Rationale and design of the Self-TI Study protocol: a cross-sectional human papillomavirus self-testing pilot study among transgender adults in England.

INTRODUCTION: Persistent infection with high-risk human papillomavirus (HPV) is the causal agent of several cancers including cervical, anal and oropharyngeal cancer. Transgender men and transmasculine non-binary (TMNB) people with a cervix are much less likely to undergo cervical cancer screening than cisgender women. Transgender women and transfeminine non-binary (TWNB) people assigned male at birth may be at increased risk of HPV. Both TMNB and TWNB people face many barriers to HPV testing including medical mistrust due to stigma and discrimination. METHODS AND ANALYSIS: The Self-TI Study (Self-TI) is a pilot study designed to measure acceptability and feasibility of HPV self-testing among transgender and non-binary people in England. TMNB people aged 25-65 years, with at least 1 year of testosterone, and TWNB people, aged 18 years and over, are eligible to participate. Participants self-collect up to four samples: an oral rinse, a first void urine sample, a vaginal swab (if applicable) and an anal swab. TMNB participants are asked to have an additional clinician-collected cervical swab taken following their routine Cervical Screening Programme sample. TWNB people are asked to take a self-collection kit to perform additional self-collection at home and mail the samples back to the clinic. Acceptability is assessed by a self-administered online survey and feasibility is measured as the proportion of samples returned in the clinic and from home. ETHICS AND DISSEMINATION: Self-TI received ethical approval from the Research Ethics Committee of Wales 4 and ethical review panel within the Division of Cancer Epidemiology and Genetics at the US National Cancer Institute. Self-TI was coproduced by members of the transgender and non-binary community, who served as authors, collaborators and members of the patient and public involvement (PPI) group. Results of this study will be shared with the community prior to being published in peer-reviewed journals and the PPI group will help to design the results dissemination strategy. The evidence generated from this pilot study could be used to inform a larger, international study of HPV self-testing in the transgender and non-binary community. TRIAL REGISTRATION NUMBER: NCT05883111.

Differential effects of deep brain stimulation on reinstatement of cocaine seeking in male and female rats.

There are currently no FDA-approved treatments for cocaine use disorder. Recent preclinical and clinical studies showed that deep brain stimulation (DBS) in limbic regions reduced drug seeking behavior. Our previous work indicated that DBS of the nucleus accumbens shell attenuated reinstatement of cocaine seeking, a model of relapse, in male rats. The current experiments were designed to evaluate the effect of electrical DBS on cocaine reinstatement in female rats across the estrous cycle. Rats were allowed to self-administer cocaine and lever responding was subsequently extinguished. Cocaine seeking was reinstated by an acute injection of experimenter-delivered cocaine. The effect of nucleus accumbens shell DBS vs. sham stimulation on cocaine-primed reinstatement was evaluated in female and male rats using a within-subjects counterbalanced design. Consistent with previous work, accumbens shell DBS suppressed cocaine seeking in male rats. In sharp contrast, accumbens shell DBS had no effect on cocaine reinstatement in female rats evaluated in either the estrus or non-estrus phases. These results suggest that changes across the estrous cycle are not responsible for the differences in the effect of DBS on cocaine reinstatement between female and male rats.

Iron status is associated with tibial structure and vitamin D metabolites in healthy young men.

The influence of iron on collagen synthesis and vitamin D metabolism has implications for bone health. This cross-sectional observational study investigated associations between markers of iron status and tibial structure, vitamin D metabolites, and circulating biochemical markers of bone metabolism in young healthy men. A total of 343 male British Army recruits participated (age 22 ± 3 y, height 1.77 ± 0.06 m, body mass 75.5 ± 10.1 kg). Circulating biochemical markers of iron status, vitamin D metabolites, and bone metabolism, and tibial structure and density by high-resolution peripheral quantitative computed tomography scans (HRpQCT) were measured in participants during week 1 of basic military training. Associations between markers of iron status and HRpQCT outcomes, bone metabolism, and vitamin D metabolites were tested, controlling for age, height, lean body mass, and childhood exercise volume. Higher ferritin was associated with higher total, trabecular, and cortical volumetric bone mineral density, trabecular volume, cortical area and thickness, stiffness, and failure load (all p ≤ 0.037). Higher soluble transferrin receptor (sTfR) was associated with lower trabecular number, and higher trabecular thickness and separation, cortical thickness, and cortical pore diameter (all p ≤ 0.033). Higher haemoglobin was associated with higher cortical thickness (p = 0.043). Higher ferritin was associated with lower ßCTX, PINP, total 25(OH)D, and total 24,25(OH)2D, and higher 1,25(OH)2D:24,25(OH)2D ratio (all p ≤ 0.029). Higher sTfR was associated with higher PINP, total 25(OH)D, and total 24,25(OH)2D (all p ≤ 0.025). The greater density, size, and strength of the tibia, and lower circulating concentrations of markers of bone resorption and formation with better iron stores (higher ferritin) are likely as a result of the direct role of iron in collagen synthesis.

