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1.  The Predictive Utility of Attitudes toward Hookah Tobacco Smoking 
Objective
To determine associations between positive and negative attitudes and hookah tobacco smoking (HTS) outcomes among college students.
Methods
Among a random sample of University of Florida students (N=852), multivariable logistic regression models assessed independent associations between positive and negative attitudes toward HTS.
Results
Positive attitudes were associated with adjusted odds of 4.32 (95% CI=3.20, 5.82) for current HTS, while negative attitudes were associated with lower adjusted odds for current smoking HTS (AOR=0.64, 95% CI=0.53, 0.76). Positive attitudes were also associated with adjusted odds of 9.31 (95% CI=6.77, 12.80) for intention for future hookah use.
Conclusion
Positive attitudes toward HTS were more strongly associated with HTS outcomes compared to negative attitudes. It may be particularly valuable for future research and interventions to focus on decreasing positive attitudes towards HTS.
doi:10.5993/AJHB.37.4.1
PMCID: PMC3761412  PMID: 23985224
Hookah; Waterpipe; Tobacco; Attitude; Intention; University
2.  Substance and hookah use and living arrangement among fraternity and sorority members at US colleges and universities 
Journal of community health  2013;38(2):238-245.
Hookah tobacco smoking is associated with substantial toxicant exposures and is increasing among college students in the US. Greek (fraternity/sorority) students, especially those living in Greek housing, have high rates of risky alcohol use. The extent to which this is true for other substances, including hookah tobacco smoking, is not well known. The objective of this study is to examine associations between Greek involvement and living arrangement (non-member, non-resident member, resident member) and rates of hookah tobacco smoking, in relation to other substances, among US college students. We used national data from 82,251 student responses from the 2008–2009 administrations of the National College Health Assessment. Generalized estimating equations were utilized to determine adjusted odds ratios for substance use outcomes based on involvement and living arrangements, while adjusting for covariates and clustering of students within institutions. Among resident members, ever use was highest for marijuana (52.4%), hookah (48.5%) and cigarettes (46.6%). In multivariable models, adjusted odds were lowest for non-Greeks and highest for Greek resident members. Compared to non-Greeks, Greek resident members had nearly double the odds for current use of hookah, cigars, and marijuana, as well as two and a half times the odds for current use of smokeless tobacco and three times the odds for alcohol bingeing. Similar to other substances, hookah tobacco smoking is highest among Greek resident members, compared with both Greeks living outside Greek housing and non-Greeks. It is valuable for substance use surveillance and intervention to focus on Greek resident members.
doi:10.1007/s10900-012-9605-5
PMCID: PMC3594445  PMID: 22903805
tobacco; substance abuse; college; hookah; Greek-letter
3.  Associations between hookah tobacco smoking knowledge and hookah smoking behavior among US college students 
Health Education Research  2012;28(1):92-100.
Hookah tobacco smoking is increasing among US college students, including those who would not otherwise use tobacco. Part of hookah’s appeal is attributed to the perception that hookah is less harmful than cigarettes. The aims of this study were to assess knowledge of harmful exposures associated with hookah smoking relative to cigarette smoking and to determine associations between this knowledge and hookah smoking outcomes. Students (N = 852) at the University of Florida were randomly sampled via e-mail to obtain information on demographics, hookah smoking behavior and knowledge of five exposures (e.g. tar and nicotine). Multivariable logistic regression models assessed independent associations between knowledge and hookah smoking outcomes. Of the five factual knowledge items asked, 475 (55.8%) of the respondents answered none correctly. In multivariable models, correct responses to any knowledge items were not associated with lower odds of hookah smoking or susceptibility to hookah smoking in the future. Although college students are largely unaware of the toxicant exposures associated with hookah smoking, there is little association between knowledge and hookah smoking behavior.
doi:10.1093/her/cys095
PMCID: PMC3549589  PMID: 22987864
4.  Associations of mental health problems with waterpipe tobacco and cigarette smoking among college students 
Substance use & misuse  2013;48(3):211-219.
