Brian A. Primack

Role of video games in improving health-related outcomes: a systematic review.

CONTEXT Video games represent a multibillion-dollar industry in the U.S. Although video gaming has been associated with many negative health consequences, it also may be useful for therapeutic purposes. The goal of this study was to determine whether video games may be useful in improving health outcomes. EVIDENCE ACQUISITION Literature searches were performed in February 2010 in six databases: the Center on Media and Child Health Database of Research, MEDLINE, CINAHL, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials. Reference lists were hand-searched to identify additional studies. Only RCTs that tested the effect of video games on a positive, clinically relevant health consequence were included. Study selection criteria were strictly defined and applied by two researchers working independently. Study background information (e.g., location, funding source); sample data (e.g., number of study participants, demographics); intervention and control details; outcomes data; and quality measures were abstracted independently by two researchers. EVIDENCE SYNTHESIS Of 1452 articles retrieved using the current search strategy, 38 met all criteria for inclusion. Eligible studies used video games to provide physical therapy, psychological therapy, improved disease self-management, health education, distraction from discomfort, increased physical activity, and skills training for clinicians. Among the 38 studies, a total of 195 health outcomes were examined. Video games improved 69% of psychological therapy outcomes, 59% of physical therapy outcomes, 50% of physical activity outcomes, 46% of clinician skills outcomes, 42% of health education outcomes, 42% of pain distraction outcomes, and 37% of disease self-management outcomes. Study quality was generally poor; for example, two thirds (66%) of studies had follow-up periods of <12 weeks, and only 11% of studies blinded researchers. CONCLUSIONS There is potential promise for video games to improve health outcomes, particularly in the areas of psychological therapy and physical therapy. RCTs with appropriate rigor will help build evidence in this emerging area.

Progression to Traditional Cigarette Smoking After Electronic Cigarette Use Among US Adolescents and Young Adults

IMPORTANCE Electronic cigarettes (e-cigarettes) may help smokers reduce the use of traditional combustible cigarettes. However, adolescents and young adults who have never smoked traditional cigarettes are now using e-cigarettes, and these individuals may be at risk for subsequent progression to traditional cigarette smoking. OBJECTIVE To determine whether baseline use of e-cigarettes among nonsmoking and nonsusceptible adolescents and young adults is associated with subsequent progression along an established trajectory to traditional cigarette smoking. DESIGN, SETTING, AND PARTICIPANTS In this longitudinal cohort study, a national US sample of 694 participants aged 16 to 26 years who were never cigarette smokers and were attitudinally nonsusceptible to smoking cigarettes completed baseline surveys from October 1, 2012, to May 1, 2014, regarding smoking in 2012-2013. They were reassessed 1 year later. Analysis was conducted from July 1, 2014, to March 1, 2015. Multinomial logistic regression was used to assess the independent association between baseline e-cigarette use and cigarette smoking, controlling for sex, age, race/ethnicity, maternal educational level, sensation-seeking tendency, parental cigarette smoking, and cigarette smoking among friends. Sensitivity analyses were performed, with varying approaches to missing data and recanting. EXPOSURES Use of e-cigarettes at baseline. MAIN OUTCOMES AND MEASURES Progression to cigarette smoking, defined using 3 specific states along a trajectory: nonsusceptible nonsmokers, susceptible nonsmokers, and smokers. Individuals who could not rule out smoking in the future were defined as susceptible. RESULTS Among the 694 respondents, 374 (53.9%) were female and 531 (76.5%) were non-Hispanic white. At baseline, 16 participants (2.3%) used e-cigarettes. Over the 1-year follow-up, 11 of 16 e-cigarette users and 128 of 678 of those who had not used e-cigarettes (18.9%) progressed toward cigarette smoking. In the primary fully adjusted models, baseline e-cigarette use was independently associated with progression to smoking (adjusted odds ratio [AOR], 8.3; 95% CI, 1.2-58.6) and to susceptibility among nonsmokers (AOR, 8.5; 95% CI, 1.3-57.2). Sensitivity analyses showed consistent results in the level of significance and slightly larger magnitude of AORs. CONCLUSIONS AND RELEVANCE In this national sample of US adolescents and young adults, use of e-cigarettes at baseline was associated with progression to traditional cigarette smoking. These findings support regulations to limit sales and decrease the appeal of e-cigarettes to adolescents and young adults.

