Patterns in Tobacco, E-Cigarette, and Cannabis Advertising Exposure Among California Adolescents and Associations With Future Use Expectations

BACKGROUND

Exposure to tobacco, e-cigarette, or cannabis marketing is associated with adolescent use. Few studies have examined advertising exposure prevalence and patterns across these products concurrently.

METHODS

This study assessed past 30-day recalled exposure to promotional messages about tobacco, e-cigarettes ("vapes" on the survey), and cannabis ("marijuana") from various sources among California adolescents (ages 12-17) in the 2022 Teens, Nicotine, and Tobacco Online Survey (N = 2530). Principal components analysis (PCA) was conducted to examine the underlying structure and patterns in advertising exposure sources. Multivariable logistic regression was used to evaluate associations between any advertising exposure and future use expectations (a susceptibility measure) in one year and at age 25 among current never-users.

RESULTS

Overall, 65.9% of participants recently noticed at least one tobacco (52.5%), vape (51.5%), or marijuana (45.6%) advertisement. Gas stations or convenience stores were the most common source for tobacco or vape ads; billboards were for marijuana ads. In PCA, advertising exposure patterns correlated with advertising source, not the type of product. Exposures from tobacco-specific sources and nearer point of sale were associated with current use, older age, LGBTQ + identity, and sensation seeking. Among never-users, advertising exposure was associated with one-year and age-25 use expectations for cigarettes (one-year expectations adjusted odds ratio: 1.7; 95% CI: 1.1, 2.5), vapes (2.3; 1.5, 3.5), and marijuana (2.1; 1.5, 3.0).

CONCLUSION

California adolescents' exposure to tobacco, e-cigarette, and cannabis marketing is common, follows similar patterns, and is associated with use susceptibility. Comprehensive restrictions on marketing accessible to adolescents could help prevent youth use.

"I think we can do without [tobacco]": support for policies to end the tobacco epidemic among California adolescents

INTRODUCTION

The tobacco endgame, policies aiming to end the commercial tobacco epidemic, requires sustained public support, including among youth. We assessed endgame support among California (USA) adolescents, including their reasons and associated participant and policy-specific factors.

METHODS

Teens, Nicotine and Tobacco Project online surveys (n=4827) and focus groups were conducted in 2021 and 2022 among California residents aged 12-17 years. Cross-sectional survey participants were asked their agreement level with eight policy statements related to tobacco and/or cannabis sales restrictions, use in public places and use in multiunit housing. Ordered logistic regression modelled level of agreement according to respondent characteristics, behaviours and statement content. Qualitative data were collected through focus groups (n=51 participants), which were analysed to provide insight into support for different policies.

RESULTS

Most survey participants agreed or strongly agreed with tobacco product sales restrictions (72%-75%, depending on the policy), bans on use in public spaces (76%-82%) and smoke-free (79%) and vape-free (74%) apartment buildings. Support was stronger among younger, female, Asian and tobacco non-using participants and for policies directed at 'tobacco' (vs 'vapes' or cannabis), at flavoured tobacco (compared with all tobacco), and when statements featured 'should end' (vs 'not allowed'). Focus group participants who were supportive viewed policies as protecting children from harmful products, while those less supportive cited concerns about limiting adults' freedoms and unintended consequences.

CONCLUSIONS

Most participants supported strong tobacco control policies. Public communication that promotes broader endgame benefits besides protecting youth and accelerates industry denormalisation may counter youth concerns and further bolster their support.

Flavors increase adolescents' willingness to try nicotine and cannabis vape products

BACKGROUND

Certain product characteristics, such as flavor, may increase adolescents' willingness to try vaped nicotine and cannabis (marijuana) products.

METHODS

A discrete choice experiment embedded within the 2021-2022 California Teens Nicotine and Tobacco Project Online Survey was administered to a non-probability sample of N = 2342 adolescents ages 12-17. Participants were sequentially presented four randomly-generated pairs of hypothetical vape products that varied in device type (disposable, refillable), content (nicotine, marijuana, "just vapor"), and flavor (seven options) and asked which of these (or neither) they would be more willing to try if a best friend offered. Conditional logistic regression quantified associations between product characteristics and participants' selections, including interactions by past 30-day use of e-cigarettes, marijuana, or both.

