely to receive oral health care than those in the general population. A comprehensive understanding of barriers to and facilitators of accessing oral health care from a multidisciplinary perspective is lacking. The authors of this qualitative study sought to explore barriers and facilitators in addressing the oral health needs of individuals with mental illness from the perspectives of patients, psychiatrists, and dentists.A thematic content analysis approach was used to triangulate the perspectives of the three groups. Face-to-face semistructured interviews were conducted in 2018-2019 with patients with mental illness (N=20), psychiatrists (N=20), and dentists (N=25) at an academic medical campus in rural eastern North Carolina. Participants were recruited until thematic saturation for each group was reached.Reported barriers to oral health care were categorized under emerging themes: access to dental care, fear of dental care, characteristics of mental illness, lack of oral health screening by psychiatrists, lack of education and training, stigma of mental illness, and lack of communication. Facilitators of oral health care were linked to the reported need for education and training, financial support, dentists' chairside manner, community support, and interprofessional communication.The findings highlight health system gaps between oral health and mental health. The barriers and facilitators identified can help inform the development of interventions to improve oral health of patients with mental illness. Interventions should include interdisciplinary education and training, improved communication, and strategies to reduce financial barriers and anxiety in dental practice.

ImportanceResearch demonstrates that policies aimed at retailers who sell to minors must be strongly enforced to have an impact on youth usage rates.ObjectivesIn the USA, the Food and Drug Administration (FDA) conducts compliance checks, issues fines, and can order retailers to stop selling tobacco products (ie, no-tobacco-sale orders (NTSOs)) to enforce the Family Smoking Prevention and Tobacco Control Act. We sought to assess FDA’s utilisation of NTSOs.MethodsWe conducted a quantitative content analysis of FDA’s enforcement actions for inspections decided between 1 October 2015 and 29 March 2019. From the 536 134 inspection records we identified 148 NTSOs and 249 720 unique retailer locations, of which 2095 had three or more violations. We randomly sampled NTSOs (n=76) and retail locations (n=152) with frequent violations. We calculated the proportion of NTSOs that could have been issued earlier by FDA. We then calculated the proportion of retailers that could have been issued an NTSO, and the proportion actually issued an NTSO using FDA’s approach and a more stringent approach.ResultsAmong NTSOs, 94.7% (95% CI: 89.8% to 97.4%) of NTSOs could have been issued earlier under a more stringent approach. On average, when an NTSO could have been issued earlier, it could have been issued 453 days earlier (95% CI: 418 to 489; range: 89–1159). Among frequently violating retail locations, 73.6% (95% CI: 66.0% to 80.0%) were eligible for an NTSO. Of those, 1.9% (95% CI: 0.5% to 7.0%) had received an NTSO.ConclusionsThe FDA’s failure to fully leverage its powers to address retailers’ underage sales of tobacco products has weakened efforts to curb the youth e-cigarette epidemic.

Migrant and seasonal farmworkers, who are essential workers in the coronavirus global public health emergency, face unique risks to their health as well as longstanding health inequities. This commentary highlights these risks and argues that Internet access represents an underappreciated but critical part of the public health response. The authors first discuss the unique risk farmworkers face. We note the importance of Internet access in the time of physical distancing, the fact that many health outreach workers are no longer visiting camps, the need for telemedicine infrastructure, and the role of Internet access in providing connections to families in communities of origin. We describe existing efforts that have been implemented in North Carolina to raise awareness among public health and health promotion practitioners and researchers. The current coronavirus pandemic demands the attention of medical libraries, public health practitioners, and policy makers to address the digital divide for farmworkers and their families.

BACKGROUND AND OBJECTIVES: A previous single-county study found that retail stores usually asked young-looking tobacco customers to show proof-of-age identification, but a large proportion of illegal tobacco sales to minors occurred after the customers had shown identification proving they were too young to purchase tobacco. We sought to investigate these findings on a larger scale. METHODS: We obtained state reports for federal fiscal years 2017 and 2018 from a federal agency that tracks tobacco sales to supervised minors conducting compliance checks in retail stores. We used descriptive and multivariable logistic regression methods to determine (1) how often stores in 17 states requested identifications, (2) what proportion of violations occurred after identification requests, and (3) if violation rates differed when minors were required versus forbidden to carry identification. RESULTS: Stores asked minors for identification in 79.6% (95% confidence interval: 79.3%–80.8%) of compliance checks (N = 17 276). Violations after identification requests constituted 22.8% (95% confidence interval: 20.0%–25.6%; interstate range, 1.7%–66.2%) of all violations and were nearly 3 times as likely when minors were required to carry identification in compliance checks. Violations were 42% more likely when minors asked for a vaping product versus cigarettes. CONCLUSIONS: Stores that sell tobacco to underage customers are more likely to be detected and penalized when youth inspectors carry identification during undercover tobacco sales compliance checks. The new age-21 tobacco sales requirement presents an opportunity to require identifications be carried and address other long-standing weaknesses in compliance-check protocols to help combat the current adolescent vaping epidemic.