Impact of Standardised Packaging of Tobacco Products Regulations on cigarette consumption and youth smoking in England: interrupted time-series analysis.

BACKGROUND: In the UK in May 2016, standardised packaging of tobacco products was implemented, including minimum pack sizes of 20 sticks or 30 g loose tobacco. The change was intended to reduce uptake by increasing upfront costs to young people, but there was concern it may unintentionally increase consumption among people smoking. This study aimed to assess whether the introduction of the policy was associated with changes in (1) mean daily factory-made (FM)/roll-your-own (RYO) cigarettes consumption among people smoking predominantly (a) FM and (b) RYO cigarettes; and (2) current smoking prevalence among 16-24-year-olds. METHODS: Data (N=257 929) were from a representative monthly cross-sectional survey of adults (≥16 years) in England, collected between November 2007 and January 2020. Outcome measures were mean daily (FM/RYO) cigarette consumption among those smoking FM/RYO cigarettes, and prevalence of current smoking among 16-24-year-olds. Time-series analyses were conducted using Autoregressive Integrated Moving Average with Exogenous variables (ARIMAX) regression models including a gradual level change starting in June 2017 and ending in May 2018 for cigarette consumption and a step change in June 2016 for prevalence of current smoking. RESULTS: The ARIMAX model was not able to detect a change in mean daily cigarette consumption-for FM (Badj=-0.543, 95% CI -1.381 to 0.296) or RYO (Badj=0.002, 95% CI -0.518 to 0.522) following the implementation of standardised packaging. The unadjusted analysis suggested the implementation of standardised packaging was associated with a small (3%) decrease in smoking prevalence among 16-24-year-olds (Bunadj=-0.031, 95% CI -0.062 to 0.000), but this association was attenuated after adjustment for covariates (Badj=-0.010, 95% CI -0.039 to 0.019). CONCLUSIONS: The implementation of standardised packaging of tobacco products was not associated with a meaningful change in the mean number of FM or RYO cigarettes consumed by people smoking in England, suggesting the larger pack size has not had an unintended consequence of substantially increasing cigarette consumption. However, there was also little evidence that the policy substantially reduced smoking among 16-24-year-olds.

Evaluation of a regional tobacco control programme (Greater Manchester's Making Smoking History) on quitting and smoking in England 2014 to 2022: a time-series analysis.

INTRODUCTION: This study aimed to assess the impact of Greater Manchester's Making Smoking History programme - a region-wide smoking cessation programme launched in January 2018 - on key smoking and quitting outcomes. METHODS: Data were from a nationally-representative monthly survey, 2014-2022 (n=171,281). We used interrupted time-series analyses (Autoregressive Integrated Moving Average [ARIMA] and generalised additive models [GAM]) to examine regional differences between Greater Manchester and the rest of England, before and during the programme's first five years. Outcomes were rates of quit attempts and overall quits among smokers, quit success rates among smokers who tried to quit (pre-registered outcomes), and current smoking prevalence among adults (unregistered outcome). RESULTS: Results showed mixed effects of the programme on quitting. Primary ARIMA models showed comparative reductions in quit success rates (change in quarterly difference between regions = -11.03%; 95%CI -18.96;-3.11) and overall quit rates in Greater Manchester compared with the rest of England (-2.56%; 95%CI -4.95;-0.18), and no significant change in the difference in the quit attempt rate (+2.95%; 95%CI -11.64;17.54). These results were not consistently observed across sensitivity analyses or GAM analyses. Exploratory ARIMA models consistently showed smoking prevalence in Greater Manchester declined more quickly than in the rest of England following initiation of the programme (-2.14%; 95%CI -4.02;-0.27). CONCLUSIONS: The first five years of Greater Manchester's Making Smoking History programme did not appear to be associated with substantial increases in quitting activity. However, exploratory analyses showed a significant reduction in the regional smoking rate, over and above changes in the rest of England over the same period. IMPLICATIONS: Taken together, these results show a relative decline in smoking prevalence in Greater Manchester but equivocal data on quitting, introducing some uncertainty. It is possible the programme has reduced smoking prevalence in the absence of any substantial change in quitting activity by changing norms around smoking and reducing uptake, or by reducing the rate of late relapse. It is also possible that an undetected effect on quitting outcomes has still contributed to the programme's impact on reducing prevalence to some degree. It will be important to evaluate the overall impact of the programme over a longer timeframe.

