A pro-inflammatory gut mucosal cytokine response is associated with mild COVID-19 disease and superior induction of serum antibodies.

The relationship between gastrointestinal tract infection, the host immune response, and the clinical outcome of disease is not well understood in COVID-19. We sought to understand the effect of intestinal immune responses to SARS-CoV-2 on patient outcomes including the magnitude of systemic antibody induction. Combining two prospective cohort studies, International Severe Acute Respiratory and emerging Infections Consortium Comprehensive Clinical Characterisations Collaboration (ISARIC4C) and Integrated Network for Surveillance, Trials and Investigations into COVID-19 Transmission (INSTINCT), we acquired samples from 88 COVID-19 cases representing the full spectrum of disease severity and analysed viral RNA and host gut cytokine responses in the context of clinical and virological outcome measures. There was no correlation between the upper respiratory tract and faecal viral loads. Using hierarchical clustering, we identified a group of fecal cytokines including Interleukin-17A, Granulocyte macrophage colony-stimulating factor, Tumor necrosis factorα, Interleukin-23, and S100A8, that were transiently elevated in mild cases and also correlated with the magnitude of systemic anti-Spike-receptor-binding domain antibody induction. Receiver operating characteristic curve analysis showed that expression of these gut cytokines at study enrolment in hospitalised COVID-19 cases was associated negatively with overall clinical severity implicating a protective role in COVID-19. This suggests that a productive intestinal immune response may be beneficial in the response to a respiratory pathogen and a biomarker of a successful barrier response.

Recent advances in understanding pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) is an intractable cancer and a leading cause of cancer deaths worldwide. Over 90% of patients die within 1 year of diagnosis. Deaths from PDAC are increasing and it remains a cancer of substantial unmet need. A number of factors contribute to its poor prognosis: namely, late presentation, early metastases and limited systemic therapy options because of chemoresistance. A variety of research approaches underway are aimed at improving patient survival. Here, we review high-risk groups and efforts for early detection. We examine recent developments in the understanding of complex molecular and metabolic alterations which accompany PDAC. We explore artificial intelligence and biological targets for therapy and examine the role of tumour stroma and the immune microenvironment. We also review recent developments with respect to the PDAC microbiome. It is hoped that current research efforts will translate into earlier diagnosis, improvements in treatment and better outcomes for patients.

Effects of flavourants and humectants on waterpipe tobacco puffing behaviour, biomarkers of exposure and subjective effects among adults with high versus low nicotine dependence.

INTRODUCTION: Flavourants and humectants in waterpipe tobacco (WT) increase product appeal. Removal of these constituents, however, is associated with increased intensity of WT puffing, likely due to reduced nicotine delivery efficiency. To clarify the potential public health outcomes of restrictions on flavourants or humectants in WT, we evaluated the effects of these constituents on puffing behaviours, biomarkers of exposure and subjective effects among adults with high versus low WT dependence. METHODS: N=39 high dependence and N=49 low dependence WT smokers (Lebanese Waterpipe Dependence Scale scores >10 = high dependence) completed four smoking sessions in a cross-over experiment. Conditions were preferred flavour with humectant (+F+H), preferred flavour without humectant (+F-H), unflavoured with humectant (-F+H) and unflavoured without humectant (-F-H). Measures of puff topography, plasma nicotine and expired carbon monoxide (eCO) boost, and subjective effects were assessed. RESULTS: Level of WT dependence modified the effect of WT condition on average flow rate, average puff volume and eCO boost. Although, overall, participants puffed the +F+H WT least intensely and -F-H WT most intensely, this association was strongest among WT smokers with high dependence. Participants preferred smoking the +F+H WT and achieved the largest plasma nicotine boost in that condition. DISCUSSION: Findings underscore the complexity of setting product standards related to flavourants and humectants in WT. Future research evaluating whether WT smokers with high dependence would quit or reduce their WT smoking in response to removal of flavourants or humectants from WT is necessary to appreciate the full public health effects of such policies.

Bilateral Orbital Reconstruction With Autologous Bone Graft After Gunshot Wound to Upper Midface.

