Identifying the changes in the retail density of specialized tobacco and/or vape shops and general tobacco vendors can help understand trends in the density of retail markets and inform effective policy approach to reduce the availability of tobacco. Data on licensed tobacco retailers within California from 2015-2019 was obtained from the California Department of Tax and Fee Administration. Store type was categorized and annotated using Yelp, a crowd-sourcing business directory service. Geolocations were aggregated at the county level for visualizing and analyzing trends in tobacco retail density. Repeated measures ANOVA and mixed effects model were used to analyze the longitudinal trend in retail density before and after adjusting for covariates such as age, gender, income, race and ethnicity. The number of active tobacco retailer licenses increased from 19,825 in 2015 to 25,635 in 2019. The highest percent increase in tobacco retailer licenses (9.1%) was observed in 2017. The retail density was highest in Los Angeles, San Diego, and Riverside counties for specialized tobacco storefronts. The mixed effects model demonstrated a significant increase in the number of active licenses under all store categories after controlling for population. The time effect was significant for increase in the number of active licenses for non-specific tobacco retailer stores after adjusting for covariates. Significant covariates included female population, median household income, Hispanic population. Monitoring the distribution of tobacco retail density and associated sociodemographic factors for change over time can help identify the type, location, and point-of-sale marketing exposures to tobacco products.

Background: To curb smoking rates, the World Health Organizations’ Framework Convention on Tobacco Control recommends that countries ban all forms of tobacco advertising and restrict the use of certain terminology on packaging and branding. However, in many countries, including the United States, tobacco remains one of the most heavily marketed consumer goods. Through a series of studies I explore several issues pertaining to the marketing of tobacco products including: whether some brands act as “starter-brands” for young adults (Chapter 2), whether certain marketing practices make cigarettes seem “safer” (Chapter 3) or more appealing (Chapter 4) than other brands and how removing branding from packaging impacts these perceptions (Chapters 3 and 4).

Methods: This document is composed of three independent studies. The data for Chapter 2 are derived from a national survey of US adults known as the Population Assessment of Tobacco Use and Health (“the PATH study”), while the data for Chapters 2 & 3 were gathered using a web-based marketing experiment.

Results: In Chapter 2 we identified 13 sub-brands on the US market that were used more frequently by young adults than among the rest of adult smokers. Nine of these 13 sub-brands were menthol-flavored, three contained menthol “crush” capsules and two were from a new lower-cost Marlboro line called “Marlboro Black.” The second study suggested that packaging of a brand of cigarettes called Natural American Spirit conveys the brand is safer and that removing tobacco branding alters this perception. The final study suggests that the packaging of US cigarette brands differentiate in terms the perceived attractiveness of the pack, the perceived taste and harshness, and the social image they convey about their consumers and that standardized packaging both reduces these perceptions and forces brands to appear more similar in terms of these perceptions.

Conclusion: These data suggest that many US cigarette brands contain marketing features that are appealing to health-concerned smokers and young adults. The data also suggest that standardized packaging would constrain the ability of manufacturers to market to these consumer groups through their packaging.

Background: The United States (US) is the only high-income country that has not mandated Graphic Warning Labels (GWLs) on cigarette packaging. Pack imagery is a key element of tobacco marketing aimed at generating brand appeal to encourage continued smoking. Removing industry imagery should neutralize reactions to packaging thus lessening appeal and weakening the product’s perceived value. Adding GWLs should go further and replace appeal with aversion thus generating negative responses and subtracting from perceived valuations. Methods: This dissertation consists of three studies using data from the CASA randomized controlled trial examining the effects of cigarette packaging on smoking cognitions and behavior. Study 1 quantified smokers’ initial reactions as they examined packaging design options (i.e., own US pack, Blank pack devoid of industry imagery, and three GWL plain packs). Study 2 evaluated the psychometric properties of a 6-item measure of brand appeal for cigarette packaging. Study 3 identified the change in smokers’ appeal-aversion valuations via a willingness-to-pay assessment of packaging options after randomization to a 3-month intervention involving smokers purchasing their cigarettes repackaged into one of three pack options. Results: Smokers had largely positive reactions to their own packs, neutral reactions to the blank pack, and graded negative reactions to GWL packs that aligned with expressions of disgust, anger, fear, and sadness. Strong scalability, internal consistency, concurrent validity, and predictive validity was found for the brand appeal measure. We found upfront positive valuations (i.e., appeal) for smokers’ Own Packs, weakened yet still positive valuations for the Blank Pack, and negative valuations (i.e., aversion) for GWLs. After 3-month exposure, minimal change in willingness-to-pay was observed: appeal-aversion valuations did not change among those randomized to use their own packs, while those randomized to use Blank and GWL packs were less price aversive to GWL imagery that provoked high negative affect. Conclusion: The findings indicate that industry-designed packaging generates appeal and positive affect among adult US daily smokers. Removing industry imagery temporarily neutralizes this response and adding GWLs engenders aversion and negative affect which may decrease following repeated exposure. Plain GWL packaging would seem to be an important component of an effective tobacco control strategy.

