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Sunday, December 2, 2012

The habit

 

The Virtuous Tax: Lifesaving and Crime-Prevention Effects of the 1991 Federal Alcohol-Tax Increase

Philip Cook & Christine Piette Durrance
Journal of Health Economics, forthcoming

Abstract:
The last time that federal excise taxes on alcoholic beverages were increased was 1991. The changes were larger than the typical state-level changes that have been used to study price effects, but the consequences have not been assessed due to the lack of a control group. Here we develop and implement a novel method for utilizing interstate heterogeneity to estimate the aggregate effects of a federal tax increase on rates of injury fatality and crime. We provide evidence that the relative importance of alcohol in violence and injury rates is directly related to per capita consumption, and build on that finding to generate estimates. A conservative estimate is that the federal tax (which increased alcohol prices by 6% initially) reduced injury deaths by 4.5%, (6,480 deaths), in 1991, and had a still larger effect on violent crime.

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Portrayals of Teen Smoking, Drinking, and Drug Use in Recent Popular Movies

Susannah Stern & Lindsey Morr
Journal of Health Communication, forthcoming

Abstract:
Studies indicate that films can influence adolescents' attitudes toward and initiation of substance use. It is therefore important to periodically assess film content to assess the types of imagery adolescents are likely to encounter. This study content analyzed teen characters in top films featuring teenagers from 2007, 2008, and 2009 to assess smoking, drinking, and drug use portrayals. Results indicate a relatively low incidence of smoking and drug use. However, one in five teen characters are shown drinking. Overall, substance use depictions have diminished considerably compared with films released at the earlier end of the decade. However, consequences of substance use were infrequently depicted, and characters seldom refused invitations to drink or do drugs. Given these findings, some potentially counterproductive outcomes are discussed.

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Alcohol and tobacco use and heart rate reactivity to a psychosocial stressor in an adolescent population

Brittany Evans et al.
Drug and Alcohol Dependence, 1 December 2012, Pages 296-303

Background: Few studies have investigated physiological stress (re)activity in relation to substance use, especially in adolescents. Using substances is one way to stimulate physiological arousal, therefore inherent hypo-arousal may be associated with substance use in adolescents. The purpose of this study was to examine the relation of autonomic nervous system (ANS) activity with alcohol and tobacco use in adolescents.

Methods: ANS activity and perceived stress during a social stress procedure were examined in relation to substance use. 275 Dutch adolescents from a general population study provided complete data. Heart rate was recorded continuously during a pre-task rest period, a stressful task period and a post-task recovery period. Alcohol and tobacco use were self-reported.

Results: Adolescents who consumed a medium and high number of alcoholic drinks per week (more than two) exhibited lower heart rates during the entire stress procedure as compared to those who consumed a low number of alcoholic drinks. Adolescents who smoked every day portrayed blunted heart rate reactivity to stress as compared to adolescents who smoked less frequently or not at all. Perceived stress was not related to alcohol or tobacco use.

Conclusions: Overall lower heart rate in adolescents who drank more and blunted heart rate reactivity to stress in those who used tobacco every day may indicate inherent hypo-arousal of the ANS system in those vulnerable to use substances more often. These adolescents may actively seek out substances in order to achieve a more normalized state of arousal.

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Perceived Discrimination and DSM-IV-Based Alcohol and Illicit Drug Use Disorders

Haslyn Hunte & Adam Barry
American Journal of Public Health, December 2012, Pages e111-e117

Objectives: We examined the relationship between everyday and major discrimination and alcohol and drug use disorders in a nationally representative sample of African Americans and Black Caribbeans.

Methods: With data from the National Survey of American Life Study, we employed multivariable logistic regression analyses - while controlling for potential confounders - to examine the relationship between everyday and major discrimination and substance use disorders on the basis of Diagnostic and Statistical Manual of Mental Disorders criteria.

Results: Every 1 unit increase in the everyday discrimination scale positively predicted alcohol (odds ratio [OR] = 1.02; P < .01) and drug use (OR = 1.02; P < .05) disorders. Similarly, each additional major discrimination event positively predicted alcohol (OR = 1.10; P < .05) and drug use (OR = 1.15; P < .01) disorders.

Conclusions: To our knowledge, this study is the first to examine problematic usage patterns rather than infrequent use of alcohol and drugs in a national sample of African American and Black Caribbean adults and the first to examine this particular relationship in a national sample of Black Caribbeans.