Associations between the emerging trend of waterpipe tobacco smoking and mental health among college students have not been sufficiently explored. This study analyzed data collected from 152 academic institutions that participated in the National College Health Assessment during the 2008–2009 academic year to examine associations between mental health and waterpipe tobacco smoking among college students (N=100,891). For comparison, cigarette smoking was also examined. Associations with mental health variables were very strong for cigarette smoking but only moderate for waterpipe smoking. Study implications and limitations are noted. Funding was provided by NCI Grant [removed for blind version].
doi:10.3109/10826084.2012.750363
PMCID: PMC3582711  PMID: 23302059
Cigarette smoking; College students; Tobacco use; Waterpipe smoking
5.  Waterpipe Smoking Among U.S. University Students 
Nicotine & Tobacco Research  2012;15(1):29-35.
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.
doi:10.1093/ntr/nts076
PMCID: PMC3524056  PMID: 22641433
6.  Parental Efficacy and Child Behavior in a Community Sample of Children with and without Attention-Deficit Hyperactivity Disorder (ADHD) 
Purpose
Most studies of ADHD youth have obtained data from the perspective of either children or parents, but not both simultaneously. The purpose of this study was to examine child and parent perspectives on parenting in a large community-based sample of children with and without ADHD.
Methods
We identified children in grades 4-6 and their parents through surveys administered to a random sample of public schools. We used multivariable logistic regression to determine independent associations between child and parent characteristics and presence of ADHD while controlling for covariates and clustering by school.
Results
Sufficient data were achieved for 2509 child/parent dyads. Ten percent of youths (n=240) had been diagnosed with ADHD. Compared with those without ADHD, those with ADHD were more commonly male (67.9% vs. 48.0%, P<.001) and age 12 or over (16.3% vs. 10.3%). After adjusting for covariates and clustering, compared to children without ADHD, children with ADHD were significantly more likely to report lower self-regulation (OR= 0.68, 95% CI=0.53, 0.88) and higher levels of rebelliousness (OR= 2.00, 95% CI=1.52, 2.69). Compared with parents whose children did not have ADHD, parents of children with ADHD rated their overall parental efficacy substantially lower (OR=0.23, 95% CI=0.15, 0.33). However, child assessment of parenting style was similar by ADHD.
Conclusions
Despite the internal challenges community-based youth with ADHD face, many parents of ADHD youth exhibit valuable parental skills from the perspective of their children. Feedback of this information to parents may improve parental self-efficacy, which is known to be positively associated with improved ADHD outcomes.
doi:10.1007/s12402-012-0089-z
PMCID: PMC3562484  PMID: 22886756
ADHD; child behavior; parental efficacy; school performance
7.  ER vs. ED: A Comparison of Televised and Real-Life Emergency Medicine 
The Journal of emergency medicine  2012;43(6):1160-1166.
Background
Although accurate health-related representations of medical situations on television can be valuable, inaccurate portrayals can engender misinformation.
Objective
The purpose of this study was to compare socio-demographic and medical characteristics of patients depicted on television vs. actual U.S. Emergency Department (ED) patients.
Methods
Two independently working coders analyzed all 22 programs in one complete year of the popular emergency room drama ER. Inter-rater reliability was excellent, and all initial coding differences were easily adjudicated. Actual health data were obtained from the National Heath and Ambulatory Medical Care Survey data from the same year. We used Pearson’s chi-squared test to compare televised vs. real distribution across key socio-demographic and medical variables.
Results
Ages at the extremes (e.g., ≤4 and ≥45) were less commonly represented on television compared with reality. Compared with reality, characters on television were less commonly women (31.2% vs. 52.9%), African American (12.7% vs. 20.3%) or Hispanic (7.1% vs. 12.5%). The two most common acuity categories for television were the extreme categories “non-urgent” and “emergent,” whereas the two most common categories for reality were the middle categories “semi-urgent” and “urgent.” Compared with reality, televised visits were most commonly due to injury (63.5% vs. 37.0%), and televised injuries were less commonly work-related (4.2% vs. 14.8%).
Conclusions
Comparison of represented and actual characteristics of ED patients may be valuable in helping us determine what types of patient misperceptions may exist as well as what types of interventions may be beneficial in correcting that potential misinformation.
doi:10.1016/j.jemermed.2011.11.002
PMCID: PMC3573875  PMID: 22766407
Television; emergency department; content analysis; NHAMCS; health disparities
8.  U.S. health policy related to hookah tobacco smoking 
American journal of public health  2012;102(9):e47-e51.
Background
Although cigarette smoking is decreasing in the U.S., hookah tobacco smoking (HTS) is an emerging trend associated with substantial toxicant exposures. The purpose of this study was to assess how a representative sample of U.S. tobacco control policies may apply to HTS.
