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1.  Association of breakfast intake with obesity, dietary and physical activity behavior among urban school-aged adolescents in Delhi, India: results of a cross-sectional study 
BMC Public Health  2012;12:881.
Background
In developed countries, regular breakfast consumption is inversely associated with excess weight and directly associated with better dietary and improved physical activity behaviors. Our objective was to describe the frequency of breakfast consumption among school-going adolescents in Delhi and evaluate its association with overweight and obesity as well as other dietary, physical activity, and sedentary behaviors.
Methods
Design: Cross-sectional study. Setting: Eight schools (Private and Government) of Delhi in the year 2006. Participants: 1814 students from 8th and 10th grades; response rate was 87.2%; 55% were 8th graders, 60% were boys and 52% attended Private schools. Main outcome measures: Body mass index, self-reported breakfast consumption, diet and physical activity related behaviors, and psychosocial factors. Data analysis: Mixed effects regression models were employed, adjusting for age, gender, grade level and school type (SES).
Results
Significantly more Government school (lower SES) students consumed breakfast daily as compared to Private school (higher SES) students (73.8% vs. 66.3%; p<0.01). More 8th graders consumed breakfast daily vs.10th graders (72.3% vs. 67.0%; p<0.05). A dose–response relationship was observed such that overall prevalence of overweight and obesity among adolescents who consumed breakfast daily (14.6%) was significantly lower vs. those who only sometimes (15.2%) or never (22.9%) consumed breakfast (p<0.05 for trend). This relationship was statistically significant for boys (15.4 % vs. 16.5% vs. 26.0; p<0.05 for trend) but not for girls. Intake of dairy products, fruits and vegetables was 5.5 (95% CI 2.4-12.5), 1.7 (95% CI 1.1-2.5) and 2.2 (95% CI 1.3-3.5) times higher among those who consumed breakfast daily vs. those who never consumed breakfast. Breakfast consumption was associated with greater physical activity vs. those who never consumed breakfast. Positive values and beliefs about healthy eating; body image satisfaction; and positive peer and parental influence were positively associated with daily breakfast consumption, while depression was negatively associated.
Conclusion
Daily breakfast consumption is associated with less overweight and obesity and with healthier dietary- and physical activity-related behaviors among urban Indian students. Although prospective studies should confirm the present results, intervention programs to prevent or treat childhood obesity in India should consider emphasizing regular breakfast consumption.
doi:10.1186/1471-2458-12-881
PMCID: PMC3549919  PMID: 23075030
Breakfast; Obesity; Adolescent; Diet; Physical activity; Behavior
2.  Discussions with adults and youth to inform the development of a community-based tobacco control programme 
Health Education Research  2012;28(1):58-71.
Project Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth (ACTIVITY) is a community-based group randomized intervention trial focused on disadvantaged youth (aged 10–19 years) residing in 14 low-income communities (slums and resettlement colonies) in Delhi, India. This article discusses the findings of Focus Group Discussions (FGDs) conducted to inform the development and test the appropriateness of Project ACTIVITY’s intervention model. The findings of the FGDs facilitated the understanding of factors contributing to increased tobacco uptake and cessation (both smoking and smokeless tobacco) among youth in this setting. Twenty-two FGDs were conducted with youth (10–19 years) and adults in two urban slums in Delhi. Key findings revealed: (i) youth and adults had limited knowledge about long-term health consequences of tobacco use; (ii) socio-environmental determinants and peer pressure were important variables influencing initiation of tobacco use; (iii) lack of motivation, support and sufficient skills hinder tobacco cessation and (iv) active involvement of community, family, religious leaders, local policy makers and health professionals is important in creating and reinforcing tobacco-free norms. The results of these FGDs aided in finalizing the intervention model for Project ACTIVITY and guided its intervention development.
doi:10.1093/her/cys084
PMCID: PMC3549588  PMID: 22824533
3.  Influence of Grade-Level Drinking Norms on Individual Drinking Behavior 
Objective
To investigate which points of the middle-school drinking distribution are the most influential in the social contagion of drinking across the middle-school years, in order to identify potential social multipliers.
Methods
We measured drinking intentions and behaviors by gender, school, and grade among urban middle-school students who participated in Project Northland Chicago in a longitudinal cohort design.
Results
Individual drinking behaviors were consistently influenced by extreme (80th percentile) drinking intentions and behaviors. This effect was mediated through normal or average levels of drinking, over time.