Investigations examining the association between pregaming, or the consumption of alcohol prior to attending a social gathering or drinking establishment, and blood alcohol concentrations have primarily relied on estimations (i.e., Widmark equation), rather than objective biologic samples, such as breath alcohol concentration (BrAC).The current study assessed: (1) pregaming, using quantity-based measures, among a sample of college and non-college affiliated bar patrons, (2) associations between pregaming intensity/status and participant intoxication (BrAC), and (3) whether participants who pregamed were more likely to identify as a hazardous drinker.548 bar patrons provided data on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and a single pregaming item assessing quantity of alcohol consumed prior to visiting a bar/restaurant district in 2015. BrAC samples were collected post interview. We used hierarchical linear regression models, respectively, to assess whether pregaming significantly impacted BrAC and whether presence of hazardous drinking predicted pregaming behavior.After controlling for sex, race/ethnicity, age, student status, and Greek affiliation, the linear regression model explained 32.3% (RFindings further highlight pregaming as a harmful risk behavior linked to elevated levels of hazardous drinking and intoxication.

Background. There are substantial health inequities for lesbian, gay, bisexual, and transgender (LGBT) people compared to their straight/cisgendered counterparts. As evidence of these inequities has become unequivocal, better strategies to address them are needed. One approach is to leverage communications and media advocacy efforts to raise awareness about inequities. However, some research suggests that highlighting health inequities can have negative consequences. This study aimed to explore how LGBT leaders view communication about health inequities. Method. We used an inductive qualitative approach and conducted 12 semistructured phone interviews with LGBT community leaders in North Carolina between September and October 2017. Results. Four themes emerged in the data. There was support for reporting health differences between LGBT and straight/cisgendered people to raise awareness of health issues facing LGBT communities. However, participants were concerned about the stigmatizing effects of messages and worried about their effectiveness. Conclusion. Emphasizing health differences between LGBT and straight people can be problematic; our findings suggest that health educators (1) must be cautious, (2) must be aware of the audience, and (3) should consider focusing messages on finding a solution to the identified problem. Future work should explore how to best craft messages that address health inequities for LGBT communities.

Introduction The purpose of this study is to determine the past-year prevalence estimates of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder based on sexual identity among U.S. adults, and to examine potential variations in these estimates by age, race/ethnicity, and sexual identity–attraction concordance/discordance. Methods The 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions collected data via in-person interviews with a cross-sectional nationally representative sample of non-institutionalized adults (response rate=60.1%) and analyses for the present study were conducted in 2017. Results Any past-year nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder were most prevalent among sexual minority–identified adults compared with heterosexual-identified adults, with notable variations based on sex, age, race/ethnicity, and sexual identity–attraction discordance. Elevated rates of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder among sexual minorities were most prevalent among younger lesbian women and gay men, and all age groups of bisexual men and women. The odds of any nicotine/tobacco use, cigarette smoking, and DSM-5 tobacco use disorder were significantly greater among sexual identity–attraction discordant women and significantly lower among sexual identity–attraction discordant men. Conclusions These findings provide valuable new information about sexual minority subgroups, such as self-identified bisexual older adults and sexual identity–attraction discordant women, that appear to be at higher risk for adverse smoking-related health consequences as a result of their elevated rates of cigarette smoking. Additional attention is warranted to examine these high-risk subpopulations prospectively and, if the results are replicated with larger samples, this information can be used to target smoking-cessation and lung cancer screening efforts.

Introduction Older lesbian, gay, and bisexual (LGB) adults are often neglected in healthcare settings, despite increases in risk behaviors and substance use. The present study assessed drugged driving among older adults in the United States and investigated differences by sexual orientation. Methods The 2015–2019 National Survey on Drug Use and Health data were analyzed among 43,238 adults aged 50 years or older. Associations between drugged driving and demographic information were examined using weighted logistic regression models. Results An estimated 4.82% (n = 2,120) of older adults drove under the influence of alcohol in the past year, 1.33% (n = 619) drove under the influence of marijuana in the past year, and 1.48% (n = 683) drove under the influence of illicit drugs in the past year. Compared to heterosexual counterparts, individuals who identified as a sexual minority were at increased risk for driving under the influence, with individuals who identified as bisexual nearly 4 times more likely to drive under the influence of marijuana (95% CI = 2.39, 6.51) and 4.5 times more likely to drive under the influence of illicit drugs (95% CI = 2.84, 7.08) within the past year. Conclusions Older LGB adults are at increased risk for drugged driving. Harm reduction efforts and behavioral interventions are currently warranted for healthcare improvement.