Methods
We examined municipal, county, and state legal texts that apply to the largest 100 cities in the U.S. We developed a summary policy variable that distinguishes cities without clean air legislation preventing cigarette or HTS in freestanding bars; with anti-smoking legislation exempting HTS by name; with anti-smoking legislation providing for a different exemption under which HTS may fall; and with anti-smoking legislation and no clear exemption governing HTS. We used multinomial logistic regression to determine associations between community-level socio-demographic variables and our policy outcome variable.
Results
Although 73 of the 100 largest cities in the U.S. have laws that disallow cigarette smoking in bars, HTS may be allowed due to exemptions in 69 of these 73 cities. While 4 of these cities have passed legislation specifically exempting HTS, 65 may permit HTS via generic tobacco retail establishment exemptions. Compared with cities without clean air legislation, the cities in which HTS may be exempted had denser populations.
Conclusions
Although three-fourths of the largest cities in the U.S. disallow cigarette smoking in bars, HTS may be permitted in nearly 90% of these cities via exemptions. Closing this gap in clean air regulation may significantly reduce exposure to HTS.
doi:10.2105/AJPH.2012.300838
PMCID: PMC3482044  PMID: 22827447
9.  A Comparison of Cigarette- and Hookah-Related Videos on YouTube 
Tobacco control  2012;22(5):319-323.
Objective
YouTube is now the second most visited site on the Internet. We 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 3 trained qualitative researchers used an iterative approach to develop and refine definitions for the coding of variables, 2 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 and 102,307 for hookahs (P<.001). However, the number of comments per 1,000 views was significantly lower for cigarette-related videos than for hookah-related videos (1.6 vs 2.5, P=.003). There was no significant difference in the number of “like” designations per 100 reactions (91 vs. 87, P=.39). Cigarette-related videos were less likely than hookah-related videos to portray tobacco use in a positive light (24% vs. 92%, P<.001). In addition, cigarette-related videos were more likely to be of high production quality (42% vs. 5%, P<.001), to mention short-term consequences (50% vs. 18%, P<.001) and long-term consequences (44% vs. 2%, P<.001) of tobacco use, to contain explicit antismoking messages (39% vs. 0%, P<.001), and to provide specific information on how to quit tobacco use (21% vs. 0%, P<.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 programs to correct common misconceptions regarding hookah use.
doi:10.1136/tobaccocontrol-2011-050253
PMCID: PMC3655091  PMID: 22363069
waterpipe; hookah; cigarette; internet; user-generated content
10.  Teaching Health Literacy Using Popular Television Programming: A Qualitative Pilot Study 
Background
Teaching of health and medical concepts in the K-12 curriculum may help improve health literacy.
Purpose
The purpose of this project was to determine acceptability and preliminary efficacy of pilot implementation of a health literacy curriculum using brief clips from a popular television program.
Methods
Participants included 55 ninth-grade students in a low-income school with a high proportion of minority students. The curriculum used three brief interspersed segments from the television show ER to teach basic topics in cardiology. After the 30-minute experimental curriculum, students completed open-ended surveys which were coded qualitatively.
Result
The most common codes described “enjoyment” (N=28), “acquisition of new knowledge” (N=28), “informative” (N=15), “interesting” (N=12), and “TV/video” (N=10). We found on average 2.9 examples of medical content per participant. Of the 26 spontaneously-generated verifiable statements, 24 (92.3%) were judged as accurate by two independent coders (κ=0.70, P=.0002).
Discussion
Use of brief segments of video material contributed to the acceptability of health education curricula without detracting from students’ acquisition of accurate information.
Translation to Health Education Practice
Health education practitioners may wish to include brief clips from popular programming to motivate students and provide context for health-related lessons.
doi:10.1080/19325037.2010.10598856
PMCID: PMC3757562  PMID: 23998135
11.  Tobacco, Marijuana, and Alcohol Use in University Students: A Cluster Analysis 
Objective
Segmentation of populations may facilitate development of targeted substance abuse prevention programs. We aimed to partition a national sample of university students according to profiles based on substance use.
Participants
We used 2008–2009 data from the National College Health Assessment from the American College Health Association. Our sample consisted of 111,245 individuals from 158 institutions.
Method
We partitioned the sample using cluster analysis according to current substance use behaviors. We examined the association of cluster membership with individual and institutional characteristics.
