ABSTRACT People of the U.S. Affiliated Pacific Islands (USAPI) face significant health disparities in terms of higher morbidity and mortality due to cancer and other diseases. Approximately half a million people live in the USAPI and Pacific Islanders constitute one of the fastest growing demographic groups in the U.S. Morbidity and mortality due to lung and bronchus cancer and head-and-neck cancer appear to be markedly higher in the USAPI than the U.S. nationally. The higher rates for lung/bronchus and oral cancer incidence in the USAPI may be due to higher rates of tobacco and areca (betel) nut use in the region. Areca nut is the fruit of a type of palm, Areca catechu, which is commonly chewed with or without tobacco mixed with the nut, for stimulating effects. Our recent research suggests that tobacco product use, including electronic or e- cigarette use, among Guam middle school students may be 4-5 times higher than the U.S. national average. Clearly, preventing tobacco product use (i.e., cigarette, chewing tobacco, e-cigarette use) and areca nut use among USAPI adolescents is likely to reduce cancer disparities faced by the USAPI in the long run. Currently there are NO culturally grounded, evidence-based tobacco and betel nut prevention programs designed for USAPI youth. The long-term goal of this research project is to develop a culturally grounded, evidence-based tobacco and betel nut prevention program that may be delivered in the classrooms across schools in the USAPI. The project will continue a productive collaboration between researchers from the University of Hawaii Cancer Center (UHCC) and University of Guam (UOG), which initiated as a pilot study funded by the previous cycle of the UHCC/UOG Partnership grant (U54). The proposed study will adapt and test Ho'ouna Pono, an innovative video-based classroom substance use prevention curriculum developed for Native Hawaiians, who are Pacific Islanders and culturally similar to Pacific Islanders in the USAPI. In addition to the video-based curriculum, we will test a social media-based social marketing campaign to prevent tobacco and betel nut use initiation and escalation. Of the 8 public middle schools in Guam, 4 will be randomly assigned to the "video-based curriculum + social marketing campaign" condition (i.e., treatment) and 4 will be assigned to the "social marketing campaign only" condition (i.e., control). The decision to provide an intervention, albeit weaker, to the control group as well was guided by the ethics of good community practice. If efficacious, the school-based tobacco and betel nut use prevention curriculum may be delivered throughout the USAPI so as to reduce the adolescent tobacco and betel nut use prevalence in the region. Ultimately, the program may contribute to reducing the high cancer burden faced by the USAPI.

PROJECT NARRATIVE High rates of tobacco and areca nut use in Guam and the rest of the U.S.-Affiliated Pacific Islands are of concern, especially in the context of the cancer disparities faced by the USAPI populations. Most tobacco/areca nut users initiate use during adolescence and our data suggests that adolescent tobacco product and betel nut use in Guam are alarmingly high compared to the U.S. nationally. The current application proposes to develop an adolescent tobacco and areca nut use prevention program for Guam youths. If successful, the program may be disseminated to the rest of the USAPI. The program may thus help curb the initiation of tobacco and areca nut use among USAPI adolescents and, by doing so, may reduce the high rates of cancer-related morbidity and mortality faced by the USAPI populations. For this reason, the current proposal has high public health relevance.