Review and special articleRole of Video Games in Improving Health-Related Outcomes: A Systematic Review

CONTEXT Video games represent a multibillion-dollar industry in the U.S. Although video gaming has been associated with many negative health consequences, it also may be useful for therapeutic purposes. The goal of this study was to determine whether video games may be useful in improving health outcomes. EVIDENCE ACQUISITION Literature searches were performed in February 2010 in six databases: the Center on Media and Child Health Database of Research, MEDLINE, CINAHL, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials. Reference lists were hand-searched to identify additional studies. Only RCTs that tested the effect of video games on a positive, clinically relevant health consequence were included. Study selection criteria were strictly defined and applied by two researchers working independently. Study background information (e.g., location, funding source); sample data (e.g., number of study participants, demographics); intervention and control details; outcomes data; and quality measures were abstracted independently by two researchers. EVIDENCE SYNTHESIS Of 1452 articles retrieved using the current search strategy, 38 met all criteria for inclusion. Eligible studies used video games to provide physical therapy, psychological therapy, improved disease self-management, health education, distraction from discomfort, increased physical activity, and skills training for clinicians. Among the 38 studies, a total of 195 health outcomes were examined. Video games improved 69% of psychological therapy outcomes, 59% of physical therapy outcomes, 50% of physical activity outcomes, 46% of clinician skills outcomes, 42% of health education outcomes, 42% of pain distraction outcomes, and 37% of disease self-management outcomes. Study quality was generally poor; for example, two thirds (66%) of studies had follow-up periods of <12 weeks, and only 11% of studies blinded researchers. CONCLUSIONS There is potential promise for video games to improve health outcomes, particularly in the areas of psychological therapy and physical therapy. RCTs with appropriate rigor will help build evidence in this emerging area.

Association Between Media Use in Adolescence and Depression in Young Adulthood: A Longitudinal Study

CONTEXT Although certain media exposures have been linked to the presence of psychiatric conditions, few studies have investigated the association between media exposure and depression. OBJECTIVE To assess the longitudinal association between media exposure in adolescence and depression in young adulthood in a nationally representative sample. DESIGN Longitudinal cohort study. SETTING AND PARTICIPANTS We used the National Longitudinal Survey of Adolescent Health (Add Health) to investigate the relationship between electronic media exposure in 4142 adolescents who were not depressed at baseline and subsequent development of depression after 7 years of follow-up. Main Outcome Measure Depression at follow-up assessed using the 9-item Center for Epidemiologic Studies-Depression Scale. RESULTS Of the 4142 participants (47.5% female and 67.0% white) who were not depressed at baseline and who underwent follow-up assessment, 308 (7.4%) reported symptoms consistent with depression at follow-up. Controlling for all covariates including baseline Center for Epidemiologic Studies-Depression Scale score, those reporting more television use had significantly greater odds of developing depression (odds ratio [95% confidence interval], 1.08 [1.01-1.16]) for each additional hour of daily television use. In addition, those reporting more total media exposure had significantly greater odds of developing depression (1.05 [1.0004-1.10]) for each additional hour of daily use. We did not find a consistent relationship between development of depressive symptoms and exposure to videocassettes, computer games, or radio. Compared with young men, young women were less likely to develop depression given the same total media exposure (odds ratio for interaction term, 0.93 [0.88-0.99]). CONCLUSION Television exposure and total media exposure in adolescence are associated with increased odds of depressive symptoms in young adulthood, especially in young men.

Waterpipe Smoking Among U.S. University Students

INTRODUCTION While cigarette use is declining, smoking tobacco with a waterpipe is an emerging trend. We aimed to determine the prevalence of waterpipe use in a large diverse sample of U.S. university students and to assess the association of waterpipe use with individual and institution-related characteristics. METHODS We assessed students from 152 U.S. universities participating in the National College Health Assessment during 2008-2009. We used multivariable regression models to determine independent associations between individual and institutional characteristics and waterpipe tobacco use in the past 30 days and ever. RESULTS Of 105,012 respondents included in the analysis, most were female (65.7%), White (71.2%), and attending public (59.7%) nonreligious (83.1%) institutions. Mean age was 22.1 years. A total of 32,013 (30.5%) reported ever using a waterpipe to smoke tobacco. Rates for current tobacco use were 8.4% for waterpipes, 16.8% for cigarettes, 7.4% for cigars (including cigarillos), and 3.5% for smokeless tobacco. Of current waterpipe users, 51.4% were not current cigarette smokers. Although current waterpipe use was reported across all individual and institutional characteristics, fully adjusted multivariable models showed that it was most strongly associated with younger age, male gender, White race, fraternity/sorority membership, and nonreligious institutions in large cities in the western United States. CONCLUSIONS After cigarettes, waterpipe use was the most common form of tobacco use among university students. Because waterpipe use affects groups with a wide variety of individual and institutional characteristics, it should be included with other forms of tobacco in efforts related to tobacco surveillance and intervention.