Conclusions
Interventions can target extreme drinkers as the influential persons in middle-school grades.
doi:10.5993/AJHB.37.1.8
PMCID: PMC3707398  PMID: 22943103
social norms; drinking; middle school; gender; mediation
5.  Sixth Grade Students Who Use Alcohol 
Young adolescent alcohol users drink at higher rates than their peers throughout adolescence and appear to be less amenable to intervention. This study compares those who reported alcohol use in the past year to those who reported no use in a multiethnic, urban sample of sixth graders in 61 schools in Chicago in 2002 (N = 4,150). Demographic, behavioral, intrapersonal, and socioenvironmental factors were identified based on behavioral theories and potential mediators of the Project Northland Chicago intervention. Single and multiple regression models were created for users and nonusers to determine associations between these factors and alcohol use behavior and intentions. The multiple regression models explained 35% and 56% of the variance in alcohol use behavior and intentions between students for nonusers and users, respectively. Results suggest that primary prevention programs for alcohol use should occur prior to sixth grade, particularly for the substantial group at high risk for early use.
doi:10.1177/1090198107308374
PMCID: PMC2717188  PMID: 18303109
alcohol use; adolescents; nonusers
6.  Preventing Tobacco Use Among Young People in India: Project MYTRI 
American journal of public health  2009;99(5):899-906.
Objectives
We assessed the effectiveness of a 2-year multicomponent, school-based intervention designed to reduce tobacco use rates among adolescents in an urban area of India.
Methods
Students from 32 schools in Delhi and Chennai, India, were recruited and randomly assigned to an intervention or control group. Baseline, intermediate, and outcome data were collected from 2 cohorts of 6th- and 8th-grade students in 2004; 14|063 students took part in the study and completed a survey in 2004, 2005, or 2006. The intervention consisted of behavioral classroom curricula, school posters, a parental involvement component, and peer-led activism. The main outcome measures were self-reported use of cigarettes, bidis (hand-rolled cigarettes), and chewing tobacco and future intentions to smoke or use chewing tobacco.
Results
Findings showed that students in the intervention group were significantly less likely than students in the control group to exhibit increases in cigarette smoking or bidi smoking over the 2-year study period. They were also less likely to intend to smoke or chew tobacco in the future.
Conclusions
School-based programs similar to the intervention examined here should be considered as part of a multistrategy approach to reducing tobacco use among young people in India.
doi:10.2105/AJPH.2008.145433
PMCID: PMC2667859  PMID: 19299670
7.  Classroom Norms and Individual Smoking Behavior in Middle School 
Objectives
To investigate whether smoking prevalence in grade-level networks influences individual smoking, suggesting that peers are important social multipliers in teen smoking.
Methods
We measured gender-specific, grade-level recent and life-time smoking among urban middle-school students who participated in Project Northland Chicago in a longitudinal cohort design.
Results
Within schools, grade-level recent smoking had comparable effects on girls’ and boys’ individual-level smoking. Grade-level lifetime smoking had a greater effect on girls’ smoking.
Conclusion
Interventions can target middle school classes and schools broadly, without making the identification of friendship networks a concern.
PMCID: PMC3686270  PMID: 22251779
social norms; smoking; middle school; gender
8.  Do High Risk Urban Youth also have Older Friends? 
Purpose
The purpose of this study was to explore how behavioral, intra-personal and socio-environmental factors were associated with the likelihood of having at least one older friend.
Methods
Participants included 3709 ethnically-diverse 8th grade students in the Project Northland Chicago intervention trial. Socio-demographic characteristics included gender, family composition, language spoken at home, race/ethnicity, and age. Behavioral factors included cigarette, alcohol, and marijuana use, depressed feelings, willingness to wear alcohol-branded merchandise, and violent and delinquent behavior. Intrapersonal factors included low refusal self efficacy and outcome expectations and expectancies. Socio-environmental factors included alcohol offers and access, normative estimates and expectations, and peer alcohol use. Having an older friend was defined as having at least one friend aged 16 or older (students’ mean age=14.2). Logistic mixed-effects regression models were used and controlled for gender, race/ethnicity, treatment status, and age.
Results
Females and older eighth graders were significantly more likely to have at least one older friend. Students who scored higher on all of the behavioral, intra-personal and socio-environmental risk factors were significantly more likely to have at least one older friend. Significant gender interactions were found for several of the relationships.