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Alcohol and Student Performance: Estimating the Effect of Legal Access

Jason Lindo, Isaac Swensen & Glen Waddell
Journal of Health Economics, January 2013, Pages 22-32

Abstract:
We consider the effect of legal access to alcohol on student achievement. Our preferred approach identifies the effect through changes in one's performance after gaining legal access to alcohol, controlling flexibly for the expected evolution of grades as one makes progress towards their degree. We also report RD-based estimates but argue that an RD design is not well suited to the research question in our setting. We find that students' grades fall below their expected levels upon being able to drink legally, but by less than previously documented. We also show that there are effects on women and that the effects are persistent. Using the 1997 National Longitudinal Survey of Youth, we show that students drink more often after legal access but do not consume more drinks on days on which they drink.

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Moral decision-making in polysubstance dependent individuals

Martina Carmona-Perera et al.
Drug and Alcohol Dependence, 1 December 2012, Pages 389-392

Background: Moral judgments depend on the integration of complex cognitive and emotional processes. Addiction is associated with core deficits in both cognitive and emotional processing, which may jointly lead to utilitarian biases in moral decision-making.

Methods: We assessed 32 polysubstance dependent males and 32 non-drug using controls using a previously validated moral judgment task, including non-moral scenarios, and moral dilemmas that were either high in emotional salience ("personal scenarios") or low in emotional salience ("impersonal scenarios").

Results: Polysubstance dependent individuals endorsed more utilitarian choices for personal dilemmas (e.g., smothering a baby to save a group of hidden people during wartime). These choices were also perceived as less difficult. Severity of alcohol use correlated with the proportion of utilitarian judgments.

Conclusion: Polysubstance dependent individuals show a more utilitarian pattern of moral decision-making for personal moral scenarios.

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The Effect of Recessions on Gambling Expenditures

Csilla Horváth & Richard Paap
Journal of Gambling Studies, December 2012, Pages 703-717

Abstract:
This article examines the influence of the business cycle on expenditures of three major types of legalized gambling activities: Casino gambling, lottery, and pari-mutuel wagering. Empirical results are obtained using monthly aggregated US per capita consumption time series for the period 1959.01-2010.08. Among the three gambling activities only lottery consumption appears to be recession-proof. This series is characterized by a vast and solid growth that exceeds the growth in income and the growth in other gambling sectors. Casino gambling expenditures show a positive growth during expansions and no growth during recessions. Hence, the loss in income during recessions affects casino gambling. However, income shocks which are not directly related to the business cycle do not influence casino gambling expenditures. Pari-mutuel wagering displays an overall negative trend and its average growth rate is smaller than the growth in income, especially during recessions. The findings of this article provide important implications for the gambling industry and for local governments.

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Trajectories of Reinforcement Sensitivity During Adolescence and Risk for Substance Use

Craig Colder et al.
Journal of Research on Adolescence, forthcoming

Abstract:
Developmental neuroscience models suggest that changes in responsiveness to incentives contribute to increases in adolescent risk behavior, including substance use. Trajectories of sensitivity to reward (SR) and sensitivity to punishment (SP) were examined and tested as predictors of escalation of early substance use in a community sample of adolescents (N = 765, mean baseline age 11.8 years, 54% female). SR and SP were assessed using a laboratory task. Across three annual assessments, SR increased, and rapid escalation was associated with increases in substance use. SP declined and was unrelated to substance use. Findings support contemporary views of adolescent brain development and suggest that early adolescent substance use is motivated by approach responses to reward, rather than failure to avoid potential aversive consequences.

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Does mandating offenders to treatment improve completion rates?

Donna Coviello et al.
Journal of Substance Abuse Treatment, forthcoming

Abstract:
While it is known that community-based outpatient treatment for substance abusing offenders is effective, treatment completion rates are low and much of the prior research has been conducted with offenders in residential treatment or therapeutic communities. The aim of the present study was to assess whether offenders who are mandated to community-based outpatient treatment have better completion rates compared to those who enter treatment voluntarily. The 160 research participants were a heterogeneous group of substance abusers who were under various levels of criminal justice supervision (CJS) in the community. The participants were enrolled in an intensive outpatient program and were recruited into the study between July 2007 and October 2010. All offenders received weekly therapy sessions using a cognitive problem solving framework and 45% completed the 6 month treatment program. Interestingly, those who were mandated demonstrated less motivation at treatment entry, yet were more likely to complete treatment compared to those who were not court-ordered to treatment. While controlling for covariates known to be related to treatment completion, the logistic regression analyses demonstrated that court-ordered offenders were over 10 times more likely to complete treatment compared to those who entered treatment voluntarily (OR = 10.9, CI = 2.0-59.1, p = .006). These findings demonstrate that stipulated treatment for offenders may be an effective way to increase treatment compliance.