RESULTS

Candy/dessert, fruit, and fruit-ice combination flavors were all associated with greater willingness to try a vape product (versus tobacco flavor) among participants not using e-cigarettes or marijuana, those using only e-cigarettes, and those co-using e-cigarettes and marijuana. Among participants only using marijuana, the most preferred flavors were no flavor, candy/dessert, and icy/frost/menthol. Among participants not using e-cigarettes or marijuana, model-predicted willingness to try a displayed vape product was greater when products were sweet or fruit flavored than tobacco or unflavored, regardless of whether displayed options contained nicotine (fruit/sweet: 21 %, tobacco/unflavored: 4 %), marijuana (fruit/sweet: 18 %, tobacco/unflavored: 6 %), or "just vapor" (fruit/sweet: 29 %, tobacco/unflavored: 16 %).

CONCLUSIONS

In this online non-probability sample, flavors in nicotine and cannabis vape products increased adolescents' willingness to try them. Comprehensive bans on flavored vapes would likely reduce adolescent use.

Calibration and reliability testing of a novel asynchronous photographic plaque scoring system in young children

OBJECTIVES

The Simplified Oral Hygiene Index for Maxillary Incisors (OHI-MIS) is a novel plaque scoring system adapted for young children. This study describes calibration training and testing used to establish the inter- and intra-rater reliability for OHI-MIS measured from clinical photographs.

METHODS

Two raters from the Coordinated Oral Health Promotion Chicago (CO-OP) and one from the Behavioral EConomics for Oral health iNnovation (BEECON) randomized controlled trials (RCTs) underwent calibration with gold standard raters, followed by annual re-calibration. Raters from CO-OP also completed inter-rater reliability testing; all three raters completed intra-rater reliability testing rounds. Photographs were obtained from children aged 9-39 months.

RESULTS

All three raters achieved greater than 0.77 Lin's Concordance Correlation (LCC) versus gold standard consensus during calibration. All three raters had LCC ≥0.83 at recalibration 1 year later. CO-OP trial raters scored 604 photos (151 sets of 4 photographs); mostly both raters were somewhat/very confident in their scoring (≥89%), describing the most photos as "clear" (90% and 81%). The CO-OP inter-rater LCC for total OHI-MIS score was 0.86, changing little when low quality or confidence photos were removed. All three raters demonstrated high intra-rater reliability (≥0.83).

CONCLUSIONS

The OHI-MIS plaque scoring system on photos had good reliability within and between trials following protocol training and calibration. OHI-MIS provides a novel asynchronous plaque scoring system for use in young children. Non-clinicians in field or clinical settings can obtain photographs, offering new opportunities for research and clinical care.

Mediation analysis for count and zero-inflated count data

Different conventional and causal approaches have been proposed for mediation analysis to better understand the mechanism of a treatment. Count and zero-inflated count data occur in biomedicine, economics, and social sciences. This paper considers mediation analysis for count and zero-inflated count data under the potential outcome framework with nonlinear models. When there are post-treatment confounders which are independent of, or affected by, the treatment, we first define the direct, indirect, and total effects of our interest and then discuss various conditions under which the effects of interest can be identified. Proofs are provided for the sensitivity analysis proposed in the paper. Simulation studies show that the methods work well. We apply the methods to the Detroit Dental Health Project's Motivational Interviewing DVD trial for the direct and indirect effects of motivational interviewing on count and zero-inflated count dental caries outcomes.

Randomized Trial of Motivational Interviewing to Prevent Early Childhood Caries in American Indian Children

Introduction

In a randomized controlled trial, the effectiveness of motivational interviewing (MI) combined with enhanced community services (MI + ECS) was compared with ECS alone for reducing dental caries in American Indian children on the Pine Ridge Reservation. The intervention was developed and delivered with extensive tribal collaboration.

Methods

A total 579 mother-newborn dyads were enrolled and randomized to the MI + ECS and ECS groups. They were followed for 36 mo. Four MI sessions were provided, the first shortly after childbirth and then 6, 12, and 18 mo later. Both groups were exposed to ECS, which included public service announcements through billboards and tribal radio, as well as broad distribution of brochures on behavioral risk factors for early childhood caries (ECC), toothbrushes, and toothpaste. MI impact was measured as decayed, missing, and filled tooth surfaces (dmfs). Secondary outcomes included decayed surfaces, caries prevalence, and maternal oral health knowledge and behaviors. Modified intention-to-treat analyses were conducted. Eighty-eight percent of mothers completed at least 3 of 4 MI sessions offered.