Water-pipe tobacco smoking among middle and high school students in arizona

BACKGROUND. Using a water pipe to smoke tobacco is increasing in prevalence among US college students, and it may also be common among younger adolescents. The purpose of this study of Arizona middle and high school students was to examine the prevalence of water-pipe tobacco smoking, compare water-pipe tobacco smoking with other forms of tobacco use, and determine associations between sociodemographic variables and water-pipe tobacco smoking in this population. METHODS. We added items assessing water-pipe tobacco smoking to Arizonas 2005 Youth Tobacco Survey and used them to estimate statewide water-pipe tobacco smoking prevalence among various demographic groups by using survey weights. We also used multiple logistic regression to determine which demographic characteristics had independent relationships with each of 2 outcomes: ever use of water pipe to smoke tobacco and water-pipe tobacco smoking in the previous 30 days. RESULTS. Median age of the sample was 14. Accounting for survey weights, among middle school students, 2.1% had ever smoked water-pipe tobacco and 1.4% had done so within the previous 30 days. Among those in high school, 10.3% had ever smoked from a water pipe and 5.4% had done so in the previous 30 days, making water-pipe tobacco smoking more common than use of smokeless tobacco, pipes, bidis, and kreteks (clove cigarettes). In multivariate analyses that controlled for covariates, ever smoking of water-pipe tobacco was associated with older age, Asian race, white race, charter school attendance, and lack of plans to attend college. CONCLUSIONS. Among Arizona youth, water pipe is the third most common source of tobacco after cigarettes and cigars. Increased national surveillance and additional research will be important for addressing this threat to public health.

Association Between Initial Use of e-Cigarettes and Subsequent Cigarette Smoking Among Adolescents and Young Adults: A Systematic Review and Meta-analysis

Importance The public health implications of e-cigarettes depend, in part, on whether e-cigarette use affects the risk of cigarette smoking. Objective To perform a systematic review and meta-analysis of longitudinal studies that assessed initial use of e-cigarettes and subsequent cigarette smoking. Data Sources PubMed, EMBASE, Cochrane Library, Web of Science, the 2016 Society for Research on Nicotine and Tobacco 22nd Annual Meeting abstracts, the 2016 Society of Behavioral Medicine 37th Annual Meeting & Scientific Sessions abstracts, and the 2016 National Institutes of Health Tobacco Regulatory Science Program Conference were searched between February 7 and February 17, 2017. The search included indexed terms and text words to capture concepts associated with e-cigarettes and traditional cigarettes in articles published from database inception to the date of the search. Study Selection Longitudinal studies reporting odds ratios for cigarette smoking initiation associated with ever use of e-cigarettes or past 30-day cigarette smoking associated with past 30-day e-cigarette use. Searches yielded 6959 unique studies, of which 9 met inclusion criteria (comprising 17 389 adolescents and young adults). Data Extraction and Synthesis Study quality and risk of bias were assessed using the Newcastle-Ottawa Scale and the Risk of Bias in Non-randomized Studies of Interventions tool, respectively. Data and estimates were pooled using random-effects meta-analysis. Main Outcomes and Measures Among baseline never cigarette smokers, cigarette smoking initiation between baseline and follow-up. Among baseline non–past 30-day cigarette smokers who were past 30-day e-cigarette users, past 30-day cigarette smoking at follow-up. Results Among 17 389 adolescents and young adults, the ages ranged between 14 and 30 years at baseline, and 56.0% were female. The pooled probabilities of cigarette smoking initiation were 30.4% for baseline ever e-cigarette users and 7.9% for baseline never e-cigarette users. The pooled probabilities of past 30-day cigarette smoking at follow-up were 21.5% for baseline past 30-day e-cigarette users and 4.6% for baseline non–past 30-day e-cigarette users. Adjusting for known demographic, psychosocial, and behavioral risk factors for cigarette smoking, the pooled odds ratio for subsequent cigarette smoking initiation was 3.62 (95% CI, 2.42-5.41) for ever vs never e-cigarette users, and the pooled odds ratio for past 30-day cigarette smoking at follow-up was 4.28 (95% CI, 2.52-7.27) for past 30-day e-cigarette vs non–past 30-day e-cigarette users at baseline. A moderate level of heterogeneity was observed among studies (I2 = 60.1%). Conclusions and Relevance e-Cigarette use was associated with greater risk for subsequent cigarette smoking initiation and past 30-day cigarette smoking. Strong e-cigarette regulation could potentially curb use among youth and possibly limit the future population-level burden of cigarette smoking.