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Do socio-economic gradients in smoking emerge differently across time by gender? Implications for the tobacco epidemic from a pregnancy cohort in California, USA

Katherine Keyes et al.
Social Science & Medicine, forthcoming

Abstract:
Understanding current patterns of population smoking by socioeconomic position (SEP) can be substantially enhanced by research that follows birth cohorts over long periods of time, yet such data in the US are rare. Information from birth cohorts followed during critical time periods when the health consequences of smoking became widely known can inform the ways in which current smoking prevalence has been shaped by the historical processes that preceded it. The present study utilizes data from a substudy of the Child Health and Development Study pregnancy cohort (N=1,612). Women were queried about smoking status in 1959-1962, 1971-1972 and 1977-1980. Women were divided into three cohorts based on date of birth. Offspring represented another birth cohort assessed for smoking in 1977-1980. Results indicated that the overall prevalence of smoking exhibited cohort-specific patterns that persisted across time. Notably, the youngest maternal cohort (born 1937-1946) had high smoking prevalence throughout and showed no appreciable decrease (44.7%, 41.4%, 40.1% for 1959-1962, 1971-1972, and 1977-1980). Results also indicated that the relation of smoking to SEP exhibited cohort-specific patterns over time. Among the oldest birth cohort (born 1914-1930), no inverse relation of SEP to smoking was observed at any time; in contrast, an inverse relation emerged by 1959-1962 among the youngest cohort of mothers. Among the adolescent offspring, there was a strong SEP gradient (OR=2.0, 95% CI=1.4-3.0) that was stronger than in any maternal birth cohort at any assessment (β=0.40, SE=0.1, p<0.01). We conclude that SEP gradients in smoking emerge across birth cohorts rather than time alone, with increasingly strong gradients across time especially among younger cohorts.

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Sympathetic Magic and Gambling: Adherence to the Law of Contagion Varies with Gambling Severity

Moira Teed et al.
Journal of Gambling Studies, December 2012, Pages 691-701

Abstract:
This study assessed adherence to the law of contagion by 118 undergraduate students (39 males). Participants were students who played a slot machine game after viewing a prior player who seemed to be winning ("lucky" condition) or losing ("unlucky" condition). Adherence to the law of contagion was assessed by the selection of the coin holder used by a "lucky" prior player and the avoidance of the coin holder used by an "unlucky" prior player. Contagion varied directly with scores on the Problem Gambling Severity Index and scores on the Luck/Perseverance subscale of the Gamblers' Belief Questionnaire (Steenbergh et al. in Psychol Addict Behav 16(2):143-149, 2002). Gamblers high in problem severity chose the "lucky" coin holder and avoided the "unlucky" coin holder significantly more than gamblers low in problem severity. Problem gamblers, therefore, exhibit evidence of magical thinking related to the transfer of a "lucky" essence. The same was the case for individuals with a strong level of belief that sheer continuation in gambling (luck perseverance) results in success and for individuals who believe that luck is a personal rather than a situational characteristic. All three variables (problem gambling severity, luck perseverance and personal luck) had direct effects on behavior reflecting irrational magical thinking. A belief that knowledge or skill has a role in successful gaming was unrelated to magical thinking. These findings suggest potential foci for cognitive interventions with problem gamblers and those with non-skill based evidence of irrational thinking.