Changes in sex-specific incidence of lymphoid neoplasms across the lifespan.

Not available.

Nicotine strength of e-liquids used by adult vapers in Great Britain: A population survey 2016 to 2024.

BACKGROUND AND AIMS: In March 2024, the UK government announced plans to introduce a Vaping Products Duty that will tax e-liquids based on their nicotine strength. This study examined trends in the nicotine strength of e-liquids used by adult vapers and differences in those currently used across relevant subgroups. DESIGN: Nationally-representative, cross-sectional household survey, July 2016 to January 2024. SETTING: Great Britain. PARTICIPANTS: 7981 adult vapers. MEASUREMENTS: Participants were asked whether the e-cigarette they mainly use contains nicotine (yes/no) and the e-liquid strength (no nicotine, >0-≤ 6, 7-11, 12-19 or ≥20 mg/ml). We also collected information on the main device type used (disposable/refillable/pod), age, gender, occupational social grade, history of ≥1 mental health conditions, smoking status and (among past-year smokers) level of cigarette addiction. FINDINGS: The proportion of vapers in England using high-strength (≥20 mg/ml) e-liquids increased from an average of 3.8% (95% confidence interval [CI] = 2.9-5.0) up to June 2021 to 32.5% (CI = 27.9-37.4) in January 2024 (the vast majority of whom [93.3% in January 2024] reported using exactly 20 mg/ml; the legal limit). This rise was most pronounced among those using disposable e-cigarettes, those aged 18-24 years and all smoking statuses (including never smokers) except long-term (≥1y) ex-smokers. Of those surveyed in 2022-2024 in Great Britain, overall, 89.5% (CI = 88.1-90.8) said they usually used e-cigarettes containing nicotine, 8.7% (CI = 7.5-10.0) used nicotine-free e-cigarettes, and 1.8% (CI = 1.2-2.4) were unsure. The proportion using ≥20 mg/ml was higher among those mainly using disposable (47.9%) compared with pod (16.3%) or refillable (11.5%) devices; never smokers (36.0%), current smokers (28.8%) or recent (<1y) ex-smokers (27.4%), compared with long-term ex-smokers (13.9%); and younger (16-24y; 44.2%) compared with older (≥25y; range 9.4-25.1%) age groups. There were no notable differences across other subgroups of interest. CONCLUSIONS: Use of high-strength nicotine e-liquids in England appears to have increased sharply in recent years. Most adult vapers in Great Britain appear to use e-cigarettes that contain nicotine but different subgroups use different strengths: nicotine strengths tend to be higher among those who mainly use disposable devices and those aged 16-24y, and lower among long-term ex-smokers.

Electronic cigarettes and subsequent use of cigarettes in young people: An evidence and gap map.