Ballistic maxillofacial injuries are highly destructive, producing significant morbidity and mortality. Survivors' defects pose unique reconstructive challenges, such as loss of periorbital bone stock in upper midface injuries. While orbital reconstruction has transitioned from primarily autologous grafts to alloplastic implants, ballistic trauma remains a niche that warrants the use of autologous bone equally with alloplastic materials. We report a case of an upper midface gunshot wound in a 20-year-old male producing bilateral comminuted medial orbital wall fractures. Reconstruction utilized bilateral split-thickness calvarial bone grafts through preseptal transcaruncular transconjunctival incisions. This case illustrates the utility of autologous bone grafts in the setting of lost periorbital bone stock and minimizing foreign body in surgical fields at high risk of infection or complication. Further studies are necessary to refine the indications for autologous bone grafting and its benefit relative to alloplastic implants in ballistic periorbital trauma.

Harm Perceptions of Tobacco/Nicotine Products and Child Exposure: Differences between Non-Users, Cigarette-Exclusive, and Electronic Cigarette-Exclusive Users.

OBJECTIVE: This study examined caregiver perception of harm and child secondhand exposure to nicotine in a sample of e-cigarette-exclusive, cigarette-exclusive, and non-tobacco/nicotine users (non-users). METHODS: Cigarette-exclusive (n = 19), e-cigarette-exclusive (n = 12), and non-users (n = 20) and their children (N = 51, Mage = 10.47) completed self-report questionnaires about perceptions of harm, child secondhand exposure, and provided urine to assess child nicotine exposure (cotinine). ANOVAs examined differences between caregiver use status on tobacco harm perceptions and child cotinine levels. Independent samples t-test compared differences in caregiver-reported child secondhand exposure in the home and car. RESULTS: All 3 caregiver groups rated cigarettes as highly harmful (P = .14), but e-cigarette users rated all 3 types of e-cigarette products (Cartridge-based: P < .001; Tank: P < .001; Box Mod: P < .001) as less harmful than cigarette users and non-users. Caregivers from the e-cigarette user group reported greater child secondhand exposure than caregivers using cigarettes (past 7-day in-home exposure (P = .03); past 7-day exposure in-home + in-car exposure (P = .02); in-home exposure by caregivers and other people exposure (P = .02)). Children from the cigarette user group had significantly higher levels of cotinine (M = 16.6, SD = 21.7) compared to children from the Non-User group (M = .43, SD = .95; P = .001), but no significant difference when compared to children from the E-Cigarette User group (M = 6.5, SD = 13.5). DISCUSSION: In this sample, caregivers who used e-cigarettes perceived them as less harmful, reported using them more frequently at home and in the car, even when their children were present, compared to cigarette users. As a result, children appear to be exposed to nicotine at levels similar to children living with cigarette users. Future caregiver prevention and intervention efforts should target education around the potential harms of secondhand e-cigarette aerosol to children.

Myopathy associated LDB3 mutation causes Z-disc disassembly and protein aggregation through PKCα and TSC2-mTOR downregulation.

Mechanical stress induced by contractions constantly threatens the integrity of muscle Z-disc, a crucial force-bearing structure in striated muscle. The PDZ-LIM proteins have been proposed to function as adaptors in transducing mechanical signals to preserve the Z-disc structure, however the underlying mechanisms remain poorly understood. Here, we show that LDB3, a well-characterized striated muscle PDZ-LIM protein, modulates mechanical stress signaling through interactions with the mechanosensing domain in filamin C, its chaperone HSPA8, and PKCα in the Z-disc of skeletal muscle. Studies of Ldb3Ala165Val/+ mice indicate that the myopathy-associated LDB3 p.Ala165Val mutation triggers early aggregation of filamin C and its chaperones at muscle Z-disc before aggregation of the mutant protein. The mutation causes protein aggregation and eventually Z-disc myofibrillar disruption by impairing PKCα and TSC2-mTOR, two important signaling pathways regulating protein stability and disposal of damaged cytoskeletal components at a major mechanosensor hub in the Z-disc of skeletal muscle.

The Effect of Substance Abuse Programs on Positive Drug Screening Tests in Trauma Patients.