Conclusion
Overall this study found multiple risk-related factors are associated with having older friends in eighth grade. Particularly important factors appear to be cigarette, marijuana and alcohol use, having friends who use alcohol, having increased alcohol offers, and being willing to wear or use alcohol-branded merchandise.
doi:10.1016/j.jadohealth.2010.08.002
PMCID: PMC3079854  PMID: 21501805
Peers; Friends; Risk Behaviors; Risk Factors; Adolescence
9.  Using Salivary Cotinine to Validate Self-Reports of Tobacco Use by Indian Youth Living in Low-Income Neighborhoods 
Background
Self-reported tobacco use among young people can underestimate the actual prevalence of tobacco use. Biochemical validation of self-reports is particularly recommended for intervention studies where cessation outcomes are to be measured. Literature on biochemical validation of self-reports of multiple forms of tobacco use in India is sparse, particularly among young people.
Methods
The study was conducted during the baseline household survey of a community based tobacco prevention and cessation intervention trial for youth (10–19 years old) residing in slum communities in Delhi, India in 2009. Salivary cotinine measurement on 1224 samples showed that youth were under-reporting use of chewing and smoking tobacco.
Results
Self-reports had a low sensitivity (36.3%) and a positive predictive value of 72.6%. No statistically significant difference in under-reporting was found between youth in the control and intervention conditions of the trial, which will be taken into consideration in assessing intervention outcomes at a later time point.
Conclusion
Biochemical validation of self-reported tobacco use should be considered during prevention and cessation studies among youth living in low-income settings in developing countries like India.
Impact
The future results of biochemical validation from Project ACTIVITY (Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth) will be useful to design validation studies in resource-poor settings.
PMCID: PMC3310162  PMID: 22320954
Tobacco; Youth; Saliva; Cotinine; India
10.  Process evaluation of a tobacco prevention program in Indian schools—methods, results and lessons learnt 
Health Education Research  2010;25(6):917-935.
In India, 57% of men between 15 and 54 years and 10.8% of women between 15 and 49 years use tobacco. A wide variety of tobacco gets used and the poor and the underprivileged are the dominant victims of tobacco and its adverse consequences. Project MYTRI (Mobilizing Youth for Tobacco-Related Initiatives in India) was a tobacco prevention intervention program, a cluster-randomized trial in 32 Indian schools which aimed to decrease susceptibility to tobacco use among sixth- to ninth-grade students in urban settings in India. This culture-specific intervention, which addressed both smokeless and smoked forms of tobacco, was Indian in content and communication. We qualitatively developed indicators which would help accurately measure the dose of the intervention given, received and reached. A multi-staged process evaluation was done through both subjective and objective measures. Training the teachers critically contributed toward a rigorous implementation and also correlated with the outcomes, as did a higher proportion of students participating in the classroom discussions and better peer–leader–student communication. A sizeable proportion of subjective responses were ‘socially desirable’, making objective assessment a preferred methodology even for ‘dose received’. The peer-led health activism was successful. Teachers' manuals need to be concise.
doi:10.1093/her/cyq042
PMCID: PMC3003490  PMID: 20884731
11.  Longitudinal associations between family dinner and adolescent perceptions of parent-child communication among racially-diverse urban youth 
Growth curve models examined changes in adolescent self-reported parent-child communication conditional on family meal frequency over a 3.5 year period among a population of racially-diverse, low-income adolescents from an urban environment (n = 4750). Results indicated that although both family dinner frequency and adolescent perceptions of parent-child communication scores were characterized by negative linear growth over time (both p < .0001), family dinner frequency was positively associated with adolescent perceptions of parent-child communication scores over time (p < .0001). Study findings suggest that families with teenagers may enhance parent-child communication and ultimately promote healthy adolescent development by making family dinner a priority. Additionally, the communication benefits of family dinner at the beginning of 6th grade may be protective through 8th grade.