BACKGROUND AND AIMS: The use of e-cigarettes may influence later smoking uptake in young people. Evidence and gap maps (EGMs) are interactive on-line tools that display the evidence and gaps in a specific area of policy or research. The aim of this study was to map clusters and gaps in evidence exploring the relationship between e-cigarette use or availability and subsequent combustible tobacco use in people aged < 30 years. METHODS: We conducted an EGM of primary studies and systematic reviews. A framework and an interactive EGM was developed in consultation with an expert advisory group. A systematic search of five databases retrieved 9057 records, from which 134 studies were included. Systematic reviews were appraised using AMSTAR-2, and all included studies were coded into the EGM framework resulting in the interactive web-based EGM. A descriptive analysis of key characteristics of the identified evidence clusters and gaps resulted in this report. RESULTS: Studies were completed between 2015 and 2023, with the first systematic reviews being published in 2017. Most studies were conducted in western high-income countries, predominantly the United States. Cohort studies were the most frequently used study design. The evidence is clustered on e-cigarette use as an exposure, with an absolute gap identified for evidence looking into the availability of e-cigarettes and subsequent cessation of cigarette smoking. We also found little evidence analysing equity factors, and little exploring characteristics of e-cigarette devices. CONCLUSIONS: This evidence and gap map (EGM) offers a tool to explore the available evidence regarding the e-cigarette use/availability and later cigarette smoking in people under the age of 30 years at the time of the search. The majority of the 134 reports is from high-income countries, with an uneven geographic distribution. Most of the systematic reviews are of lower quality, suggesting the need for higher-quality reviews. The evidence is clustered around e-cigarette use as an exposure and subsequent frequency/intensity of current combustible tobacco use. Gaps in evidence focusing on e-cigarette availability, as well as on the influence of equity factors may warrant further research. This EGM can support funders and researchers in identifying future research priorities, while guiding practitioners and policymakers to the current evidence base.

Social smoker identity and associations with smoking and quitting behaviour: A cross-sectional study in England.

BACKGROUND: 'Social smoking' typically occurs predominantly or exclusively in the presence of others who are smoking. Relatively little is known about changes in the prevalence of 'social smoking identity' over time and its association with other smoking-related correlates. METHODS: Data were from the Smoking Toolkit Study, a nationally-representative cross-sectional survey in England. Participants were 26,774 adults who currently smoked or had quit in the past year, surveyed between February-2014 and April-2021. We estimated the proportion identifying as having a social smoking identity, changes over time, and associations with smoking in social situations, cigarette dependence, motivation to stop, quit attempts and success. RESULTS: Of adults who currently smoked or had quit in the past year, 34.0% (95% Confidence Interval (CI)=33.5-34.6) identified as having a social smoking identity. There was a near linear increase in this proportion from 31.9% (95%CI=29.7-34.2) in February-2014 to 36.5% (95%CI=34.1-38.9) in April-2021. Adults who currenty smoked identifying as having a social smoking identity were less cigarette dependent (adjusted B=0.34, 95%CI=0.31-0.37) and more motivated to stop (aOR=1.20, 95%CI=1.15-1.26) than those who did not. Adults who currently smoked or had quit in the past year identifying as having a social smoking identity reported more smoking in social situations (aOR=6.45, 95%CI=6.13-6.80) and past-year quit attempts (aOR=1.22, 95%CI=1.14-1.30) than those who did not. Quit success was not associated with having a social smoking identity among adults who currently smoked or had quit in the past year and who had attempted to quit (aOR=0.90, 95%CI=0.79-1.02). CONCLUSIONS: An increasing proportion, over a third, of adults who currently smoked or had quit in the past year in England identify as having a social smoking identity. Despite being associated with lower dependence, greater motivation to quit and more quit attempts, social smoking identity is not associated with greater quit success, suggesting a complex interplay between identity and smoking-related behaviours.

Trends in Daily Cigarette Consumption Among Smokers: A Population Study in England, 2008-2023.

INTRODUCTION: This study aimed to estimate time trends in cigarette consumption among smokers in England between 2008 and 2023 and to explore differences by key potential moderators. AIMS AND METHODS: We used data from 57 778 adult cigarette smokers participating in a nationally representative monthly cross-sectional survey between January 2008 and September 2023. We estimated monthly time trends in mean daily consumption of (1) any, (2) manufactured, and (3) hand-rolled cigarettes among all smokers and by main type of cigarettes smoked, smoking frequency, age, gender, occupational social grade, region, nicotine replacement therapy use, and vaping status. RESULTS: Overall cigarette consumption fell from 13.6 [95% CI = 13.3 to 13.9] to 10.6 [10.5 to 10.8] per day between January 2008 and October 2019 (a 22% decrease), then remained stable up to September 2023. Over this period, the proportion mainly or exclusively smoking hand-rolled cigarettes increased (from 30.6% [29.1%-32.1%] in 2008 to 52.1% [49.7%-54.5%] in 2023). As a result, manufactured cigarette consumption fell by 47%, from 9.5 [9.2-9.8] per day in January 2008 to 5.0 [4.7-5.3] in September 2023, while hand-rolled cigarette consumption increased by 35%, from 4.2 [3.9-4.4] to 5.6 [5.3-5.9], respectively. The decline in overall cigarette consumption was observed across all subgroups, but was greater among non-daily smokers, younger smokers, and those who vaped. CONCLUSIONS: Over the last 15 years, the average number of cigarettes consumed each day by smokers in England has fallen by almost a quarter, but has plateaued since October 2019. There has been a sharp decline in the number of manufactured cigarettes consumed and an increase in the number of hand-rolled cigarettes consumed, as smokers have increasingly shifted towards using hand-rolled tobacco. IMPLICATIONS: While average cigarette consumption in England has fallen over the past 15 years, this declining trend has stalled (and reversed in some population groups) since 2019. The availability of cheap, hand-rolled tobacco appears to be undermining policies that aim to reduce smoking by raising the price of tobacco (eg, through taxation) and could be targeted to reignite the decline in cigarette consumption.