Results
Cluster analysis yielded six distinct clusters. Three individual factors—gender, year in school, and fraternity/sorority membership—were the most strongly associated with cluster membership.
Conclusions
In a large sample of university students, we were able to identify six distinct patterns of substance abuse. It may be valuable to target specific populations of college-aged substance users based on individual factors. However, comprehensive intervention will require a multifaceted approach.
doi:10.1080/07448481.2012.663840
PMCID: PMC3401532  PMID: 22686360
University; tobacco; marijuana; alcohol; cluster analysis
12.  Motives for Smoking in Movies Affect Future Smoking Risk in Middle School Students: An Experimental Investigation 
Drug and Alcohol Dependence  2011;123(1-3):66-71.
Background
Exposure to smoking in movies has been linked to adolescent smoking uptake. However, beyond linking amount of exposure to smoking in movies with adolescent smoking, whether the way that smoking is portrayed in movies matters for influencing adolescent smoking has not been investigated. This study experimentally examined how motivation for smoking depicted in movies affects self-reported future smoking risk (a composite measure with items that assess smoking refusal self-efficacy and smoking intentions) among early adolescents.
Methods
A randomized laboratory experiment was used. Adolescents were exposed to movie scenes depicting one of three movie smoking motives: social smoking motive (characters smoked to facilitate social interaction); relaxation smoking motive (characters smoked to relax); or no smoking motive (characters smoked with no apparent motive, i.e., in neutral contexts and/or with neutral affect). Responses to these movie scenes were contrasted (within subjects) to participants’ responses to control movie scenes in which no smoking was present; these control scenes matched to the smoking scenes with the same characters in similar situations but where no smoking was present. A total of 358 adolescents, aged 11–14 years, participated.
Results
Compared with participants exposed to movie scenes depicting characters smoking with no clear motive, adolescents exposed to movie scenes depicting characters smoking for social motives and adolescents exposed to movie scenes depicting characters smoking for relaxation motives had significantly greater chances of having increases in their future smoking risk.
Conclusions
Exposure to movies that portray smoking motives places adolescents at particular risk for future smoking.
doi:10.1016/j.drugalcdep.2011.10.019
PMCID: PMC3288217  PMID: 22074766
tobacco; smoking; advertising; marketing; adolescence
13.  Role of Video Games in Improving Health-Related Outcomes 
Context
Video games represent a multibillion-dollar industry in the U.S. Although video gaming has been associated with many negative health consequences, it may also 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.
doi:10.1016/j.amepre.2012.02.023
PMCID: PMC3391574  PMID: 22608382
14.  Association of Media Literacy With Cigarette Smoking Among Youth in Jujuy, Argentina 
Nicotine & Tobacco Research  2011;14(5):516-521.
Introduction:
Latin America has the highest prevalence of tobacco use by youth. Higher media literacy, defined as the ability to analyze and evaluate media messages, has been associated with lower smoking among youth in the United States. The objective of this study was to determine whether media literacy related to smoking is independently associated with current smoking and susceptibility to future smoking in a sample of mostly indigenous youth in Jujuy, Argentina.
Methods:
In 2006, a self-administered survey was conducted among 10th grade students sampled from 27 randomly selected urban and rural schools in Jujuy. Survey items measured smoking behavior (ever, never, and current), susceptibility to future smoking among never-smokers (definitely not accept a cigarette from a friend or to smoke in the future), 5 items assessing smoking media literacy (SML), and risk factors for smoking.
Results:
Of the 3,470 respondents, 1,170 (34%) reported having smoked in the previous 30 days (current). Of the 1,430 students who had never smoked, 912 (64%) were susceptible to future smoking. High media literacy was present in 38%. Using multiple logistic regression, fully adjusted models showed that high media literacy was significantly associated as a protective factor of being a current smoker (odds ratio [OR] = 0.81; 95% CI = 0.67–0.97) and of being susceptible to future smoking (OR = 0.73; 95% CI = 0.58–0.92) among those who had never smoked.
Conclusions:
Among youth in Jujuy, higher SML was significantly associated with both lower current smoking and susceptibility to future smoking. Teaching SML may be a valuable component in a prevention intervention in this population.
doi:10.1093/ntr/ntr240
PMCID: PMC3337534  PMID: 22193569
15.  Association of Established Smoking Among Adolescents With Timing of Exposure to Smoking Depicted in Movies 
Background
It is not known whether exposure to smoking depicted in movies carries greater influence during early or late adolescence. We aimed to quantify the independent relative contribution to established smoking of exposure to smoking depicted in movies during both early and late adolescence.