Results

After 3 y, dmfs was not significantly different for the 2 groups (MI + ECS = 10, ECS = 10.38, P = 0.68). In both groups, prevalence of caries experience was 7% to 9% after 1 y, 35% to 36% at 2 y, and 55% to 56% at 3 y. Mean knowledge scores increased by 5.0, 5.3, and 5.9 percentage points at years 1, 2, and 3 in the MI + ECS group and by 1.9, 3.3, and 5.0 percentage points in the ECS group (P = 0.03), respectively. Mean maternal oral health behavior scores were not statistically significantly different between the treatment arms.

Conclusion

In summary, the MI intervention appeared to improve maternal knowledge but had no effect on oral health behaviors or on the progression of ECC (ClinicalTrials.gov NCT01116726).

Knowledge Transfer Statement

The findings of this study suggest that motivational interviewing focusing on parental behaviors may not be as effective as previously hoped for slowing the development of childhood caries in some high-risk groups. Furthermore, social factors may be even more salient determinants of oral health than what we previously supposed, perhaps interfering with the capacity to benefit from behavioral strategies that have been useful elsewhere. The improvement of children's oral health in high-risk populations characterized by poverty and multiple related life stresses may require more holistic approaches that address these formidable barriers.

Absence of Fluoride Varnish-Related Adverse Events in Caries Prevention Trials in Young Children, United States

Introduction

Fluoride varnish is an effective prevention intervention for caries in young children. Its routine use in clinical care is supported by meta-analyses and recommended by clinical guidelines, including the US Preventive Services Task Force (B rating). This report is the first prospective systematic assessment of adverse events related to fluoride varnish treatment in young children.

Methods

We determined the incidence of adverse events related to fluoride varnish treatment in 3 clinical trials on the prevention of early childhood caries, conducted under the auspices of the Early Childhood Caries Collaborating Centers, an initiative sponsored by the National Institute of Dental and Craniofacial Research. Each trial incorporated use of fluoride varnish in its protocol and systematically queried all children’s parents or legal guardians about the occurrence of acute adverse events after each fluoride varnish treatment.

Results

A total of 2,424 community-dwelling, dentate children aged 0 to 5 years were enrolled and followed for up to 3 years. These children received a cumulative total of 10,249 fluoride varnish treatments. On average, each child received 4.2 fluoride varnish treatments. We found zero fluoride varnish–related adverse events.

Conclusion

Fluoride varnish was not associated with treatment-related adverse events in young children. Our findings support its safety as an effective prevention intervention for caries in young children.

A Cluster-Randomized, Community-Based, Tribally Delivered Oral Health Promotion Trial in Navajo Head Start Children

The authors tested the effectiveness of a community-based, tribally delivered oral health promotion (OHP) intervention (INT) at reducing caries increment in Navajo children attending Head Start. In a 3-y cluster-randomized trial, we developed an OHP INT with Navajo input that was delivered by trained Navajo lay health workers to children attending 52 Navajo Head Start classrooms (26 INT, 26 usual care [UC]). The INT was designed as a highly personalized set of oral health-focused interactions (5 for children and 4 for parents), along with 4 fluoride varnish applications delivered in Head Start during academic years of 2011 to 2012 and 2012 to 2013. The authors evaluated INT impact on decayed, missing, and filled tooth surfaces (dmfs) increment compared with UC. Other outcomes included caries prevalence and caregiver oral health-related knowledge and behaviors. Modified intention-to-treat and per-protocol analyses were conducted. The authors enrolled 1,016 caregiver-child dyads. Baseline mean dmfs/caries prevalence equaled 19.9/86.5% for the INT group and 22.8/90.1% for the UC group, respectively. INT adherence was 53% (i.e., ≥3 child OHP events, ≥1 caregiver OHP events, and ≥3 fluoride varnish). After 3 y, dmfs increased in both groups (+12.9 INT vs. +10.8 UC; P = 0.216), as did caries prevalence (86.5% to 96.6% INT vs. 90.1% to 98.2% UC; P = 0.808) in a modified intention-to-treat analysis of 897 caregiver-child dyads receiving 1 y of INT. Caregiver oral health knowledge scores improved in both groups (75.1% to 81.2% INT vs. 73.6% to 79.5% UC; P = 0.369). Caregiver oral health behavior scores improved more rapidly in the INT group versus the UC group (P = 0.006). The dmfs increment was smaller among adherent INT children (+8.9) than among UC children (+10.8; P = 0.028) in a per-protocol analysis. In conclusion, the severity of dental disease in Navajo Head Start children is extreme and difficult to improve. The authors argue that successful approaches to prevention may require even more highly personalized approaches shaped by cultural perspectives and attentive to the social determinants of oral health (ClinicalTrials.gov NCT01116739).