Statin use is not associated with inflammation among Chilean women of Mapuche and non-Mapuche ancestry with gallstones.

Aim: Statins are associated with lower risk of gallstones due to anti-inflammatory effects. We assessed whether statins impact circulating inflammation among Chilean women with gallstones. Materials & methods: 200 Mapuche women were matched on statin use and age to 200 non-Mapuche women in the Chile Biliary Longitudinal Study. We analyzed 92 inflammatory biomarkers using multivariable-adjusted regression models, random forests and pathway analyses. Results: Statins were not significantly associated with any inflammation marker when women were analyzed jointly or stratified by ancestry. No significant associations were found through random forest methods and pathway analyses. Discussion: We did not find significant associations between statin use and inflammation markers in women with gallstones, suggesting that statins do not reduce inflammation once gallstones have formed.

Statins are prescribed to lower cholesterol and can also decrease the risk of gallstone formation by reducing inflammation. We assessed whether statin use reduces inflammation among women who have already developed gallstones. We analyzed 92 inflammation markers among 400 women in Chile, including 200 women with Mapuche Amerindian ancestry and 200 women of Latina/European ancestry. We found that statin use was not correlated with inflammation in this group of women overall nor by ancestry. This may mean that statin use does not reduce inflammation in women who already were diagnosed with gallstones.

Impact of the disruption in supply of varenicline since 2021 on smoking cessation in England: A population study.

BACKGROUND AND AIMS: Varenicline is one of the most effective smoking cessation treatments. Its supply in England was disrupted in July 2021 due to nitrosamine impurities found by its supplier, Pfizer. This study measured the impact of this disruption on smoking cessation in England. DESIGN, SETTING AND PARTICIPANTS: The study used repeated cross-sectional surveys conducted monthly, from June 2018 to December 2022. Set in England, it comprised a total of 3024 adults who reported smoking during the past year and had made at least one serious attempt to quit in the past 6 months. MEASUREMENTS: Generalized additive models analyzed the association of the varenicline supply disruption with the trend in self-reported varenicline use in the most recent quit attempt. We used these results to estimate the population-level impact of the disruption on smoking cessation. FINDINGS: Before July 2021, the proportion of past 6-month quit attempts using varenicline was stable at approximately 3.9% [risk ratio (RR)trend = 1.034, 95% confidence interval (CI) = 0.823-1.298]. The trend in varenicline use has changed sharply since the supply disruption (RRΔtrend = 0.297, 95% CI = 0.120-0.738), with prevalence falling by 69.3% per year since; from 4.1% in June 2021 to 0.8% in December 2022. Convergently, National Health Service general practitioner prescribing data reported that just 0.1% of prescriptions for smoking cessation treatments in December 2022 were for varenicline. Assuming that varenicline does not return to the market, we estimate that this could result in ~8400 fewer people stopping smoking for at least 6 months, ~4200 fewer long-term ex-smokers and ~1890 more avoidable deaths each year. CONCLUSIONS: In England, the disruption in supply of varenicline since 2021 has coincided with a substantial fall in the use of varenicline in attempts to quit smoking.

Are people more likely to vape or smoke indoors? A population survey of adults in England.