BackgroundThe political determinants of health are pronounced in the Palestinian community, particularly among Palestinian adolescents, due to living under Israeli military occupation. Understanding the consequences of such determinants that contribute to stress as structural violence, forced displacement, discrimination, and marginalization is vital to grasp its role on the health and health management of Palestinian adolescents living in Palestine. This dissertation examines the relationship of psychosocial stressors on Palestinian adolescent blood pressure and the acceptability of mobile health interventions in the region. Methods A multi-method cross-sectional study was conducted in Palestinian adolescents, parents, and family members living in refugee camps, cities, and villages across Palestine. A sample of 720 Palestinian adolescents were sampled through schools and centers across Palestine from November 2022 to January 2023. Blood pressure, anthropometric, and psychosocial measures via surveys were collected. Psychometric and ordinal logistic regression analyses were conducted to assess the relationship between each psychosocial factor, refugee status, and blood pressure. Moreover, qualitative interviews and analyses were conducted among 13 Palestinian families to assess the acceptability of mobile health adoption for health management in Palestine. Results The overall prehypertension and hypertension prevalence for this participant sample was three and two and half times the global average. There was no significant association between refugee status and prehypertension and hypertension categories in unadjusted models or models adjusting for age and sex. However, there were significant inverse relationships between refugee status, prehypertension and hypertension for females and males. Female refugees had higher odds of higher blood pressure than non-refugees after adjusting for age. In contrast, male refugees had lower odds of having higher blood pressure than male non-refugee counterparts. As a result, our findings suggest sex- specific differences among refugee and non-refugee groups when assessing blood pressure levels (Chapter 1). Chapter 2 demonstrated that high blood pressure levels were associated with different psychosocial factors differing by encampment experience. Bivariate regression analyses showed that psychosocial factors as settler colonial violence to friends/neighbors, tear gas/bombs, and depression symptoms were inversely related dependent on refugee status i.e., an increase of settler colonial violence to friends/neighbors, tear gas/bombs, and depression symptoms were related to higher odds of high blood among non-refugee groups and lower blood pressure in refugee groups. Moreover, an increase of cultural resistance resilience and adaptive coping were related to lower blood pressure in refugee groups. Further, multivariate regression analysis showed an increase of settler colonial violence to the individual’s home was associated with higher blood pressure among refugees. Chapter 3 showed that there are potential benefits of mobile health adoption for self-management of stress and diverse health outcomes among adults and youth with health conditions as cardiovascular disease and diabetes; However, the adaptation of interventions prior to implementation are crucial to account for contextual factors to avoid introducing risk of harm to the Palestinian population. Conclusion Our research demonstrated that relationship of higher blood pressure levels among Palestinian adolescents varied by refugee status, types of settler colonial violence, and the adoption of cultural resistance. Further, our research demonstrated that living under Israeli military occupation challenges the acceptability of adoption of mobile health interventions to manage health outcomes as non-communicable diseases in Palestine; Such mobile health interventions require a cultural, historical, and geopolitical adaptation of interventions alongside working with local stakeholders prior to implementation to account for contextual factors to avoid placing the population at risk of harm. Future longitudinal research must consider exposures experienced living in encampment among Palestinian adolescents over a lifespan to understand how psychosocial factors relate cardiovascular health and guide future overall health intervention implementation.

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Background: Continuous glucose monitors (CGM) are becoming a norm for type 1 diabetes management and provide the opportunity to describe hypoglycemic and hyperglycemic events experienced by people with type 1 diabetes (T1Ds). This dissertation had four objectives: 1) derive scales from the Hypoglycemia Fear Survey- Behavior (HFS-B) scale that represent unique constructs of hypoglycemia- related behavior, 2) describe the frequency and severity of CGM- measured hypoglycemic events, and assess how these relate to levels of hypoglycemia- related behaviors, 3) develop severity categories for CGM- measured hyperglycemic events and describe how the severity categories relate to A1C, and 4) collate insulin pump and CGM data to describe how participants at different levels of A1C use insulin boluses to manage their hyperglycemic events.

Methods: Four analyses were conducted using CGM, insulin pump, demographic, and HFS-B data collected over 26 weeks from 216 T1Ds in the REPLACE-BG trial. The first was a psychometric analysis of the HFS-B. The second identified and measured hypoglycemic events and assessed how these events related to hypoglycemia-related behaviors. The third identified hyperglycemic events, categorized them by severity, and assessed how measures of hyperglycemic event severity predict A1C, the standard measure of glucose control. The fourth identified hyperglycemic events in which insulin boluses were administered and assessed the association of proactive insulin bolusing with the occurrence of severe hyperglycemic events.

Results: Three scales were derived from the HFS-B, labelled hypoglycemia avoidance, reaction, and prevention behavior. Higher levels of hypoglycemia prevention behavior were associated with a lower percentage and shorter duration of moderate hypoglycemic events. Four categories of hyperglycemic event severity were developed, and those in the best glucose control (A1C < 7.1) had 1) a larger percent occurrence of non-severe hyperglycemic events and 2) a smaller percentage of time in the most severe event category. Finally, those in the best glucose control were more likely to practice proactive bolusing to prevent severe hyperglycemic events.

Conclusion. This analysis demonstrated the importance of CGM data in its continuous form. CGM identifies behaviors associated with prevention of both hypo- and hyperglycemia, which are preferentially performed by those with the best glucose control.