doi:10.1037/a0019311
PMCID: PMC2896222  PMID: 20545399
adolescents; family dinner; family meals; parent-child communication; race/ethnicity; urban
12.  A mediation analysis of a tobacco prevention program for adolescents in India: How did Project MYTRI work? 
This paper presents the results of a mediation analysis of Project MYTRI (Mobilizing Youth for Tobacco Related Initiatives in India), a randomized, controlled trial of a multiple component, school-based tobacco prevention program for 6th–9th graders (n=14085) in Delhi and Chennai, India. A mediation analysis identifies how an intervention achieves its effects. In MYTRI, changes in students’ (a) knowledge about the negative health effects of tobacco; (b) beliefs about its social consequences; (c) reasons to use tobacco; (d) reasons not to use tobacco; (e) advocacy skills self-efficacy; and (f) normative beliefs about tobacco use were significantly associated with reductions in students’ intentions to use tobacco and tobacco use behaviors. Changes in students’ perceptions of the prevalence of (a) smoking and (b) chewing tobacco were significantly related to increases, in contrast, in students’ intentions to use and use of tobacco. Implications for intervention design are considered.
doi:10.1177/1090198110372330
PMCID: PMC3096703  PMID: 21411716
13.  EFFECTS OF ALCOHOL USE INITIATION PATTERNS ON HIGH-RISK BEHAVIORS AMONG URBAN, LOW-INCOME, YOUNG ADOLESCENTS 
This study examined associations between patterns of alcohol use initiation and progression from age 12 to 14 years and recent cigarette and marijuana use, and violent and delinquent behavior at age 14. The study sample (n=2,193) was predominantly African American or Hispanic (43% and 37%, respectively) and low-income (68% receiving free, or reduced price, lunch). They completed classroom-based surveys when in 6th–8th grades. Multilevel latent class analyses were used to identify the heterogeneous alcohol use trajectories. Linear and logistic mixed-effects regression was then used to examine the association between these patterns and high-risk behaviors in 8th grade. Five alcohol use trajectories were identified: (1) No Use (63.3%), (2) Onset of Consistently Infrequent Use at Age < 12 (13.3%), (3) Onset of Monthly Use at Age 14 (9.9%), (4) Onset of Monthly Use at Age 13 to Heavy Use at Age 14 (6.6%), and (5) Onset of Consistently Heavy Use at Age 12 (6.9%). Relative to non-users, membership in any of the alcohol use trajectory classes was significantly associated with greater past month cigarette and marijuana use, as well as violent behaviors in 8th grade. Higher levels of delinquent behaviors were significantly associated with membership in all but one of the alcohol use trajectory classes relative to the “no use” class. Results suggest that any use of alcohol in early adolescence is associated with other high-risk behaviors and support the critical need for efforts to prevent early initiation and progression of alcohol use among youth as a key component to prevent future high-risk behaviors.
doi:10.1007/s11121-009-0144-y
PMCID: PMC2822085  PMID: 19639410
alcohol use; high-risk behaviors; adolescent; trajectory classes
14.  Parents’ and children’s self report of parenting factors 
Health education journal  2010;69(1):31-42.
Objective
The purpose of this study was to determine if parents’ and children’s reports of parenting practices were correlated, if the reports were differentially associated with alcohol use, and which report had the strongest association with alcohol use.
Design
Cross-sectional and longitudinal.
Setting
Public schools, Chicago, Illinois.
Method
Participants included 1373 ethnically-diverse students and parents involved in an alcohol use prevention intervention. Surveys were conducted in sixth grade and eighth grade. Mixed-effects regression analyses were used to model relationships cross-sectionally and longitudinally.
Results
Parents’ and children’s perceptions of parenting practices, while significantly correlated, were not strongly associated. Analyses within each parenting domain found parents’ report of parental monitoring and children’s reports of alcohol-specific communication, general communication, and relationship satisfaction were associated with alcohol use behaviors and intentions. After adjusting for all other parenting practices, parents’ report of parental monitoring and children’s report of alcohol-specific communication were most strongly related to alcohol use behaviors and intentions both cross-sectionally and longitudinally.
Conclusions
When comparing results across studies, it is important to identify whose report was used, parent or child, as the results may differ based on reporter. Studies with limited resources may consider using parents’ reports about parental monitoring and using children’s reports for alcohol-specific communication, general communication, and relationship satisfaction.
doi:10.1177/0017896910363325
PMCID: PMC2885720  PMID: 20563227
Parenting; parent-child relationships; alcohol use; early adolescence
15.  Weight-related concerns and weight-control behaviors among overweight adolescents in Delhi, India: A cross-sectional study 
Background
Obesity is emerging as a public health problem among adolescents in India. The aim of this study was to describe specific weight-related concerns among school-going youth in Delhi, India and to assess the prevalence of weight control behaviors, including healthy and unhealthy ones. Differences by weight status, gender, grade level, and school-type (a proxy for SES in this setting) are considered.
