Rebecca S. Williams

A systematic review of measures used in studies of human papillomavirus (HPV) vaccine acceptability

BACKGROUND The recent proliferation of studies describing factors associated with HPV vaccine acceptability could inform health care providers in improving vaccine coverage and support future research. This review examined measures of HPV and HPV-vaccine knowledge, attitudes, beliefs and acceptability, described psychometric characteristics, and provided recommendations about their use. METHODS A systematic search of Medline, CINAHL, PsychoInfo, and ERIC through May 2008 for English language reports of quantitative data from parents, young adults or adolescents yielded 79 studies. RESULTS The majority of studies were cross-sectional surveys (87%), self-administered (67%), conducted before prophylactic vaccines were publicly available (67%) and utilized convenience samples (65%). Most measured knowledge (80%), general attitudes about HPV vaccination (40%), and willingness to vaccinate ones daughter (26%). Two-thirds did not report reliability or validity of measures. The majority did not specify a theoretical framework. CONCLUSIONS Use of a theoretical framework, consistent labeling of constructs, more rigorous validation of measures, and testing of measures in more diverse samples are needed to yield measurement instruments that will produce findings to guide practitioners in developing successful community and clinical interventions.

Web sites selling cigarettes: how many are there in the USA and what are their sales practices?

OBJECTIVES To estimate the number and geographic location of web sites selling cigarettes in the USA, and to examine their sales and marketing practices. METHODS Comprehensive searches were conducted using four keyword terms and five popular internet search engines, supplemented by sites identified in a news article. Over 1800 sites were examined to identify 88 internet cigarette vendors. MEASURES Trained raters examined the content of each site using a standardised coding instrument to assess geographic location, presence of warnings, products sold, and promotional strategies. SETTING USA. RESULTS Internet cigarette vendors were located in 23 states. Nearly half (n = 43) were located in New York state, and many were in tobacco producing states with low cigarette excise taxes. Indian reservations housed 49 of the 88 sites. Only 28.4% of sites featured the US Surgeon Generals health warnings and 81.8% featured minimum age of sale warnings. Nearly all sites (96.6%) sold premium or value brand cigarettes, 21.6% sold duty-free Marlboros, and 8.0% sold bidis. Approximately one third featured special promotional programmes. CONCLUSIONS Internet cigarette vendors present new regulatory and enforcement challenges for tobacco control advocates because of the difficulty in regulating internet content and because many vendors are on Indian reservations.

Electronic Cigarette Sales to Minors via the Internet

IMPORTANCE Electronic cigarettes (e-cigarettes) entered the US market in 2007 and, with little regulatory oversight, grew into a

Cancer control planners' perceptions and use of evidence-based programs.

2-billion-a-year industry by 2013. The Centers for Disease Control and Prevention has reported a trend of increasing e-cigarette use among teens, with use rates doubling from 2011 to 2012. While several studies have documented that teens can and do buy cigarettes online, to our knowledge, no studies have yet examined age verification among Internet tobacco vendors selling e-cigarettes. OBJECTIVE To estimate the extent to which minors can successfully purchase e-cigarettes online and assess compliance with North Carolinas 2013 e-cigarette age-verification law. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study conducted from February 2014 to June 2014, 11 nonsmoking minors aged 14 to 17 years made supervised e-cigarette purchase attempts from 98 Internet e-cigarette vendors. Purchase attempts were made at the University of North Carolina Internet Tobacco Vendors Study project offices using credit cards. MAIN OUTCOME AND MEASURE Rate at which minors can successfully purchase e-cigarettes on the Internet. RESULTS Minors successfully received deliveries of e-cigarettes from 76.5% of purchase attempts, with no attempts by delivery companies to verify their ages at delivery and 95% of delivered orders simply left at the door. All delivered packages came from shipping companies that, according to company policy or federal regulation, do not ship cigarettes to consumers. Of the total orders, 18 failed for reasons unrelated to age verification. Only 5 of the remaining 80 youth purchase attempts were rejected owing to age verification, resulting in a youth buy rate of 93.7%. None of the vendors complied with North Carolinas e-cigarette age-verification law. CONCLUSIONS AND RELEVANCE Minors are easily able to purchase e-cigarettes from the Internet because of an absence of age-verification measures used by Internet e-cigarette vendors. Federal law should require and enforce rigorous age verification for all e-cigarette sales as with the federal PACT (Prevent All Cigarette Trafficking) Acts requirements for age verification in Internet cigarette sales.