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Does Mandatory Diversion to Drug Treatment Eliminate Racial Disparities in the Incarceration of Drug Offenders? An Examination of California's Proposition 36

Nancy Nicosia, John MacDonald & Rosalie Liccardo Pacula
NBER Working Paper, November 2012

Abstract:
Like other states, minorities are disproportionately represented in the California's state prison system, particularly for drug offenses. Unlike other states, California has had a policy of mandatory diversion to drug treatment for non-violent drug offenders since mid-2001 (Proposition 36). Using a rich dataset including current and prior criminal charges from 1995 through 2005 in California, we examine whether disparities in court dispositions to prison and drug treatment between White and Blacks male drug offenders are explained by observable case and criminal justice characteristics. We estimate the extent to which remaining observable disparities are affected by Proposition 36. We find that Black and White male drug offenders differ considerably on covariates, but by weighting on the inverse of a nonparametric estimate of the propensity score, we can compare Blacks to Whites that are on average equivalent on covariates. Unadjusted disparities in the likelihood of being sentenced to prison are substantially reduced by propensity score weighting. Proposition 36 reduces the likelihood of prison overall, but not differentially for Blacks. By contrast, racial disparity in diversion to drug treatment is not reduced by propensity score weighting. There is some evidence that Proposition 36 increased diversion for Blacks.

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Responding to Tobacco Craving: Experimental Test of Acceptance Versus Suppression

Erika Litvin et al.
Psychology of Addictive Behaviors, forthcoming

Abstract:
Acceptance and Commitment Therapy (ACT) provides a theoretical rationale for "acceptance" of thoughts and feelings, and proscribes suppression, a more intuitive and commonly used coping strategy. Suppression is theorized to have negative consequences not applicable to acceptance, including depletion in self-control and ironic postsuppression rebound effects. However, it remains largely unknown whether these strategies differentially affect frequency of drug-related thoughts, craving intensity, drug use behavior, or other relevant outcomes. Adult smokers (N = 162) were randomly assigned to receive a brief laboratory-based coping intervention (acceptance or suppression) or were not given coping instructions (control group) and then were exposed to smoking cues. Results indicated that the suppression group was successful at suppressing thoughts of smoking, as they reported fewer thoughts of smoking than the other two groups. Also, both coping strategies were associated with benefits with respect to craving and affect. However, there were no group differences in depletion, and rebound effects did not occur when coping was discontinued. Following the laboratory session, all participants attempted to quit or at least reduce their smoking for 3 days; the acceptance and suppression groups resumed use of their strategy. At 3-day follow-up, the acceptance and suppression groups reported greater self-efficacy for avoiding smoking when experiencing craving compared to the control group. However, there were no group differences in the number of cigarettes smoked during the 3 days. This study provides support for the value of acceptance-based coping, but it also suggests that more research is needed to differentiate its benefits compared to suppression.

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Maternal smoking during pregnancy and reproductive health of daughters: A follow-up study spanning two decades

A. Ernst et al.
Human Reproduction, December 2012, Pages 3593-3600

Study question: Does in utero exposure to constituents of cigarette smoke have a programming effect on daughters' age of menarche and markers of long-term reproductive health?

Summary answer: In utero exposure to constituents of cigarette smoke was associated with earlier age of menarche and - to a lesser extent - changes in the testosterone profile of the young women.

Study design, size and duration: A prospective cohort study was designed using data from 965 pregnant women enrolled prior to a routine 30th-week antenatal examination at a midwifery practice in Denmark from 1988 to 1989 and a follow-up of their 19-21-year-old daughters in 2008.

Participants/materials, setting and methods: The pregnant women provided information on lifestyle factors during pregnancy, including the exact number of cigarettes smoked per day during the first and the second trimesters. A total of 438 eligible daughters were asked to complete a web-based questionnaire on reproductive health and subsequently invited to participate in a clinical examination during 2008. Of the 367 daughters (84%) who answered the questionnaire, 267 (61%) agreed to further examination. Information on menstrual pattern was provided at examination, blood samples were drawn to be analyzed for serum levels of reproductive hormones [FSH, LH, estradiol (E2), sex hormone-binding globulin, anti-Müllerian hormone, dehydroepiandrosterone-sulphate (DHEAS), free testosterone and free E2] and number of follicles (2-9 mm) were examined by transvaginal ultrasound. The daughters were divided into three exposure groups according to the level of maternal smoking during first trimester [non-exposed (reference), low-exposed (mother smoking >0-9 cigarettes/day) and high-exposed (mother smoking ≥10 cigarettes/day)]. Data were analyzed by multiple regression analyses in which we adjusted for potential confounders. Both crude and adjusted test for trend were carried out using maternal smoking during the first trimester as a continuous variable.