Purpose In the U.S., tobacco products are now regulated by the Food and Drug Administration (FDA). Litigation has quickly followed. One area of controversy is when a change to the design of the cigarette pack requires approval through FDA's rigorous premarket review process. In this paper, we examine how adult U.S. smokers view the connection between the design of cigarette packs and the characteristics of the cigarettes within. Methods Data for this qualitative study came from six focus groups conducted in March 2017 with adult smokers. Two groups consisted of lesbian, gay, and bisexual (LGB) participants; two groups of participants with less than four years of college education; one group of LGB and straight identity; and, one group of the general population. All groups were selected for regional, gender, and racial/ethnic diversity. Participants (n = 33) represented all nine U.S. Census divisions. We conducted constant comparison qualitative analysis utilizing a grounded theory approach. Results Participants' views reflected a belief that pack design is clearly a reflection of the cigarettes within and that a change in the pack signaled a change in the cigarettes. However, some participants felt price was the salient characteristic of cigarettes and design mattered more for enticing young people to smoke. Conclusions Changes in pack design signal changes to the product for smokers. Pack design and changes to pack design are seen as particularly relevant to new and young smokers. These findings provide support for regulations that require assessment of cigarette pack design changes for impacts on public health.

ObjectiveRetailers that primarily or exclusively sell electronic cigarettes (e-cigarettes) or vaping products represent a new category of tobacco retailer. We sought to identify (a) how vape shops can be identified and (b) sales and marketing practices of vape shops.Data sourcesA medical librarian iteratively developed a search strategy and in February 2017 searched seven academic databases (ABI/INFORM Complete, ECONLit, Embase, Entrepreneurship, PsycINFO, PubMed/MEDLINE and Scopus). We hand searched Tobacco Regulatory Science and Tobacco Prevention & Cessation.Study selectionWe used dual, independent screening. Records were eligible if published in 2010 or later, were peer-reviewed journal articles and focused on vape shops.Data extractionWe used dual, independent data abstraction and assessed risk of bias. Of the 3605 records identified, 22 were included.Data synthesisWe conducted a narrative systematic review. Researchers relied heavily on Yelp to identify vape shops. Vape shop owners use innovative marketing strategies that sometimes diverge from those of traditional tobacco retailers. Vape shop staff believe strongly that their products are effective harm-reduction products. Vape shops were more common in areas with more White residents.ConclusionsVape shops represent a new type of retailer for tobacco products. Vape shops have potential to promote e-cigarettes for smoking cessation but also sometimes provide inaccurate information and mislabelled products. Given their spatial patterning, vape shops may perpetuate inequities in tobacco use. The growing literature on vape shops is complicated by researchers using different definitions of vape shops (eg, exclusively selling e-cigarettes vs also selling traditional tobacco products).

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Increasing the per-unit cost of tobacco products is one of the strongest interventions for tobacco control. In jurisdictions with higher taxes in the U.S., however, cigarette pack litter studies show a substantial proportion of littered packs lack the appropriate tax stamp. More limited but still present counterfeiting also exists. We sought to examine the role of tobacco retailers as a source for untaxed and counterfeit products. Data collectors purchased Newport Green (menthol) or Marlboro Red cigarette packs in a national probability-based sample of tobacco retailers (in 97 counties) from June–October 2012. They made no effort to buy counterfeit or untaxed cigarettes. In this cross-sectional study, we assessed the presence, tax authority, and type (low-tech thermal vs. encrypted) of cigarette pack tax stamps; concordance of tax stamps with where the pack was purchased; and, for Marlboro cigarettes, publicly available visible indicators of counterfeiting. We purchased 2147 packs of which 2033 had tax stamps. Packs missing stamps were in states that do not require them. We found very limited discordance between store location and tax stamp(s) (, Highlights • This study purchased 2147 cigarette packs in 97 U.S. counties. • No clear indicators of cigarette counterfeiting were found. • Virtually all packs had the correct tax stamp affixed. • Inspection protocols for illicit cigarettes should consider real-world behaviors.