Mary V. Carroll

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.

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.

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.

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.

A comparison of cigarette- and hookah-related videos on YouTube

Objective YouTube is now the second most visited site on the internet. The authors aimed to compare characteristics of and messages conveyed by cigarette- and hookah-related videos on YouTube. Methods Systematic search procedures yielded 66 cigarette-related and 61 hookah-related videos. After three trained qualitative researchers used an iterative approach to develop and refine definitions for the coding of variables, two of them independently coded each video for content including positive and negative associations with smoking and major content type. Results Median view counts were 606 884 for cigarettes-related videos and 102 307 for hookah-related videos (p<0.001). However, the number of comments per 1000 views was significantly lower for cigarette-related videos than for hookah-related videos (1.6 vs 2.5, p=0.003). There was no significant difference in the number of ‘like’ designations per 100 reactions (91 vs 87, p=0.39). Cigarette-related videos were less likely than hookah-related videos to portray tobacco use in a positive light (24% vs 92%, p<0.001). In addition, cigarette-related videos were more likely to be of high production quality (42% vs 5%, p<0.001), to mention short-term consequences (50% vs 18%, p<0.001) and long-term consequences (44% vs 2%, p<0.001) of tobacco use, to contain explicit antismoking messages (39% vs 0%, p<0.001) and to provide specific information on how to quit tobacco use (21% vs 0%, p<0.001). Conclusions Although internet user-generated videos related to cigarette smoking often acknowledge harmful consequences and provide explicit antismoking messages, hookah-related videos do not. It may be valuable for public health programmes to correct common misconceptions regarding hookah use.

US health policy related to hookah tobacco smoking.

A hookah, also known as a water pipe, consists of a head, body, bowl, and hose. Moist, sweetened, flavored tobacco is placed in the head, and lit charcoal is placed on it. Users inhale through the mouthpiece, drawing smoke through the hookah. This practice is associated with substantial inhalation of smoke. For example, the World Health Organization1 has estimated that a hookah smoker may inhale as much smoke during 1 standard hookah tobacco smoking (HTS) session as a cigarette smoker would from 100 cigarettes. Other studies have suggested that, compared with a single cigarette, 1 hookah smoking session may expose the user to more inhaled tar, carbon monoxide, nicotine, and polycyclic aromatic hydrocarbons.1–5 In vivo studies have shown HTS to be associated with plasma nicotine concentrations comparable to those seen with cigarette smoking and increases in carbon monoxide levels that are much higher than those typically observed with cigarette smoking.6 Secondhand smoke exposure from a hookah may also be a concern. Although more study is needed, a published report7 has suggested that expired air from nonsmokers in a hookah tobacco cafe had a higher concentration of carbon monoxide than expired air from nonsmokers in a regular bar allowing cigarette smoking. The increase in HTS in the United States8–13 has coincided with a decrease in the rate of cigarette smoking to its lowest level in nearly 60 years.14,15 The rate of HTS is highest among young people, with 30% of college students having ever used and 10% having used in the past 30 days, making HTS nearly as common as cigarette use.8,9,11,16 The rate of HTS has also increased substantially among high school students and noncollege populations,10,13,17 and it is popular across gender, age, race, geographic location, and socioeconomic status.9,11,16,18 Although some hookah users also smoke cigarettes, as many as half of users would have otherwise been naive to nicotine.12,13 Clean air policies have successfully curbed cigarette smoking in certain regions of the United States. As of July 1, 2011, 35 states and thousands of local municipalities had passed smoke-free laws. Whether HTS is affected by laws such as these or whether provisions included in these laws may have intentionally or unintentionally exempted HTS is, however, not known.19,20 Because of the importance of HTS establishments in promoting use of these products, these exemptions are likely to contribute to the prevalence of HTS.15,16 Thus, a systematic assessment of extant clean air laws, with special attention paid to implications for HTS, would be valuable. Moreover, determining what community factors are associated with HTS policy status may be valuable; this information may ultimately help focus interventions on communities in which the need is greatest. The purposes of this study were to assess how a representative sample of US tobacco control policies may apply to HTS and to determine associations between community-level sociodemographic factors and HTS policy status.