Main results and the role of chance: We observed an inverse association between in utero exposure to constituents of cigarette smoke and age of menarche (P = 0.001). Daughters exposed to >0-9 cigarettes/day debuted with -2.7 [95% confidence interval (CI) -5.2 to -0.1] percentage earlier age of menarche, whereas daughters exposed to ≥10 cigarettes/day had -4.1 (95% CI: -6.6 to -1.5) percentage earlier age of menarche corresponding to 6.5 (95% CI: -10.7 to -2.2) months. There was a non-significant tendency towards lower levels of testosterone and DHEAS with increasing in utero exposure to constituents of cigarette smoke but no associations with follicle number, cycle length or serum levels of the other reproductive hormones were observed.

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Adolescent Work and Alcohol Use Revisited: Variations by Family Structure

Gregory Rocheleau & Raymond Swisher
Journal of Research on Adolescence, December 2012, Pages 694-703

Abstract:
Previous research finds adolescent work hours to be associated with increased alcohol use. Most studies, however, fail to account for possible selection effects that lead youth to both work and substance use. Using data from the first two waves of the National Longitudinal Study of Adolescent Health (N = 12,620), a fixed effects regression method is employed to control for stable between-person differences neglected by previous studies. Results show little relationship between work hours and alcohol use when controlling for individual heterogeneity. Results reveal variations, however, by family structure, with work hours being negatively associated with alcohol use among those from single-parent households. Although exhibiting significant main effects, family and peer processes fail to account for differences by family structure.

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Do Smoke-Free Car Laws Work? Evidence from a Quasi-Experiment

Hai Nguyen
Journal of Health Economics, January 2013, Pages 138-148

Abstract:
In response to increased risks of second-hand smoke exposure for children travelling in cars and its resulting deleterious health impacts, several jurisdictions passed legislation that bans smoking in private vehicles when children are present. In this study, I exploit a unique quasi-experiment from Canada and employ the difference-in-differences and triple-differences techniques to empirically evaluate this legislation. I find that the legislation reduces exposure to second-hand smoke inside cars for children. Further, there appears no marked increase in smoking at home after the implementation of the legislation.

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The Raising of Minimum Alcohol Prices in Saskatchewan, Canada: Impacts on Consumption and Implications for Public Health

Tim Stockwell et al.
American Journal of Public Health, December 2012, Pages e103-e110

Objectives: We report impacts on alcohol consumption following new and increased minimum alcohol prices in Saskatchewan, Canada.

Methods: We conducted autoregressive integrated moving average time series analyses of alcohol sales and price data from the Saskatchewan government alcohol monopoly for 26 periods before and 26 periods after the intervention.

Results: A 10% increase in minimum prices significantly reduced consumption of beer by 10.06%, spirits by 5.87%, wine by 4.58%, and all beverages combined by 8.43%. Consumption of coolers decreased significantly by 13.2%, cocktails by 21.3%, and liqueurs by 5.3%. There were larger effects for purely off-premise sales (e.g., liquor stores) than for primarily on-premise sales (e.g., bars, restaurants). Consumption of higher strength beer and wine declined the most. A 10% increase in minimum price was associated with a 22.0% decrease in consumption of higher strength beer (> 6.5% alcohol/volume) versus 8.17% for lower strength beers. The neighboring province of Alberta showed no change in per capita alcohol consumption before and after the intervention.

Conclusions: Minimum pricing is a promising strategy for reducing the public health burden associated with hazardous alcohol consumption. Pricing to reflect percentage alcohol content of drinks can shift consumption toward lower alcohol content beverage types.

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Decoding of Emotional Components in Complex Communicative Situations (Irony) and Its Relation to Empathic Abilities in Male Chronic Alcoholics: An Issue for Treatment

Simona Amenta et al.
Alcoholism, forthcoming

Background: Previous research has shown that deficits in the domain of emotions strongly characterize alcoholism. Patients diagnosed with alcoholism show impairments in emotional mimic recognition, as well as in the domain of emotional prosody. These data suggest that male alcoholics might suffer from a generalized emotional impairment associated with dysfunctions in empathy. Taken altogether, those deficits might influence alcoholics' relational domain and their performance in complex communicative situations such as ironic interactions. The present study investigates the ability of chronic male alcoholics to recognize the emotional component of ironic contexts and its relation to the comprehension of ironic meaning as a function of their empathic abilities.