Methods
This study is cross-sectional by design. A sample of eighth and tenth graders (n = 1818) enrolled in Private (middle-high SES) and Government (low SES) schools (n = 8) in Delhi, India participated. All students' height and weight were measured. Students participated in a survey of weight-related concerns and weight-control behaviors, as well. Mixed-effects regression models were used to test for differences in weight-related concerns and weight-control behaviors across key factors of interest (i.e., weight status, gender, grade level, and SES).
Results
The combined prevalence of obesity and overweight was 16.6%, overall. Controlling one's weight was important to overweight and non-overweight youth, alike (94.2% v. 84.8%, p < 0.001). Significantly more overweight or obese youth reported trying to control their weight last year, compared to those who were not overweight (68.1% v. 18.0%, p < 0.001). Healthy weight control behaviors were more common than unhealthy or extreme practices, although the latter were still prevalent. Half of the overweight or obese students misclassified their weight status, while about 1 in 10 non-overweight youth did the same. Body dissatisfaction was highest among overweight youth and girls.
Conclusions
Interventions to promote healthy weight control should be pertinent to and well-received by school-going youth in India. Healthy weight control practices need to be explicitly encouraged and unhealthy practices reduced. Future interventions should address issues specific to body image, too, as body dissatisfaction was not uncommon among youth.
doi:10.1186/1479-5868-8-9
PMCID: PMC3045278  PMID: 21299879
16.  School-Based Programs to Prevent and Reduce Alcohol Use among Youth 
Alcohol Research & Health  2011;34(2):157-162.
Schools are an important setting for interventions aimed at preventing alcohol use and abuse among adolescents. A range of school-based interventions have been developed to prevent or delay the onset of alcohol use, most of which are targeted to middle-school students. Most of these interventions seek to reduce risk factors for alcohol use at the individual level, whereas other interventions also address social and/or environmental risk factors. Not all interventions that have been developed and implemented have been found to be effective. In-depth analyses have indicated that to be most effective, interventions should be theory driven, address social norms around alcohol use, build personal and social skills helping students resist pressure to use alcohol, involve interactive teaching approaches, use peer leaders, integrate other segments of the population into the program, be delivered over several sessions and years, provide training and support to facilitators, and be culturally and developmentally appropriate. Additional research is needed to develop interventions for elementary-school and high-school students and for special populations.
PMCID: PMC3860568  PMID: 22330213
Alcohol and other drug use (AODU); alcohol consumption; alcohol abuse; age of AODU onset; underage drinking; adolescent; risk factors; individual risk factors; social environmental risk factors; elementary school; middle school; high school; school-based prevention; school-based intervention
17.  Westernization and Tobacco Use Among Young People in Delhi, India 
Social science & medicine (1982)  2010;71(5):891-897.
Few studies have explored the relationship between acculturation and health in non-immigrant populations. The purpose of this study was to investigate the relationship between “westernization” and tobacco use among adolescents living in Delhi, India. A bi-dimensional model of acculturation was adapted for use in this study to examine (a) whether young people's identification with Western culture in this setting is related to tobacco use and (b) whether their maintenance of more traditional Indian ways of living is related to tobacco use, also. Multiple types of tobacco use common in India (e.g., cigarettes, bidis, chewing tobacco) were considered. Socioeconomic status (SES), gender, and grade level were examined as potential effect modifiers of the relationship between “westernization” and tobacco use. The study was cross-sectional by design and included 3,512 students in eighth and tenth grades who were enrolled in 14 Private (higher SES) and Government (lower SES) schools in Delhi, India. A self-report survey was used to collect information on tobacco use and “westernization.” The results suggest that young people's identification with Western influences may increase their risk for tobacco use (p<0.001), while their maintenance of traditional Indian ways of living confers some protection (p<0.001). Importantly, these effects were independent of one another. Boys benefitted more from protective effects than girls, and tenth graders gained more consistent benefits than eighth graders in this regard, too. Negative effects associated with identification with Western ways of living were, in contrast, consistent across gender and grade level. The positive and negative effects of acculturation on adolescent tobacco use generalized across all tobacco products considered here. Future interventions designed to curb youth tobacco use in India may benefit by paying closer attention to cultural preferences of these young consumers.
doi:10.1016/j.socscimed.2010.06.002
PMCID: PMC2910122  PMID: 20598413
18.  Does outdoor alcohol advertising around elementary schools vary by the ethnicity of students in the school? 
Ethnicity & health  2009;14(2):225-236.
