Jennifer M. Kreslake

Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults.

OBJECTIVES We examined whether tobacco manufacturers manipulate the menthol content of cigarettes in an effort to target adolescents and young adults. METHODS We analyzed data from tobacco industry documents describing menthol product development, results of laboratory testing of US menthol brands, market research reports, and the 2006 National Survey on Drug Use and Health. RESULTS The tobacco industry attracted new smokers by promoting cigarettes with lower menthol content, which were popular with adolescents and young adults, and provided cigarettes with higher menthol content to long-term smokers. Menthol cigarette sales remained stable from 2000 to 2005 in the United States, despite a 22% decline in overall packs sold. CONCLUSIONS Tobacco companies manipulate the sensory characteristics of cigarettes, including menthol content, thereby facilitating smoking initiation and nicotine dependence. Menthol brands that have used this strategy have been the most successful in attracting youth and young adult smokers and have grown in popularity.

Marketing Little Cigars and Cigarillos: Advertising, Price, and Associations With Neighborhood Demographics

OBJECTIVES We have documented little cigar and cigarillo (LCC) availability, advertising, and price in the point-of-sale environment and examined associations with neighborhood demographics. METHODS We used a multimodal real-time surveillance system to survey LCCs in 750 licensed tobacco retail outlets that sold tobacco products in Washington, DC. Using multivariate models, we examined the odds of LCC availability, the number of storefront exterior advertisements, and the price per cigarillo for Black & Mild packs in relation to neighborhood demographics. RESULTS The odds of LCC availability and price per cigarillo decreased significantly in nearly a dose-response manner with each quartile increase in proportion of African Americans. Prices were also lower in some young adult neighborhoods. Having a higher proportion of African American and young adult residents was associated with more exterior LCC advertising. CONCLUSIONS Higher availability of LCCs in African American communities and lower prices and greater outdoor advertising in minority and young adult neighborhoods may establish environmental triggers to smoke among groups susceptible to initiation, addiction, and long-term negative health consequences.

Role of cigarette sensory cues in modifying puffing topography

BACKGROUND Human puffing topography promotes tobacco dependence by ensuring nicotine delivery, but the factors that determine puffing behavior are not well explained by existing models. Chemosensory cues generated by variations in cigarette product design features may serve as conditioned cues to allow the smoker to optimize nicotine delivery by adjusting puffing topography. Internal tobacco industry research documents were reviewed to understand the influence of sensory cues on puffing topography, and to examine how the tobacco industry has designed cigarettes, including modified risk tobacco products (MRTPs), to enhance puffing behavior to optimize nicotine delivery and product acceptability. METHODS Relevant internal tobacco industry documents were identified using systematic searching with key search terms and phrases, and then snowball sampling method was applied to establish further search terms. RESULTS Modern cigarettes are designed by cigarette manufacturers to provide sensory characteristics that not only maintain appeal, but provide cues which inform puffing intensity. Alterations in the chemosensory cues provided in tobacco smoke play an important role in modifying smoking behavior independently of the central effects of nicotine. CONCLUSIONS An associative learning model is proposed to explain the influence of chemosensory cues on variation in puffing topography. These cues are delivered via tobacco smoke and are moderated by design features and additives used in cigarettes. The implications for regulation of design features of modified risk tobacco products, which may act to promote intensive puffing while lowering risk perceptions, are discussed.

Methods Used in Internal Industry Clinical Trials to Assess Tobacco Risk Reduction

Objective: Methods to assess reduced exposure products should include those that aid in determining likely patterns of human use and exposure. Tobacco industry clinical trial methods may provide insight into strategies to assess potential reduced exposure products (PREP) for public health purposes. Internal tobacco industry documents detailing human clinical research with PREPs were examined to document major research strategies used and identify potentially fruitful methods not currently used in the mainstream arena. Methods: Primary data were obtained from records of research conducted internally by tobacco companies and affiliated researchers, and included manuscript drafts, presentations, protocols, and instruments relating to internal clinical trials of human tobacco use and exposure. Results: Tobacco industry clinical research has focused on reduced exposure products, most notably Premier, Accord, and Eclipse. The most widely used strategy observed is switching studies, and details of study designs and protocols favored by the industry are described. Key measures include biomarkers of exposure (e.g., cotinine, CO, and specific carcinogens) and acute health effects such as physical health and fitness. Conclusions: Tobacco industry clinical research has used relatively standard switching study methods, but with a broad set of measures. Clinical switching studies have been conducted by the industry primarily to support existing claims or to develop new claims. Knowledge of prior industry activity can guide and inform future public health research efforts. Although industry clinical trial methods are comparable with current mainstream methods, limited information about the validity of outcome measures used limits their viability for immediate adoption in mainstream science. (Cancer Epidemiol Biomarkers Prev 2009;18(12):3196–208)