U.S. Hookah Tobacco Smoking Establishments Advertised on the Internet

BACKGROUND Establishments dedicated to hookah tobacco smoking recently have proliferated and helped introduce hookah use to U.S. communities. PURPOSE To conduct a comprehensive, qualitative assessment of websites promoting these establishments. METHODS In June 2009, a systematic search process was initiated to access the universe of websites representing major hookah tobacco smoking establishments. In 2009-2010, codebook development followed an iterative paradigm involving three researchers and resulted in a final codebook consisting of 36 codes within eight categories. After two independent coders had nearly perfect agreement (Cohens κ = 0.93) on double-coding the data in the first 20% of sites, the coders divided the remaining sites and coded them independently. A thematic approach to the synthesis of findings and selection of exemplary quotations was used. RESULTS The search yielded a sample of 144 websites originating from states in all U.S. regions. Among the hookah establishments promoted on the websites, 79% served food and 41% served alcohol. Of the websites, none required age verification, <1% included a tobacco-related warning on the first page, and 4% included a warning on any page. Although mention of the word tobacco was relatively uncommon (appearing on the first page of only 26% sites and on any page of 58% of sites), the promotion of flavorings, pleasure, relaxation, product quality, and cultural and social aspects of hookah smoking was common. CONCLUSIONS Websites may play a role in enhancing or propagating misinformation related to hookah tobacco smoking. Health education and policy measures may be valuable in countering this misinformation.

Waterpipe tobacco and cigarette smoking among university students in Jordan.

SETTING While waterpipe and cigarette smoking have been well studied in Syria and Lebanon, data from Jordan are limited. OBJECTIVES To characterize the relative prevalence of waterpipe tobacco and cigarette smoking among university students in Jordan, and to compare the demographic and environmental factors associated with each form of tobacco use. DESIGN We surveyed 1845 students randomly recruited from four universities in Jordan. We used multivariable logistic regression controlling for clustering of individuals within universities to determine associations between demographic and environmental covariates and waterpipe tobacco and cigarette use. RESULTS Waterpipe tobacco smoking rates were 30% in the past 30 days and 56% ever, while cigarette smoking rates were 29% in the past 30 days and 57% ever. Past 30-day waterpipe tobacco smoking rates were 59% for males and 13% for females. Females had substantially lower odds than males of being current waterpipe (OR 0.12, 95%CI 0.10-0.15) or cigarette (OR 0.08, 95%CI 0.05-0.14) smokers. Current cigarette smoking was more significantly associated with markers of high socio-economic status (SES) than waterpipe tobacco smoking. CONCLUSION Waterpipe tobacco smoking is as common as cigarette smoking among Jordanian university students. While cigarette smoking is consistently associated with high SES, waterpipe tobacco smoking is more evenly distributed across various populations.

Associations Between Smoking and Media Literacy in College Students

Organizations recommend media literacy to reduce tobacco use, and higher media literacy has been associated with lower smoking among high school students. The relationship between smoking media literacy and tobacco use, however, has not been systematically studied among college students. The purpose of this study was to determine the association between smoking and smoking media literacy among college students. We conducted the National College Health Assessment (NCHA) at a large, urban university, adding six items measuring smoking media literacy. A total of 657 students responded to this random sample e-mail survey. We used multiple logistic regression to determine independent associations between smoking media literacy items and current smoking. The media literacy scale was internally consistent (α = 0.79). Of the respondents, 21.5% reported smoking cigarettes over the past 30 days. In a fully adjusted multivariate model, participants with medium media literacy had an odds ratio (OR) for current smoking of 0.45 (95% CI = 0.29, 0.70), and those with high media literacy had an OR for current smoking of 0.38 (95% CI = 0.20, 0.70). High smoking media literacy is independently associated with lower odds of smoking. Smoking media literacy may be a valuable construct to address in college populations.

Systematic Review and Meta-Analysis of Inhaled Toxicants from Waterpipe and Cigarette Smoking

Objective. Waterpipe tobacco smoking (WTS) is an emerging trend worldwide. To inform public health policy and educational programming, we systematically reviewed the biomedical literature to compute the inhaled smoke volume, nicotine, tar, and carbon monoxide (CO) associated with a single WTS session and a single cigarette. Methods. We searched seven biomedical bibliographic databases for controlled laboratory or natural environment studies designed to mimic human tobacco consumption. Included studies quantified the mainstream smoke of a single cigarette and/or single WTS session for smoke volume, nicotine, tar, and/or CO. We conducted meta-analyses to calculate summary estimates for the inhalation of each unique substance for each mode of tobacco consumption. We assessed between-study heterogeneity using chi-squared and I-squared statistics. Results. Sufficient data from 17 studies were available to derive pooled estimates for inhalation of each exposure via each smoking method. Two researchers working independently abstracted measurement of smoke volume in liters, and nicotine, tar, and CO in milligrams. All numbers included in meta-analyses matched precisely between the two researchers (100% agreement, Cohens κ=1.00). Whereas one WTS session was associated with 74.1 liters of smoke inhalation (95% confidence interval [CI] 38.2, 110.0), one cigarette was associated with 0.6 liters of smoke (95% CI 0.5, 0.7). One WTS session was also associated with higher levels of nicotine, tar, and CO. Conclusions. One WTS session consistently exposed users to larger smoke volumes and higher levels of tobacco toxicants compared with one cigarette. These computed estimates may be valuable to emphasize in prevention programming.