Methods
We prospectively assessed 2049 nonsmoking students recruited from 14 randomly selected public schools in New Hampshire and Vermont. At baseline enrollment, students aged 10–14 years completed a written survey to determine personal, family, and sociodemographic characteristics and exposure to depictions of smoking in the movies (early exposure). Seven years later, we conducted follow-up telephone interviews to ascertain follow-up exposure to movie smoking (late exposure) and smoking behavior. We used multiple regression models to assess associations between early and late exposure and development of established smoking.
Results
One-sixth (17.3%) of the sample progressed to established smoking. In analyses that controlled for covariates and included early and late exposure in the same model, we found that students in the highest quartile for early exposure had 73% greater risk of established smoking than those in the lowest quartile for early exposure (27.8% vs 8.6%; relative risk for Q4 vs Q1 = 1.73, 95% confidence interval = 1.14 to 2.62). However, late exposure to depictions of smoking in movies was not statistically significantly associated with established smoking (22.1% vs 14.0%; relative risk for Q4 vs Q1 = 1.13, 95% confidence interval = 0.89 to 1.44). Whereas 31.6% of established smoking was attributable to early exposure, only an additional 5.3% was attributable to late exposure.
Conclusions
Early exposure to smoking depicted in movies is associated with established smoking among adolescents. Educational and policy-related interventions should focus on minimizing early exposure to smoking depicted in movies.
doi:10.1093/jnci/djs138
PMCID: PMC3317882  PMID: 22423010
16.  Alcohol Brand Appearances in U.S. Popular Music 
Addiction (Abingdon, England)  2011;107(3):557-566.
Aims
The average US adolescent is exposed to 34 references to alcohol in popular music daily. Although brand recognition is an independent, potent risk factor for alcohol outcomes among adolescents, alcohol brand appearances in popular music have not been systematically assessed. We aimed to determine the prevalence of and contextual elements associated with alcohol brand appearances in U.S. popular music.
Design
Qualitative content analysis.
Setting
We used Billboard Magazine to identify songs to which US adolescents were most exposed in 2005-2007. For each of the 793 songs, two trained coders independently analyzed the lyrics of each song for references to alcohol and alcohol brand appearances. Subsequent in-depth assessments utilised Atlas.ti to determine contextual factors associated with each of the alcohol brand appearances.
Measurements
Our final code book contained 27 relevant codes representing 6 categories: alcohol types, consequences, emotional states, activities, status, and objects.
Findings
Average inter-rater reliability was high (κ=0.80), and all differences were easily adjudicated. Of the 793 songs in our sample, 169 (21.3%) explicitly referred to alcohol, and of those, 41 (24.3%) contained an alcohol brand appearance. Consequences associated with alcohol were more often positive than negative (41.5% vs. 17.1%, P<.001). Alcohol brand appearances were commonly associated with wealth (63.4%), sex (58.5%), luxury objects (51.2%), partying (48.8%), other drugs (43.9%), and vehicles (39.0%).
Conclusions
One-in-five songs sampled from U.S. popular music had explicit references to alcohol, and one quarter of these mentioned a specific alcohol brand. These alcohol brand appearances are commonly associated with a luxury lifestyle characterised by wealth, sex, partying, and other drugs.
doi:10.1111/j.1360-0443.2011.03649.x
PMCID: PMC3273659  PMID: 22011113
Alcohol; music; product placement; marketing; advertising; adolescent; vodka; tequila; rap music; hip-hop music; country music
17.  Processes of Care and Outcomes for Community-Acquired Pneumonia 
The American journal of medicine  2011;124(12):1175.e9-1175.17.
BACKGROUND
Although processes of care are common proxies for health care quality, their associations with medical outcomes remain uncertain.
METHODS
For 2076 patients hospitalized with pneumonia from 32 emergency departments, we used multilevel logistic regression modeling to assess independent associations between patient outcomes and the performance of 4 individual processes of care (assessment of oxygenation, blood cultures, and rapid initiation [<4 hours] and appropriate selection of antibiotic therapy) and the cumulative number of processes of care performed.