Understanding treatment effect mechanisms of the CAMBRA randomized trial in reducing caries increment

The Caries Management By Risk Assessment (CAMBRA) randomized controlled trial showed that an intervention featuring combined antibacterial and fluoride therapy significantly reduced bacterial load and suggested reduced caries increment in adults with 1 to 7 baseline cavitated teeth. While trial results speak to the overall effectiveness of an intervention, insight can be gained from understanding the mechanism by which an intervention acts on putative intermediate variables (mediators) to affect outcomes. This study conducted mediation analyses on 109 participants who completed the trial to understand whether the intervention reduced caries increment through its action on potential mediators (oral bacterial load, fluoride levels, and overall caries risk based on the composite of bacterial challenge and salivary fluoride) between the intervention and dental outcomes. The primary outcome was the increment from baseline in decayed, missing, and filled permanent surfaces (ΔDMFS) 24 mo after completing restorations for baseline cavitated lesions. Analyses adjusted for baseline overall risk, bacterial challenge, and fluoride values under a potential outcome framework using generalized linear models. Overall, the CAMBRA intervention was suggestive in reducing the 24-mo DMFS increment (reduction in ΔDMFS: -0.96; 95% confidence interval [CI]: -2.01 to 0.08; P = 0.07); the intervention significantly reduced the 12-mo overall risk (reduction in overall risk: -19%; 95% CI, -7 to -41%;], P = 0.005). Individual mediators, salivary log10 mutans streptococci, log10 lactobacilli, and fluoride level, did not represent statistically significant pathways alone through which the intervention effect was transmitted. However, 36% of the intervention effect on 24-mo DMFS increment was through a mediation effect on 12-mo overall risk (P = 0.03). These findings suggest a greater intervention effect carried through the combined action on multiple aspects of the caries process rather than through any single factor. In addition, a substantial portion of the total effect of the CAMBRA intervention may have operated through unanticipated or unmeasured pathways not included among the potential mediators studied.

Functional remineralization of dentin lesions using polymer-induced liquid-precursor process

It was hypothesized that applying the polymer-induced liquid-precursor (PILP) system to artificial lesions would result in time-dependent functional remineralization of carious dentin lesions that restores the mechanical properties of demineralized dentin matrix. 140 µm deep artificial caries lesions were remineralized via the PILP process for 7–28 days at 37°C to determine temporal remineralization characteristics. Poly-L-aspartic acid (27 KDa) was used as the polymeric process-directing agent and was added to the remineralization solution at a calcium-to-phosphate ratio of 2.14 (mol/mol). Nanomechanical properties of hydrated artificial lesions had a low reduced elastic modulus (E_R = 0.2 GPa) region extending about 70 μm into the lesion, with a sloped region to about 140 μm where values reached normal dentin (18–20 GPa). After 7 days specimens recovered mechanical properties in the sloped region by 51% compared to the artificial lesion. Between 7–14 days, recovery of the outer portion of the lesion continued to a level of about 10 GPa with 74% improvement. 28 days of PILP mineralization resulted in 91% improvement of E_R compared to the artificial lesion. These differences were statistically significant as determined from change-point diagrams. Mineral profiles determined by micro x-ray computed tomography were shallower than those determined by nanoindentation, and showed similar changes over time, but full mineral recovery occurred after 14 days in both the outer and sloped portions of the lesion. Scanning electron microscopy and energy dispersive x-ray analysis showed similar morphologies that were distinct from normal dentin with a clear line of demarcation between the outer and sloped portions of the lesion. Transmission electron microscopy and selected area electron diffraction showed that the starting lesions contained some residual mineral in the outer portions, which exhibited poor crystallinity. During remineralization, intrafibrillar mineral increased and crystallinity improved with intrafibrillar mineral exhibiting the orientation found in normal dentin or bone.

Caregiver acceptability and preferences for preventive dental treatments for young African-American children

Our prior research focused on parental treatment acceptability (TA) and treatment preferences (TPs) for preventive dental treatments for young Hispanic children. We adapted the interview for administration to parents of young African-American children.

OBJECTIVE

In a sample of African-American parents, determine parental TA and TP for five dental treatments to prevent early childhood caries.

METHODS

Interviewed 48 parents/caregivers of African-American children attending Head Start, assessing TA and TP for three treatments for children: toothbrushing (TB) with fluoride toothpaste, fluoride varnish (FV), and xylitol in food (XF); and two treatments for mothers: xylitol gum (XG) and chlorhexidine (CHX) rinse. The interview included verbal information, illustrated treatment cards, photos/video clips, and samples. Parents provided TA of each treatment (one to five scale), TP between each of 10 pairs of the five treatments, and open-ended reasons for their preferences. TPs were summed (zero to four) to create overall preference.