BACKGROUND: Increasingly, people smoke cigarettes outdoors and avoid exposing bystanders to harm. People may not have the same motivation to vape outdoors since e-cigarettes, unlike cigarettes, do not create side stream emissions and exhaled aerosol contains fewer toxicants than secondhand smoke. This study aims to estimate the prevalence and correlates of vaping and smoking indoors among adults in England. METHODS: Data came from the Health Survey for England 2019, a cross-sectional household survey. Adults who vape or smoke (N=1,530) were asked whether they had vaped or smoked indoors inside the home, car, or other places within the past seven days. Logistic regression was used to estimate prevalence and key correlates of indoor use, including age, sex, presence of adults/children in home, housing tenure and nicotine dependence. RESULTS: People who exclusively vaped were much more likely to use their product indoors than those who exclusively smoked (87.0% versus 52.0%; odds ratio [OR]=6.16, 95% confidence interval [CI]=4.09-9.28). Similarly, people who dual used had higher odds of vaping than smoking indoors (62.1% versus 44.3%; within-person OR=3.76, 95%CI=2.06-6.84). The preference for vaping over smoking indoors was found across different locations, including at home and in cars. Those who were older, highly dependent on nicotine, and lived alone were most prone to use any product indoors. While housing tenure was not strongly associated with vaping indoors, those living in social housing were much more likely to smoke indoors than homeowners. CONCLUSIONS: Adults in England are much more likely to vape than smoke indoors. Age, nicotine dependence, and living alone are strongly associated with both behaviours. IMPLICATIONS: Our results show that people have a strong preference for vaping over smoking indoors, including in the home. Given the high prevalence of vaping indoors, policymakers, landlords and businesses must weigh up the ethics, benefits, and harms of extending smoke-free laws to include e-cigarettes.

Characterising smoking and nicotine use behaviours among women of reproductive age: a 10-year population study in England.

BACKGROUND: Tobacco smoking affects women's fertility and is associated with substantial risks of adverse pregnancy outcomes. This study explored trends by socioeconomic position in patterns of smoking, use of non-combustible nicotine products, and quitting activity among women of reproductive age in England. METHODS: Data come from a nationally representative monthly cross-sectional survey. Between October 2013 and October 2023, 197,266 adults (≥ 18 years) were surveyed, of whom 44,052 were women of reproductive age (18-45 years). Main outcome measures were current smoking, vaping, and use of nicotine replacement therapy (NRT), heated tobacco products (HTPs), and nicotine pouches; mainly/exclusively smoking hand-rolled cigarettes and level of dependence among current smokers; past-year quit attempts among past-year smokers; and success of quit attempts among those who tried to quit. We modelled time trends in these outcomes, overall and by occupational social grade (ABC1 = more advantaged/C2DE = less advantaged). RESULTS: Smoking prevalence among women of reproductive age fell from 28.7% [95%CI = 26.3-31.2%] to 22.4% [19.6-25.5%] in social grades C2DE but there was an uncertain increase from 11.7% [10.2-13.5%] to 14.9% [13.4-16.6%] in ABC1. By contrast, among all adults and among men of the same age, smoking prevalence remained relatively stable in ABC1. Vaping prevalence among women of reproductive age more than tripled, from 5.1% [4.3-6.0%] to 19.7% [18.0-21.5%], with the absolute increase more pronounced among those in social grades C2DE (reaching 26.7%; 23.3-30.3%); these changes were larger than those observed among all adults but similar to those among men of the same age. The proportion of smokers mainly/exclusively smoking hand-rolled cigarettes increased from 40.5% [36.3-44.9%] to 61.4% [56.5-66.1%] among women of reproductive age; smaller increases were observed among all adults and among men of the same age. Patterns on other outcomes were largely similar between groups. CONCLUSIONS: Among women of reproductive age, there appears to have been a rise in smoking prevalence in the more advantaged social grades over the past decade. Across social grades, there have been substantial increases in the proportion of women of reproductive age who vape and shifts from use of manufactured to hand-rolled cigarettes among those who smoke. These changes have been more pronounced than those observed in the general adult population over the same period.

Risk perceptions and behaviors concerning rural tourism and economic-political drivers of COVID-19 policy in 2020.