Implementation of a Multimodal Mobile System for Point-of-Sale Surveillance: Lessons Learned From Case Studies in Washington, DC, and New York City

Background In tobacco control and other fields, point-of-sale surveillance of the retail environment is critical for understanding industry marketing of products and informing public health practice. Innovations in mobile technology can improve existing, paper-based surveillance methods, yet few studies describe in detail how to operationalize the use of technology in public health surveillance. Objective The aims of this paper are to share implementation strategies and lessons learned from 2 tobacco, point-of-sale surveillance projects to inform and prepare public health researchers and practitioners to implement new mobile technologies in retail point-of-sale surveillance systems. Methods From 2011 to 2013, 2 point-of-sale surveillance pilot projects were conducted in Washington, DC, and New York, New York, to capture information about the tobacco retail environment and test the feasibility of a multimodal mobile data collection system, which included capabilities for audio or video recording data, electronic photographs, electronic location data, and a centralized back-end server and dashboard. We established a preimplementation field testing process for both projects, which involved a series of rapid and iterative tests to inform decisions and establish protocols around key components of the project. Results Important components of field testing included choosing a mobile phone that met project criteria, establishing an efficient workflow and accessible user interfaces for each component of the system, training and providing technical support to fieldworkers, and developing processes to integrate data from multiple sources into back-end systems that can be utilized in real-time. Conclusions A well-planned implementation process is critical for successful use and performance of multimodal mobile surveillance systems. Guidelines for implementation include (1) the need to establish and allow time for an iterative testing framework for resolving technical and logistical challenges; (2) developing a streamlined workflow and user-friendly interfaces for data collection; (3) allowing for ongoing communication, feedback, and technology-related skill-building among all staff; and (4) supporting infrastructure for back-end data systems. Although mobile technologies are evolving rapidly, lessons learned from these case studies are essential for ensuring that the many benefits of new mobile systems for rapid point-of-sale surveillance are fully realized.

Cigarette price variation around high schools: evidence from Washington DC.

This study examines lowest cigarette prices in all tobacco retail outlets in Washington D.C. (n=750) in relation to the type and number of high schools nearby, controlling for confounders. The lowest overall and Newport menthol prices were significantly lower at outlets near public non-charter and charter schools compared with outlets near private schools. Given higher smoking prevalence and more price-sensitive youth subgroups in U.S. public schools, exposure to low prices may contribute to tobacco-related health disparities in minority and low-income populations. Tobacco taxes combined with policies to minimize the increasing use of price as a marketing tool are critical.

Healthcare-seeking behaviors for acute respiratory illness in two communities of Java, Indonesia: a cross-sectional survey.

Understanding healthcare-seeking patterns for respiratory illness can help improve estimations of disease burden and inform public health interventions to control acute respiratory disease in Indonesia. The objectives of this study were to describe healthcare-seeking behaviors for respiratory illnesses in one rural and one urban community in Western Java, and to explore the factors that affect care seeking. From February 8, 2012 to March 1, 2012, a survey was conducted in 2520 households in the East Jakarta and Bogor districts to identify reported recent respiratory illnesses, as well as all hospitalizations from the previous 12-month period. We found that 4% (10% of those less than 5 years) of people had respiratory disease resulting in a visit to a healthcare provider in the past 2 weeks; these episodes were most commonly treated at government (33%) or private (44%) clinics. Forty-five people (0.4% of those surveyed) had respiratory hospitalizations in the past year, and just over half of these (24/45, 53%) occurred at a public hospital. Public health programs targeting respiratory disease in this region should account for care at private hospitals and clinics, as well as illnesses that are treated at home, in order to capture the true burden of illness in these communities.