Effectiveness of State and Federal Government Agreements with Major Credit Card and Shipping Companies to Block Illegal Internet Cigarette Sales

The Cancer Prevention and Control Research Network surveyed 282 cancer control planners to inform its efforts to increase the use of evidence-based cancer control programs (EBPs; programs that have been scientifically tested and have successfully changed behavior). Respondents included planners from organizations in state Comprehensive Cancer Control coalitions as well as other governmental and nongovernmental organizations and community-based coalitions. Respondents provided information about personal and organizational characteristics, their cancer control programs, their attitudes toward EBPs, and their awareness and use of Web-based resources for EBPs. Although findings showed strong preferences for cancer control programs that have been shown to work, less than half of respondents (48%) had ever used EBP resources. Regardless of whether they had used EBP resources, almost all respondents (97%) indicated that further training would help them and their organizations adopt and adapt EBPs for use in their communities. The most frequently endorsed training needs were finding and securing additional resources (such as funding and technical assistance), followed by adapting EBPs for cultural appropriateness. The Cancer Prevention and Control Research Network consortium is using these findings to develop a Web-based interactive training and decision support tool that is responsive to the needs identified by the survey respondents.

Are the Sales Practices of Internet Cigarette Vendors Good Enough to Prevent Sales to Minors

Most Internet vendors offer tax-free cigarettes making them cheaper than those sold at stores. This undermines the impact that higher prices have upon reducing consumption. Most Internet tobacco sales have violated taxation and youth access laws, which led to landmark voluntary agreements in 2005 with the major credit card companies and major private shippers to ban payment transactions and shipments for all Internet cigarette sales. Objective To assess whether these bans increased the rate of Internet Cigarette Vendors (ICVs) ceasing online sales, decreased the proportion of vendors offering banned payment and shipping options, and decreased consumer traffic to the most popular ICVs. Design Websites in a longitudinal study of ICVs were visited in 2003 (n = 338), 2004 (n = 775), 2005 (n = 664), 2006 (n = 762), and 2007 (n = 497) to assess whether they were in business and monitor their advertised sales practices. The number of unique monthly visitors to the 50 most popular ICVs at baseline was examined for the period one year before and two years after the bans to determine whether the bans altered traffic. Results Following the bans, the rate of ICVs ceasing online sales year to year increased, but due to an influx of new vendors, there was a net increase in ICVs. The proportion of vendors accepting banned payment options dropped from 99.2% to 37.4% after the bans, and the proportion offering banned shipping options dropped from 32.2% to 5.6%, but there was a corresponding increase in vendors offering non-banned payment options (e.g., personal checks) and shipping options (e.g., US Postal Service). Following the bans, there was a 3.5 fold decline in traffic to the most popular ICV websites. Conclusions This promising approach to controlling the sale of restricted goods online has implications for regulating other products such as alcohol, firearms, quack cures, and medicines sold without a prescription.

A Minimal Intervention to Promote Smoke-Free Homes Among 2-1-1 Callers: A Randomized Controlled Trial