When COVID-19 was first introduced to the United States, state and local governments enacted a variety of policies intended to mitigate the virulence of the epidemic. At the time, the most effective measures to prevent the spread of COVID-19 included stay-at-home orders, closing of nonessential businesses, and mask mandates. Although it was well known that regions with high population density and cold climates were at the highest risk for disease spread, rural counties that are economically reliant on tourism were incentivized to enact fewer precautions against COVID-19. The uncertainty of the COVID-19 pandemic, the multiple policies to reduce transmission, and the changes in outdoor recreation behavior had a significant impact on rural tourism destinations and management of protected spaces. We utilize fine-scale incidence and demographic data to study the relationship between local economic and political concerns, COVID-19 mitigation measures, and the subsequent severity of outbreaks throughout the continental United States. We also present results from an online survey that measured travel behavior, health risk perceptions, knowledge and experience with COVID-19, and evaluation of destination attributes by 407 out-of-state visitors who traveled to Maine from 2020 to 2021. We synthesize this research to present a narrative on how perceptions of COVID-19 risk and public perceptions of rural tourism put certain communities at greater risk of illness throughout 2020. This research could inform future rural destination management and public health policies to help reduce negative socioeconomic, health and environmental impacts of pandemic-derived changes in travel and outdoor recreation behavior.

Trends in Exclusive Non-Cigarette Tobacco Smoking in England: A Population Survey 2013-2023.

INTRODUCTION: The UK Government intends to implement a "smokefree generation" policy prohibiting the sale of all tobacco products to people born after 2008. National surveys provide comprehensive data on cigarette smoking, but little is known about patterns of non-cigarette tobacco smoking across key population groups. AIMS AND METHODS: Using data from a nationally representative cross-sectional survey of adults in England, collected monthly between September 2013 and September 2023 (n = 196 721), we estimated time trends in exclusive non-cigarette tobacco (eg, cigar/pipe/shisha) smoking prevalence, overall and by age, gender, occupational social grade, region, ethnicity, and vaping status. Interviews were conducted face-to-face until March 2020 and via telephone thereafter. RESULTS: From September 2013 to September 2023, there was a non-linear increase in exclusive non-cigarette tobacco smoking prevalence (from 0.36% to 1.68%; prevalence ratio = 4.72 [95% CI = 3.43-6.48]). Prevalence was relatively stable up to February 2020 (at an average of 0.46%), then increased sharply at the start of the COVID-19 pandemic (at the same time as survey methods changed), to 0.90% (0.82%-0.99%) in March 2020. This was followed by a steadier rise, peaking at 1.97% in May 2022, before falling slightly to 1.68% by September 2023. In 2022/2023, 1 in 10 smokers (10.8% [9.64%-12.0%]) exclusively used non-cigarette tobacco. The rise in prevalence was observed across all subgroups but was most pronounced among younger adults (eg, reaching 3.21% of 18-year-olds vs. 1.09% of 65-year-olds). Prevalence was consistently higher among men and current vapers. CONCLUSIONS: Although exclusive use of non-cigarette combustible tobacco remains rare among adults in England, it has increased in recent years, particularly among younger ages. As of September 2023, there were approximately 772 800 adult exclusive non-cigarette tobacco smokers in England; around five times more than a decade earlier. IMPLICATIONS: The proportion of adults in England who do not use cigarettes at all but smoke other combustible tobacco products has increased substantially in recent years, with a particularly pronounced rise among young people. The inclusion of non-cigarette combustible tobacco products under the proposed "smokefree generation" policy is therefore likely to be important for achieving the greatest reduction in youth uptake of tobacco smoking, as it would ensure young people who are unable to legally buy cigarettes do not buy other combustible tobacco products that are similarly harmful to health.

Trends in purchasing cross-border, illicit and home-brewed alcohol: A population study in Great Britain, 2020-2023.