Objectives
The objectives of this study were to determine: (1) if the number of outdoor alcohol advertisements around schools varied by ethnicity of students in the school, and (2) how the content of alcohol advertising around schools varied by the ethnicity of students in the school.
Methods
All outdoor alcohol advertisements within 1500 feet of 63 Chicago schools were documented and coded for content and theme. On average, the ethnic make-up of schools was 54.9% African American, 24.4% Hispanic, and 16.2% White; 79.7% of students were low SES. To compare the mean number and type of ads by ethnicity of the school, schools were coded by ethnicity (i.e. 20% or more Hispanic students compared with less than 20% Hispanic students).
Results
Youth attending schools with 20% or more Hispanic students were exposed to 6.5 times more alcohol advertising than students attending schools with less than 20% Hispanic students. Schools with 20% or more Hispanic students were also surrounded by more beer advertising and alcohol advertisements on bars and liquor stores.
Conclusions
Alcohol advertising is more prevalent around schools with 20% or more Hispanic students. Policies should be considered to reduce the amount of alcohol advertising around schools.
doi:10.1080/13557850802307809
PMCID: PMC2658768  PMID: 18821155
Alcohol advertising; Hispanic youth; Adolescents
19.  Psychosocial mediators of a school-based tobacco prevention program in India: Results from the first year of Project MYTRI 
Each day in India, an estimated 5,500 youth initiate tobacco use, contributing to predictions that by 2020, tobacco will account for 13% of all deaths in India. Project MYTRI (Mobilizing Youth for Tobacco-Related Initiatives in India) is a multi-component school-based intervention designed to prevent and reduce tobacco use among adolescents in Delhi and Chennai, India. The intervention was implemented over the 2004-2006 school years and involved 6th and 8th grade students in 32 classrooms. Students participated in peer-led classroom activities involving games, competitions, and other activities intended to target a number of psychosocial risk factors believed to prevent tobacco use among urban Indian youth. To more fully understand how Project MYTRI influenced students' intentions to smoke or chew tobacco, the current study used mediation analysis to investigate whether Project MYTRI altered the psychosocial risk factors as intended, and whether the changes in psychosocial risk factors were, in turn, responsible for altering students' tobacco-use intentions. Multi-level mediation models were estimated using student data from baseline and one-year follow-up surveys. Results indicated that the psychosocial risk factors Knowledge of Health Effects, Normative Beliefs, Reasons to Use Tobacco, and Perceived Prevalence were significant mediators between the intervention activities and students' tobacco use intentions. Evidence of inconsistent mediation was observed for the Perceived Prevalence factor. These findings, combined with those from qualitative research and the second-year student data, will help to illuminate the impact of Project MYTRI on participating youth.
doi:10.1007/s11121-008-0113-x
PMCID: PMC2821665  PMID: 19023657
mediation analysis; tobacco prevention; adolescents; India; psychosocial risk factors
20.  Symptoms of cough and shortness of breath among occasional young adult smokers 
Nicotine & Tobacco Research  2009;11(2):126-133.
Introduction:
The perception of negative health consequences is a common motive for quitting smoking, but specific information on the immediate health effects of occasional smoking among young adults is limited.
Method:
To examine the relationship between cigarette use and symptoms of (a) cough or sore throat and (b) shortness of breath or fatigue after regular activities among young adults, we performed online health screening of a random sample of 25,000 college undergraduates. The screening survey assessed demographic characteristics, smoking and related health behaviors, and respiratory symptoms in the previous 30 days.
Results:
The response rate was 26% (6,492/25,000). Among individuals reporting no smoking in the prior 30 days and smoking on 1–4, 5–10, 11–20, or 21–30 days, the prevalence of one or more days of cough/sore throat increased from 62.5% to 68.3%, 72.0%, 71.4%, and 73.7%, respectively (p < .001). Similarly, the prevalence of shortness of breath/fatigue increased from 42.7% to 47.1%, 56.2%, 59.5%, and 64.6%, respectively (p < .001). After controlling for demographics, other important health behaviors (e.g., days consuming alcohol and getting adequate sleep), and environmental tobacco smoke (ETS) exposure, reporting symptoms of cough/sore throat was associated with smoking on at least 21 days, whereas shortness of breath/fatigue was associated with smoking on 5 or more days. Among those reporting symptoms, increased number of days with respiratory symptoms was associated with smoking on most days as well as ETS exposure.