RESULTS
Overall, 141 patients (6.8%) died. Mortality was 0.3% to 1.7% lower for patients who had each of the individual processes of care performed (P ≥ .13 for each comparison); mortality was 7.5% for patients who had 0 to 2 processes of care, 7.2% for those with 3 processes of care, and 5.8% for those with all 4 processes of care performed (P = .39). Mortality was not significantly associated with either individual or cumulative process measures in multivariable models.
CONCLUSION
Neither the individual processes of care nor the cumulative number performed is associated with short-term mortality for pneumonia.
doi:10.1016/j.amjmed.2011.05.029
PMCID: PMC3578284  PMID: 22000624
Pneumonia; Processes of care; Quality of care
18.  Review: Minimal interventions (e.g., a letter) reduce long-term benzodiazepine use in primary care 
Annals of internal medicine  2012;156(4):JC2-J08.
doi:10.1059/0003-4819-156-4-201202210-02008
PMCID: PMC3578286  PMID: 22351734
19.  Waterpipe Tobacco and Cigarette Smoking Among University Students in Jordan 
Setting
While waterpipe and cigarette smoking are well studied in Syria and Lebanon, data from Jordan are sparse.
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, and 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. Compared with males, females had substantially lower odds 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. Compared with waterpipe tobacco smoking, current cigarette smoking was more significantly associated with markers of high socioeconomic status.
Conclusion
Waterpipe tobacco smoking is as common as cigarette smoking among Jordanian university students. While cigarette smoking is consistently associated with high socioeconomic status, waterpipe tobacco smoking is more evenly distributed across various populations.
doi:10.5588/ijtld.11.0764
PMCID: PMC3570564  PMID: 22525279
hookah; narghile; college; Middle East
20.  U.S. Hookah Tobacco Smoking Establishments Advertised on the Internet 
Background
Establishments dedicated to hookah tobacco smoking have recently 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 (Cohen’s 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.
doi:10.1016/j.amepre.2011.10.013
PMCID: PMC3391575  PMID: 22261211
21.  A Comprehensive Career-Success Model for Physician-Scientists 
With today’s focus on the translation of basic science discoveries into clinical practice, the demand for physician-scientists is growing. Yet, physicians have always found it challenging to juggle the demands of clinical care with the time required to perform research. The Research on Careers Workgroup of the Institute for Clinical Research Education at the University of Pittsburgh developed a comprehensive model for career success that would address, and allow for the evaluation of, the personal factors, organizational factors, and their interplay that contribute to career success. With this model, leaders of training programs could identify early opportunities for intervening with potential physician-scientists to ensure career success. Through an iterative process described in this article, the authors identified and examined potential models for career success from the literature, added other elements determined to be significant, and developed a comprehensive model to assess factors associated with career success for physician-scientists. The authors also present examples of ways in which this model can be adapted and applied to specific situations to assess the effects of different factors on career success.
doi:10.1097/ACM.0b013e31823592fd
PMCID: PMC3228877  PMID: 22030759
22.  Public Directory Data Sources Do Not Accurately Characterize the Food Environment in Two Predominantly Rural States 
Communities are being encouraged to develop locally-based interventions to address environmental risk factors for obesity. Online public directories represent an affordable and easily accessible mechanism for mapping community food environments, but may have limited utility in rural areas. The primary aim of this study was to evaluate the efficacy of public directories versus rigorous onsite field verification to characterize the community food environment in 32 geographically-dispersed towns from two rural states, covering 1237.6 square miles. Eight types of food outlets were assessed in 2007, including food markets and eating establishments, first using two publically available online directories followed by onsite field verification by trained coders. Chi-square and univariate binomial regression were used to determine whether the proportion of outlets accurately listed varied by food outlet type or town population. Among 1340 identified outlets, only 36.9% were accurately listed through public directories; 29.6% were not listed but were located during field observation. Accuracy varied by outlet type, being most accurate for big box stores and least accurate for farm/produce stands. Overall, public directories accurately identified less than half of the food outlets. Accuracy was significantly lower for rural and small towns compared to mid-size and urban towns. In this geographic sample, public directories seriously misrepresented the actual distribution of food outlets, particularly for rural and small towns. To inform local obesity-prevention efforts, communities should strongly consider utilizing field verification to characterize the food environment in low population areas.
doi:10.1016/j.jada.2011.01.008
PMCID: PMC3119892  PMID: 21443992
Food outlets; rural; fast food; convenience store; field validation; obesity
23.  Smoking motives in movies are important for understanding adolescent smoking: A preliminary investigation 
Nicotine & Tobacco Research  2010;12(8):850-854.