Methods: Forty-four male subjects participated in a story comprehension task. They were asked to read stories with either an ironic or a nonironic ending. Participants were asked to fill in a questionnaire about communicative intentions and the emotional states of the stories' characters. Moreover, the correct comprehension of the ironic meaning was assessed through a self-reported questionnaire and related to the empathy quotient (EQ) which was measured in a preexperimental phase.

Results: Alcoholic subjects showed a lower EQ in comparison to healthy subjects and recognized significant fewer ironic endings. Social skills results were particularly impaired. The correlation between EQ and ironic endings recognition was significant. Moreover, alcoholics showed a tendency to attribute positive emotions to both ironic and nonironic contexts, showing an opposite pattern in comparison with control subjects who tended to associate negative emotions to ironic contexts.

Conclusions: The present study indicates that emotional recognition deficits that have been previously observed in chronic alcoholics extend to complex interactive contexts. This deficit is associated with a more general impairment of empathy, especially in its social skill component. Clinical implications of the present results are discussed.

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Guilt Versus Shame: Coping, Fluency, and Framing in the Effectiveness of Responsible Drinking Messages

Adam Duhachek, Nidhi Agrawal & DaHee Han
Journal of Marketing Research, December 2012, Pages 928-941

Abstract:
This article presents three studies on how the negative emotions of guilt and shame differentially influence the effectiveness of health messages framed as gains or losses. Guilt appeals are more effective when paired with gain frames, whereas shame appeals are more effective when paired with loss frames. These framing effects occur because gain frames facilitate the use of problem-focused coping strategies favored by guilt, whereas loss frames facilitate the use of emotion-focused coping strategies favored by shame. Frames that fit with the emotion facilitate the activation of coping strategies consistent with that emotion and consequently lead to greater fluency and message effectiveness. These effects manifest on intentions to binge drink and time spent viewing alcohol advertising.

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Underage Drinkers' Responses to Negative-Restrictive Versus Proactive-Nonrestrictive Slogans in Humorous Anti-Alcohol Abuse Messages: Are Humorous Responsible Drinking Campaign Messages Effective?

Moon Lee & Yi-Chun (Yvonnes) Chen
Journal of Health Communication, forthcoming

Abstract:
This study examined underage drinkers' responses to negative-restrictive versus proactive-nonrestrictive slogans in humorous anti-alcohol abuse advertisements. The authors conducted a posttest-only control group experiment with 91 teenagers and college-aged participants. For underage moderate drinkers, the negative-restrictive slogans (e.g., "Don't drink") increased participants' perceived risk of excessive drinking and increased a level of intention to change their drinking behavior. However, for underage binge drinkers, the negative-restrictive slogans lowered participants' risk perception of excessive drinking and intention to change their drinking behavior.

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Cigarette Warning Label Policy Alternatives and Smoking-Related Health Disparities

James Thrasher et al.
American Journal of Preventive Medicine, December 2012, Pages 590-600

Background: Pictorial health warning labels on cigarette packaging have been proposed for the U.S., but their potential influences among populations that suffer tobacco-related health disparities are unknown.

Purpose: To evaluate pictorial health warning labels, including moderation of their influences by health literacy and race.

Methods: From July 2011 to January 2012, field experiments were conducted with 981 adult smokers who were randomized to control (i.e., text-only labels, n=207) and experimental conditions (i.e., pictorial labels, n=774). The experimental condition systematically varied health warning label stimuli by health topic and image type. Linear mixed effects (LME) models estimated the influence of health warning label characteristics and participant characteristics on label ratings. Data were analyzed from January 2012 to April 2012.

Results: Compared to text-only warning labels, pictorial warning labels were rated as more personally relevant (5.7 vs 6.8, p<0.001) and effective (5.4 vs 6.8, p<0.001), and as more credible, but only among participants with low health literacy (7.6 vs 8.2, p<0.001). Within the experimental condition, pictorial health warning labels with graphic imagery had significantly higher ratings of credibility, personal relevance, and effectiveness than imagery of human suffering and symbolic imagery. Significant interactions indicated that labels with graphic imagery produced minimal differences in ratings across racial groups and levels of health literacy, whereas other imagery produced greater group differences.

Conclusions: Pictorial health warning labels with graphic images have the most-pronounced short-term impacts on adult smokers, including smokers from groups that have in the past been hard to reach.

By KEVIN LEWIS | 09:00:00 AM