RESULTS

All treatments were acceptable (means 4.4-4.9). TB was more acceptable than FV and XF (P < 0.05). Summed TP revealed a strong preference for TB (mean 3.1) above other treatments (all P < 0.01). Primary reasons for preferring TB were the following: promotes healthy habits; child focused; and effectiveness.

CONCLUSIONS

All treatments were acceptable, however, parents/guardians strongly preferred TB. Parents' emphasis on healthy habits and child-focused treatment supports efforts for oral health education programs in early childhood settings. Some parents expressed concerns about FV, XF, and CHX. Results may be useful in planning prevention programs for young children in African-American communities.

Dose-Weighted Adjusted Mantel-Haenszel Tests for Numeric Scaled Strata in a Randomized Trial

A recent three-arm parallel groups randomized clinical prevention trial had a protocol deviation causing participants to have fewer active doses of an in-office treatment than planned. The original statistical analysis plan stipulated a minimal assumption randomization-based extended Mantel-Haenszel (EMH) trend test of the high frequency, low frequency, and zero frequency treatment groups and a binary outcome. Thus a dose-weighted adjusted EMH (DWAEMH) test was developed with an extra set of weights corresponding to the number of active doses actually available, in the spirit of a pattern mixture model. The method can easily be implemented using standard statistical software. A set of Monte Carlo simulations using a logistic model was undertaken with (and without) actual dose-response effects through 1000 replicates for empirical power estimates (and 2100 for empirical size). Results showed size was maintained and power was improved for DWAEMH versus EMH and logistic regression Wald tests in the presence of a dose effect and treatment by dose interaction.

Language and literacy relate to lack of children's dental sealant use

OBJECTIVES

This study aimed to determine the percent of California's third grade public school children lacking sealants by child and family factors and to measure social disparities for lacking sealants.

METHODS

The study analyzed data from the California Oral Health Needs Assessment (COHNA) 2004-2005, a complex stratified cluster sample of children (n = 10,450) from 182 randomly selected public elementary schools in California. The dependent variable was absence of sealants in first permanent molars. The independent variables included child race/ethnicity; socio-economic position (SEP) measured as child's participation in the free or reduced-price lunch program at the individual and school level; acculturation measured as language spoken at home and school level percent of English language learners; and parent functional health literacy measured as correctly following questionnaire instructions. Absolute differences and health disparity indices (i.e. Slope Index of Inequality, Relative Index of Inequality-mean, Absolute Concentration Index) were used to measure absolute and relative disparities.

RESULTS

The percent of children lacking sealants was high in all racial/ethnic groups; no child or school level SEP differences in lacking sealants were seen, but significant differences existed by acculturation (child and school level) and parental functional health literacy.

CONCLUSIONS

NonEnglish language and poor parental functional health literacy are potential barriers that need to be addressed to overcome disparities in sealant utilization.

Developing an acceptability assessment of preventive dental treatments

OBJECTIVES

Early childhood caries (ECC) is very prevalent among young Hispanic children. ECC is amenable to a variety of preventive procedures, yet many Hispanic families underutilize dental services. Acceptability research may assist in health care planning and resource allocation by identifying patient preferences among efficacious treatments with the goal of improving their utilization. The purposes of this study were (a) to develop a culturally competent acceptability assessment instrument, directed toward the caregivers of young Hispanic children, for five preventive dental treatments for ECC and (b) to test the instrument's reliability and validity.

METHODS

An instrument of five standard treatments known to prevent ECC was developed, translated, reviewed by focus groups, and pilot tested, then tested for reliability The instrument included illustrated cards, brief video clips, and samples of the treatments and was culturally appropriate for low-income Hispanic caregivers. In addition to determining the acceptability of the five treatments individually, the treatments were also presented as paired comparisons.

RESULTS

Focus groups and debriefing interviews following the pilot tests established that the instrument has good face validity. The illustrated cards, product samples, and video demonstrations of the five treatments resulted in an instrument possessing good content validity. The instrument has good to excellent test-retest reliability, with identical time 1-time 2 responses for each of the five treatments 92 percent of the time (range 87 to 97 percent), and the same treatment of the paired comparisons preferred 75 percent of the time (range 61 to 90 percent).

CONCLUSIONS

The acceptability instrument described is reliable and valid and may be useful in program planning efforts to identify and increase the utilization of preferred ECC preventive treatments for target populations.