Introduction:
Exposure to smoking in movies is strongly associated with smoking uptake and maintenance among adolescents. However, little is known about what features of movies (e.g., the context for smoking or motives for a character smoking) moderate the association between exposure to movie smoking and adolescent smoking. This laboratory study examined whether exposure to movie smoking that is portrayed as having a clear motive is associated with the desire to smoke differently than smoking that is portrayed as having no clear motive.
Methods:
A sample of 77 middle school students (mean age of 12.8 years, 62% male, 60% Caucasian) viewed movie clips that portrayed smoking as helping to facilitate social interaction, to relax, to appear rebellious, or as having no clear motive. After exposure to each clip, participants rated their desire to smoke.
Results:
Exposure to clips where smoking was portrayed as helping characters to relax was associated with a significantly stronger desire to smoke compared with clips where the motive for smoking was unclear. Desire to smoke was similar for clips where no motive was clear, social smoking clips, and rebellious smoking clips.
Discussion:
These results suggest that the way that smoking is portrayed in movies is important in determining its effect on adolescent smoking.
doi:10.1093/ntr/ntq099
PMCID: PMC2917740  PMID: 20576800
24.  Burnout among early-career clinical investigators 
Background
Burnout is a pervasive problem among clinicians. However, little is known about burnout among early-career clinical investigators, who must balance clinical responsibilities with challenges related to research. We aimed to determine the prevalence of and demographic associations with burnout in a cohort of early-career clinical investigators.
Methods
A cross-sectional questionnaire was administered to 179 trainees at the University of Pittsburgh Institute for Clinical Research Education in 2007-2008. We used chi-square analyses and Fisher’s exact test to determine whether associations between demographic characteristics and burnout were significant.
Results
Of the participants, 29 (16%) reported feeling burned out. Burnout was more prevalent among those over 35 years of age relative to their younger counterparts (29% vs. 13%, p=.01) and among females relative to males (22% vs. 10%, p=.03). With regard to race and ethnicity, burnout was most common among underrepresented minorities (30%) followed by Caucasians (18%) and Asians (3%); these differences were significant (p=.02).
Discussion
Considering the early-career status of these research trainees, rates of burnout were concerning. Certain demographic subgroups—including older trainees, females, and underrepresented minorities—had particularly high rates of burnout and may benefit from interventions that provide them with skills needed to sustain successful clinical research careers.
doi:10.1111/j.1752-8062.2010.00202.x
PMCID: PMC2925292  PMID: 20718821
Burnout; clinical researchers; exhaustion; cynicism; under-represented minority; African-American; Hispanic; female; clinical research training programs
25.  College students and use of K2: an emerging drug of abuse in young persons 
Background
K2 or "spice" has emerged as a popular legal alternative to marijuana among adolescents and young adults. However, no data has been published assessing prevalence of and associations with ever K2 use in any population. This study's aims were to examine prevalence of ever K2 use among a sample of college students, to determine characteristics of persons who use K2, and to access the association between K2 and other drug use.
Findings
Ever use of K2 was reported by 69 (8%) of the sample of 852 college students. Response rate was 36%. Bivariate and multivariate analyses assessed whether sociodemographic characteristics and other drug use were associated with ever use of K2. Ever use of K2 was reported by 69 (8%) of the sample. Among these 69 individuals, 61 (88%) had used a cigarette and 25 (36%) had used a hookah to smoke K2. In multivariate analyses, K2 use was more common in males (vs. females, adjusted Odds Ratio (aOR) = 2.0, 95% Confidence Interval (CI) = 1.2-3.5, p = 0.01) and 1st or 2nd year college students (vs. 3rd year or above, aOR = 2.4, 95% CI = 1.2-5.0, p = 0.02).
Conclusions
Ever use of K2 in this sample was higher than ever use of many other drugs of abuse that are commonly monitored in adolescents and young adults. Although DEA had banned five synthetic cannabinoids recently, clinicians and public health officials concerned with substance abuse in youth should be aware of and monitor the use of this drug in college students over time.
doi:10.1186/1747-597X-6-16
PMCID: PMC3142218  PMID: 21745369

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