Discussion:
In conclusion, this cross-sectional study found that occasional smoking and ETS exposure were associated with an increase in the rate of respiratory symptoms (cough/sore throat and shortness of breath/fatigue) among young adults.
doi:10.1093/ntr/ntp015
PMCID: PMC2658904  PMID: 19264863
21.  “Stay away from them until you're old enough to make a decision”: tobacco company testimony about youth smoking initiation 
Tobacco Control  2006;15(Suppl 4):iv44-iv53.
Objective
To determine common themes used by US tobacco industry witnesses pertaining to youth smoking initiation during litigation in the United States.
Methods
Qualitative thematic analysis of transcripts from 29 tobacco litigation cases dating from 1992 to 2002.
Results
Youth smoking is portrayed by the tobacco industry as a source of great concern to them. Youth smoking prevention programmes developed by US tobacco companies are supposedly intended to delay decision‐making about smoking until age 18, when individuals are then seen to be of an age where they are able to “choose to smoke”. Tobacco industry media campaigns, youth access, community and school‐based programmes are predicated on peer influence, parental factors, and commercial access being the primary influences on youth smoking uptake, rather than tobacco marketing, inaccurate risk appraisal, price and other factors known to influence youth smoking. Despite substantial financial investment in tobacco industry programmes, their witnesses were able to describe only weak evaluation methods, being preoccupied with measures of message comprehension, programme reach and uptake, and the associated costs of their efforts, rather than any evaluation designed to assess effects on youth smoking behaviour.
Conclusion
Stated concerns about youth smoking and youth smoking prevention programmes are put forward in litigation as evidence that the tobacco industry is “serious” about tackling youth smoking, and serve as a primary strategy to improve the tobacco industry's public image. The tobacco industry's evaluation of the effectiveness of their youth smoking prevention programmes is demonstrably insufficient under current public health evaluation standards. Public health and welfare agencies should avoid engagement with tobacco industry‐sponsored programmes.
doi:10.1136/tc.2005.011536
PMCID: PMC2563589  PMID: 17130624
smoking; adolescent; legislation and jurisprudence; qualitative
22.  Relationships Between Alcohol-Related informal Social Control, Parental Monitoring and Adolescent Problem Behaviors Among Racially Diverse Urban Youth 
Journal of community health  2008;33(6):425-433.
The purpose of the present study is to investigate the relationships between alcohol-related informal social control and parental monitoring on alcohol use, behavior and intentions; violent behavior; and delinquent behavior in a racially diverse population of young urban adolescents. Baseline surveys were administered to 6th grade male and female students in 61 urban Chicago schools as part of Project Northland Chicago, a group randomized trial for the prevention/reduction of substance use. A subset of their parents (n=3034) was also surveyed regarding alcohol use, violence, and delinquency and related issues. Structural equation modeling was used to assess relationships between alcohol-related informal social control (as measured by parental perceptions of neighborhood action regarding youth drinking) and parental monitoring (as reported by parents), and three adolescent outcomes (alcohol use, behaviors and intentions; violent behavior; and delinquent behavior; as reported by teens). Associations between alcohol-related informal social control and parental monitoring were positive and significant (p<.001). Direct paths from parental monitoring to all three adolescent outcomes were negative and statistically significant (alcohol use, behaviors and intentions, p<.001; violent behavior, p<.001; and delinquent behavior, p<.001). Alcohol-related informal social control was not significantly associated with adolescent outcomes. Efforts to engage parents to be more active in monitoring adolescents’ activities may be related to lower levels of underage drinking, violence and delinquency among both female and male urban youth. Neighborhood norms and action against teenage drinking may be too distal to adolescent outcomes to be directly associated.
doi:10.1007/s10900-008-9117-5
PMCID: PMC2603288  PMID: 18607698
Parental monitoring; Alcohol-related informal social control; Adolescent behaviors; Alcohol; Delinquency; Violence
23.  The adoption of risk-related factors through early adolescence: Associations with weight status and implications for causal mechanisms 
Purpose
To examine cross-sectional and longitudinal associations between weight status and measures of risk and protective factors in youth.