The Intersection of Care Seeking and Clinical Capacity for Patients With Highly Pathogenic Avian Influenza A (H5N1) Virus in Indonesia: Knowledge and Treatment Practices of the Public and Physicians

BACKGROUND Indonesia has the highest human mortality from highly pathogenic avian influenza (HPAI) A (H5N1) virus infection in the world. METHODS A survey of households (N=2520) measured treatment sources and beliefs among symptomatic household members. A survey of physicians (N=554) in various types of health care facilities measured knowledge, assessment and testing behaviors, and perceived clinical capacity. RESULTS Households reported confidence in health care system capacity but infrequently sought treatment for potential HPAI H5N1 signs/symptoms. More clinicians were confident in their knowledge of diagnosis and treatment than in the adequacy of related equipment and resources at their facilities. Physicians expressed awareness of the HPAI H5N1 suspect case definition, yet expressed only moderate knowledge in questioning symptomatic patients about exposures. Self-reported likelihood of testing for HPAI H5N1 virus was high after learning of certain exposures. Knowledge of antiviral treatment was moderate, but it was higher among clinicians in puskesmas. Physicians in private outpatient clinics, the most heavily used facilities, reported the lowest confidence in their diagnostic and treatment capabilities. CONCLUSIONS Educational campaigns can encourage recall of possible poultry exposure when patients are experiencing signs/symptoms and can raise awareness of the effectiveness of antivirals to drive people to seek health care. Clinicians may benefit from training regarding exposure assessment and referral procedures, particularly in private clinics. (Disaster Med Public Health Preparedness. 2016;10:838-847).

Physician's knowledge, attitudes, and practices regarding seasonal influenza, pandemic influenza, and highly pathogenic avian influenza A (H5N1) virus infections of humans in Indonesia

Indonesia has reported highest number of fatal human cases of highly pathogenic avian influenza (HPAI) A (H5N1) virus infection worldwide since 2005. There are limited data available on seasonal and pandemic influenza in Indonesia. During 2012, we conducted a survey of clinicians in two districts in western Java, Indonesia, to assess knowledge, attitudes, and practices (KAP) of clinical diagnosis, testing, and treatment of patients with seasonal influenza, pandemic influenza, or HPAI H5N1 virus infections. Overall, a very low percentage of physician participants reported ever diagnosing hospitalized patients with seasonal, pandemic, or HPAI H5N1 influenza. Use of influenza testing was low in outpatients and hospitalized patients, and use of antiviral treatment was very low for clinically diagnosed influenza patients. Further research is needed to explore health system barriers for influenza diagnostic testing and availability of antivirals for treatment of influenza in Indonesia.

Cantrell et al. Respond

We thank Sheehan for her comments. We are aware of the known correlation between racial segregation and neighborhood-level socioeconomic status (SES). However, the high correlation between these two measures can make it challenging to implement the analyses strategies recommended. A strong relationship between the two potential predictors can make their independent effects unidentifiable in regression analyses that include both.1 The ability to detect moderation effects is also limited because sparse data are often found in cross-tabulated categories (i.e., high African American and high SES). These issues are not always adequately addressed in published neighborhood studies. The 2010 American Community Survey census data demonstrated significant correlations between measures of block group-level SES (income, unemployment, education) and percentage of African Americans in the Washington, DC communities where outlets are based. Correlations ranged from 0.6 to 0.9, making it nearly impossible to separately evaluate whether point-of-sale (POS) tobacco marketing strategies were targeted based on SES status or the racial/ethnic composition of communities. Further, Short Form 1 census data, which were the data available for this study, did not include measures of SES at the block group.2 Finally, growing evidence suggests that cigar use is high among African American youths3,4 and adults.5 Accordingly, we focused our analysis on block group racial/ethnic demographic characteristics and did not include highly correlated SES measures. The previous literature on POS marketing has found both neighborhood-level minority composition and low SES to be associated with tobacco advertising.6–9 Yet again, many of these analyses were unable to unpack the separate influence of the two factors. This is a limitation of our study and similar studies in areas where community race/ethnicity and SES are highly correlated. Nonetheless, these patterns clearly indicate higher availability and advertising of little cigars and cigarillos (LCCs) in areas with high concentrations of African Americans, which also tend to be low SES communities. We appreciate Sheehan’s discussion of additional community structural characteristics. As she correctly notes, the lower availability of prevention programs and services found in African American communities may influence tobacco use. However, we obtained data and conducted analyses only on POS tobacco marketing and census demographics; thus, we refrained from making policy recommendations based on data that were not part of the study. We agree that neighborhood-level structural factors are likely critical in understanding LCC initiation, addiction, and cessation.10 We encourage researchers and policymakers to consider these factors when developing interventions and policies related to LCC use.