INTRODUCTION: The last 3 years have seen substantial changes in Great Britain (GB) including the COVID-19 pandemic, cost-of-living crisis and policy changes such as minimum unit pricing. We examined changes in purchasing cross-border, illicit and home-brewed alcohol among risky drinkers over this period. METHODS: Data were used from 22,086 adult (≥18 years) increasing/higher-risk drinkers (AUDIT-C ≥5) participating in a monthly cross-sectional survey between October 2020 and August 2023. We estimated time trends in the proportion reporting obtaining alcohol from: (i) cross-border (any/within-GB/international); (ii) illicit; and (iii) home-brewed sources in the past 6 months. RESULTS: Between October 2020 and August 2023, the proportion reporting cross-border alcohol purchases increased (from 8.5% to 12.5% overall; prevalence ratio [PR] = 1.47 [95% CI 1.17-1.86]). This was largely driven by an increase in cross-border purchases abroad (PR = 1.52 [1.13-2.05]), with a smaller, uncertain increase in cross-border purchases within GB (PR = 1.37 [0.96-1.95]). The prevalence of cross-border alcohol purchasing was higher in Wales (13.8% [12.3-15.4%]) and Scotland (6.1% [5.4-6.8%]) than England (3.6% [3.3-3.9%]). There was little change in illicit alcohol purchasing in England or Wales (4.1% [3.7-4.4%]; 4.2% [3.2-5.1%]), but in Scotland it fell from 5.7% to 2.4% (PR = 0.42 [0.19-0.81]). Home-brewed alcohol was rare (GB: 3.1% [2.9-3.4]) and stable. DISCUSSION AND CONCLUSIONS: The proportion of increasing/higher-risk drinkers in GB purchasing cross-border alcohol increased between October 2020 and August 2023, due to an increase in people buying alcohol abroad. Cross-border alcohol purchases within GB were more commonly reported in Wales and Scotland. The small proportion purchasing illicit alcohol did not change substantially in England or Wales, but fell by half in Scotland.

Epigenetic inheritance of phenotypes associated with parental exposure to cocaine.

Parental exposure to drugs of abuse induces changes in the germline that can be transmitted across subsequent generations, resulting in enduring effects on gene expression and behavior. This transgenerational inheritance involves a dynamic interplay of environmental, genetic, and epigenetic factors that impact an individual's vulnerability to neuropsychiatric disorders. This chapter aims to summarize recent research into the mechanisms underlying the inheritance of gene expression and phenotypic patterns associated with exposure to drugs of abuse, with an emphasis on cocaine. We will first define the epigenetic modifications such as DNA methylation, histone post-translational modifications, and expression of non-coding RNAs that are impacted by parental cocaine use. We will then explore how parental cocaine use induces heritable epigenetic changes that are linked to alterations in neural circuitry and synaptic plasticity within reward-related circuits, ultimately giving rise to potential behavioral vulnerabilities. This discussion will consider phenotypic differences associated with gestational as well as both maternal and paternal preconception drug exposure and will emphasize differences based on offspring sex. In this context, we explore the complex interactions between genetics, epigenetics, environment, and biological sex. Overall, this chapter consolidates the latest developments in the multigenerational effects and long-term consequences of parental substance abuse.

The relationship between gender discrimination and wellbeing in middle-aged and older women.

BACKGROUND: Emerging evidence suggests that perceived gender discrimination negatively impacts mental wellbeing in young women. PURPOSE: This study explored whether a similar relationship exists in middle-aged and older women. METHODS: A total of 3081 women (aged ≥52 years) from the English Longitudinal Study of Ageing provided data on perceived gender discrimination in 2010/11. Depressive symptoms, loneliness, quality of life and life satisfaction were assessed in 2010/11 and in 2016/17. RESULTS: Perceived gender discrimination was reported by 282 (9.2%) participants. Cross-sectionally, women who perceived gender discrimination reported more depressive symptoms (ß = 0.34, 95% CI 0.11 to 0.57) and had higher loneliness scores (ß = 0.14, 95% CI 0.08 to 0.20) than women who did not perceive gender discrimination. They also reported significantly lower quality of life (ß = -2.50, 95% CI -3.49 to -1.51) and life satisfaction (ß = -1.07, 95% CI -1.81 to -0.33). Prospectively, perceived gender discrimination was associated with greater loneliness scores (ß = 0.08, 95% CI 0.02 to 0.14), as well as lower ratings of quality of life (ß = -0.98, 95% CI -0.09 to -1.86), and life satisfaction (ß = -1.04, 95% CI -0.34 to -1.74), independent of baseline values. CONCLUSIONS: Middle-aged and older women who perceive gender discrimination report poorer mental wellbeing than those who do not perceive discrimination. Further, this type of discrimination may be predictive of declining mental wellbeing over time. These findings highlight the need for interventions to target gender-based discrimination to improve the wellbeing of women at mid- and older age.