Methods
Participants included 3010 students (72.1% white, 27.9% non-white), with a baseline mean age of 12.7 years from the Teens Eating for Energy and Nutrition at School (TEENS) study. Surveys were administered in seventh and eighth grade. Cross-sectional and longitudinal mixed-effects regression analyses were conducted to determine the association between body mass index z-score percentiles (BMI) and risk and protective factors (including substance use, depression, fighting, optimism, and spirituality).
Results
Only depression was associated with BMI at the beginning of seventh grade. However, by the end of eighth grade, binge drinking, ATOD (alcohol, tobacco, and other drug) use, fighting, and depression were all cross-sectionally associated with BMI. Longitudinally, BMI in seventh grade did not predict risk and protective factors in eighth grade. However, ATOD use, fighting, depression, and optimism in seventh grade predicted BMI in eighth grade.
Conclusion
This study suggests there is a notable co-occurrence of unhealthy factors (including weight status, ATOD, depression) which appears to develop during the critical transition period through early adolescence. Specifically, earlier ATOD use, depression, increased fighting, and decreased optimism may lead to unhealthy increases in weight status, whereas early indicators of increased weight status do not appear to predict increases in these factors. This work yields important insights into the causal mechanisms underlying adolescent behavior patterning and the progression with which these unhealthy risk factor profiles are adopted during this critical age.
doi:10.1016/j.jadohealth.2008.02.009
PMCID: PMC2577596  PMID: 18809137
Obesity; risk and protective factors; substance use; depression
24.  Adolescent Smoking Trajectories 
Purpose
To identify distinct smoking trajectories during adolescence and assess how smoking-related factors relate to trajectory membership.
Methods
The sample includes 3637 youth from across the state of Minnesota. Measures include tobacco use, smoking behaviors of parents and friends, youth smoking-related attitudes and beliefs, and home smoking policies. A cohort-sequential design was used to identify smoking trajectories, including five cohorts of youth (ages 12–16) followed for 3 years.
Results
Six distinct trajectories of tobacco use were found: nonsmokers (54%), triers (17%), occasional users (10%), early established (7%), late established (8%), and decliners (4%). Several factors were associated with increased likelihood of being in a smoking trajectory group (vs. the nonsmoking group): parental smoking, friend smoking, greater perceptions of the number of adults and teenagers who smoke, and higher functional meaning of tobacco use. In contrast, higher perceived difficulty smoking in public places, negative perceptions of the tobacco industry, and home smoking policies were associated with less likelihood of being in one of the smoking trajectories (vs. the nonsmoking trajectory).
Conclusions
Adolescents exhibit diverse patterns of smoking during adolescence and tobacco-related influences were strong predictors of trajectory membership.
doi:10.1016/j.jadohealth.2008.02.014
PMCID: PMC2743902  PMID: 18809130
Adolescent smoking; Smoking trajectories; Social influences; Smoking attitudes
25.  Longitudinal patterns of youth access to cigarettes and smoking progression: Minnesota Adolescent Community Cohort (MACC) study (2000 – 2003) 
Preventive medicine  2007;45(6):442-446.
OBJECTIVES
To measure community-level changes in the methods youth use to obtain cigarettes over time and to relate these methods to the progression of smoking.
METHODS
We analyzed 2000-2003 data from the Minnesota Adolescent Community Cohort study, where youth (beginning at age 12), who were living in Minnesota at baseline, were surveyed every six months via telephone. We conducted mixed model repeated measures logistic regression to obtain probabilities of cigarette access methods among past 30-day smokers (n = 340 at baseline).
RESULTS
The probability of obtaining cigarettes from a commercial source in the past month declined from 0.36 at baseline to 0.22 at the sixth survey point while the probability of obtaining cigarettes from a social source during the previous month increased from 0.54 to 0.76 (p for both trends = 0.0001). At the community level, the likelihood of adolescents obtaining cigarettes from social sources was inversely related to the likelihood of progressing to heavy smoking (p < 0.001).
CONCLUSIONS
During this time, youth shifted to greater reliance on social sources and less on commercial sources. A trend toward less commercial access to cigarettes accompanied by an increase in social access may translate to youth being less likely to progress to heavier smoking.
doi:10.1016/j.ypmed.2007.07.016
PMCID: PMC2255062  PMID: 17719080
Adolescence; Smoking; Cigarette use; Tobacco sales

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