Content Analysis of Tobacco, Alcohol, and Other Drugs in Popular Music

OBJECTIVE To perform a comprehensive content analysis of substance use in contemporary popular music. DESIGN We analyzed the 279 most popular songs of 2005 according to Billboard magazine. Two coders working independently used a standardized data collection instrument to code portrayals of substance use. OUTCOME MEASURES Presence and explicit use of substances and motivations for, associations with, and consequences of substance use. RESULTS Of the 279 songs, 93 (33.3%) portrayed substance use, with an average of 35.2 substance references per song-hour. Portrayal of substance use varied significantly (P < .001) by genre, with 1 or more references in 3 of 35 pop songs (9%), 9 of 66 rock songs (14%), 11 of 55 R & B/hip-hop songs (20%), 22 of 61 country songs (36%), and 48 of 62 rap songs (77%). While only 2.9% of the 279 songs portrayed tobacco use, 23.7% depicted alcohol use, 13.6% depicted marijuana use, and 11.5% depicted other or unspecified substance use. In the 93 songs with substance use, it was most often motivated by peer/social pressure (45 [48%]) or sex (28 [30%]); use was commonly associated with partying (50 [54%]), sex (43 [46%]), violence (27 [29%]), and/or humor (22 [24%]). Only 4 songs (4%) contained explicit antiuse messages, and none portrayed substance refusal. Most songs with substance use (63 [68%]) portrayed more positive than negative consequences; these positive consequences were most commonly social, sexual, financial, or emotional. CONCLUSIONS The average adolescent is exposed to approximately 84 references to explicit substance use daily in popular songs, and this exposure varies widely by musical genre. The substance use depicted in popular music is frequently motivated by peer acceptance and sex, and it has highly positive associations and consequences.

Waterpipe and Cigarette Smoking Among College Athletes in the United States

PURPOSE Tobacco use using a waterpipe is an emerging trend among college students. Although cigarette smoking is low among college athletes, waterpipe tobacco smoking may appeal to this population. The purpose of this study was to compare cigarette and waterpipe tobacco smoking in terms of their associations with organized sport participation. METHODS In the spring of 2008, we conducted an online survey of 8,745 college students at eight institutions as part of the revised National College Health Assessment. We used multivariable regression models to assess the associations between tobacco use (cigarette and waterpipe) and organized sports participation. RESULTS Participants reported participation in varsity (5.2%), club (11.9%), and intramural (24.9%) athletics. Varsity athletes and individuals who were not varsity athletes had similar rates of waterpipe tobacco smoking (27.6% vs. 29.5%, p=.41). However, other types of athletes were more likely than their counterparts to have smoked waterpipe tobacco (35.1% vs. 28.7%, p < .001 for club sports and 34.8% vs. 27.7%, p < .001 for intramural sports). In fully-adjusted multivariable models, sports participants of any type had lower odds of having smoked cigarettes, whereas participants who played intramural sports (odds ratio=1.15, 95% confidence interval=1.03, 1.29) or club sports (odds ratio=1.15, 95% confidence interval=1.001, 1.33) had significantly higher odds of having smoked waterpipe tobacco. CONCLUSIONS College athletes are susceptible to waterpipe tobacco use. In fact, compared with their nonathletic counterparts, club sports participants and intramural sports participants generally had higher odds of waterpipe tobacco smoking. Allure for waterpipe tobacco smoking may exist even for individuals who are traditionally considered at low risk for tobacco use.

Exploring successful community pharmacist-physician collaborative working relationships using mixed methods

BACKGROUND Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration. OBJECTIVE To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration. METHODS A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification. RESULTS On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential. CONCLUSIONS The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.