With the emergence of Web sites selling tobacco products, there is concern that they may be selling tobacco products to minors. A 1997 report identified 13 Internet cigarette vendors and found that few asked or attempted to verify the buyers age.1 Similarly, a study of 108 Internet cigar vendors found that only one third featured minimum age-of-sale warnings.2 The goal of the present study was to examine whether Internet vendors take adequate precautions to avoid selling cigarettes to minors. Data were collected as part of a larger study on the sales practices of 88 Internet cigarette vendors that is described elsewhere.3 Trained raters examined all pages of each Web site for minimum age-of-sale warnings and age verification and payment methods. Table 1 ▶ shows that 82% of the sites (n = 72) featured one or more age warnings that the buyer must be 18 years or older to purchase cigarettes. Age warnings appeared mostly on the home pages of the Web sites (n = 43); only one third featured a warning on the ordering page. The most common age verification method was self-verification, whereby potential buyers clicked a box stating that they were of legal age to purchase tobacco products (n = 43) or typed in their birthdate (n = 13). Only 8 sites featured the more rigorous age verification method of requiring a drivers license number that could be verified by the vendor. Only 6 Internet cigarette vendors stated that they required photographic age identification at point of delivery, the prevailing standard at retail outlets. TABLE 1 —Presence of Health Warnings and Minimum Age Verification Procedures for Internet Cigarette Vendors (N = 88) The results of our study suggested that most Internet cigarette vendors use inadequate procedures for age verification. Youths who misrepresent their age and obtain a money order could potentially purchase cigarettes on-line without difficulty. According to the State Youth Tobacco Surveys, 1.0% was the medium percentage of middle school and 1.4% was the medium percentage of high school current smokers who reported purchasing their last pack of cigarettes on the Internet.4 Similar findings were described in a study of California high school students.5 One limitation of this study was that we assessed the specified age verification methods, but these may differ markedly once orders are placed. Some sites may verify age on delivery, even though this information is not explicitly stated on their Web site. Likewise, some sites that mentioned having age verification procedures may not actually impose them. Substantial efforts have been made to prevent youth access to tobacco products from retail outlets,6–8 including laws requiring in-person photographic age verification at the point of sale.9 However, no federal laws ban the sale of tobacco products to minors through the Internet, and only a few states have attempted regulation. Rhode Island, for instance, banned Internet and mail-order sales of cigarettes without age verification at delivery.10,11 Parent-controlled filtering and blocking software is not a viable solution for restricting youth access to Internet cigarette vendors because most of these programs do not block tobacco sites12 and because none of the sites in this study were registered with parent-controlled access-filtering software sites. The findings of this study, combined with new data showing that youths are beginning to buy cigarettes via the Internet, emphasize the need for the passage and enforcement of policies to restrict youth access to tobacco products through this venue.

Internet cigarette sales and Native American sovereignty: political and public health contexts.

OBJECTIVES We tested the efficacy of a minimal intervention to create smoke-free homes in low-income households recruited through the United Way of Greater Atlanta 2-1-1, an information and referral system that connects callers to local social services. METHODS We conducted a randomized controlled trial (n=498) from June 2012 through June 2013, with follow-up at 3 and 6 months. The intervention consisted of 3 mailings and 1 coaching call. RESULTS Participants were mostly smokers (79.7%), women (82.7%), African American (83.3%), and not employed (76.5%), with an annual household income of

Internet Alcohol Sales to Minors

10,000 or less (55.6%). At 6-months postbaseline, significantly more intervention participants reported a full ban on smoking in the home than did control participants (40.0% vs 25.4%; P=.002). The intervention worked for smokers and nonsmokers, as well as those with or without children. CONCLUSIONS Minimal intervention was effective in promoting smoke-free homes in low income households and offers a potentially scalable model for protecting children and adult nonsmokers from secondhand smoke exposure in their homes.

When a ban really is not a ban: internet loopholes and Djarum flavoured cigarettes in the USA

Internet cigarette vendors (ICVs) advertise low prices for tobacco products, subverting public health policy efforts to curtail smoking by raising prices. Many online retailers in the United States claim affiliation with Native American tribes and share in tribal tax-free status. Sales of discounted cigarettes from both online vendors and brick-and-mortar stores have angered non-Native retailers and triggered enforcement actions by state and federal governments in the United States concerned over lost cigarette excise tax revenue. Examination of the history and politics of cigarette sales on reservations and attempts to regulate Internet cigarette sales highlights the potential role for greater use of negotiated intergovernmental agreements to address reservation-based tobacco sales. Our review notes global parallels and explicates history and politics of such regulation in the United States, and offers background for collaborative efforts to regulate tobacco sales and decrease tobacco use.