BACKGROUND: According to the National Institute on Drug Abuse, West Virginia has the highest age-adjusted rate of drug overdose deaths involving opioids. To combat this crisis, comprehensive drug counseling support services were established within the Cabell Huntington Hospital (CHH) system in October 2018 in Huntington, WV, USA. The purpose of this study was to investigate whether these services significantly reduced the number of trauma patients with a positive urine drug screen (UDS) seen at CHH. METHODS: The trauma registry at CHH was used to obtain data on trauma patients with positive UDS from January 2017 to October 2019, which was divided into groups before and after October 2018. Exclusion criteria were any patients who were prescribed the drug. The percentages of the total number of positive drug screens within each group were calculated, and a t-test analysis was performed to determine the P values. RESULTS: 345 trauma patients with positive UDS were selected. Results showed that there was an overall decrease in the rate of nonprescribed use after October 2018 of benzodiazepines (18.1%-11.5%), cocaine (19.5%-15.3%), opioids (19.1%-12.3%), and oxycodone (10.2%-4.6%). However, none of these changes were statistically significant. There was an increase in the rate of nonprescribed use of amphetamine (20.0%-23.8%) and methamphetamine (14.4%-33.8%). DISCUSSION: Our hypothesis is that the support systems are relatively new, and may need more time to identify and intervene on patients before a statistically significant effect on drug abuse rates in our region can be seen.

Impact of flavors and humectants on waterpipe tobacco smoking topography, subjective effects, toxicant exposure and intentions for continued use.

INTRODUCTION: The present study examined how the lack of characterising flavours and low levels of humectants may affect users' waterpipe tobacco (WT) smoking topography, subjective effects, toxicant exposure and intentions for continued use. METHODS: 89 WT smokers completed four ad libitum smoking sessions (characterising flavor/high humectant (+F+H); characterising flavor/low humectant (+F-H); no characterising flavor/high humectant (-F+H); no characterising flavor/low humectant (-F-H)) in a randomised cross-over design. WT was commercially available; same brand but nicotine levels were not held constant. A subsample (n=50) completed a standardised, 10-puff session preceding ad libitum smoking. Participants completed questionnaires, exhaled carbon monoxide (eCO) testing and provided blood samples for plasma nicotine. Smoking topography was measured throughout the session. Post hoc analyses showed that -F+H and -F-H did not differ significantly in humectant levels. Therefore, these groups were collapsed in analyses (-F-H). RESULTS: WT smokers reported significantly greater satisfaction, liking, enjoyment and greater intentions for continued use when smoking +F+H compared with other WT products, with -F-H receiving the lowest ratings. Significant differences in topography were observed during standardised and ad libitum sessions, with the -F-H preparation leading to greater total inhaled volume and eCO boost, but lower nicotine boost compared with +F+H (all p<0.05). DISCUSSION: The findings demonstrate the importance of flavours and humectants on improving WT smoking experience and increasing the likelihood that users will want to initiate and continue smoking. Moreover, it demonstrates that flavours and humectants influence smoking behaviour and toxicant exposure in some unexpected ways that are important for regulatory efforts.

Measuring development assistance for health systems strengthening and health security: an analysis using the Creditor Reporting System database.

Background: Health systems strengthening (HSS) and health security are two pillars of universal health coverage (UHC). Investments in these areas are essential for meeting the Sustainable Development Goals and are of heightened relevance given the emergence of the 2019 novel coronavirus disease (COVID-19). This study aims to generate information on development assistance for health (DAH) for these areas, including how to track it and how funding levels align with country needs. Methods: We developed a framework to analyze the amount of DAH disbursed in 2015 for the six building blocks of the health system ('system-wide HSS') plus health security (emergency preparedness, risk management, and response) at both the global (transnational) and country level. We reviewed 2,427 of 32,801 DAH activities in the Creditor Reporting System (CRS) database (80% of the total value of disbursements in 2015) and additional public information sources. Additional aid activities were identified through a keyword search. Results: In 2015, we estimated that US$3.1 billion (13.4%) of the US$22.9 billion of DAH captured in the CRS database was for system-wide HSS and health security: US$2.5 billion (10.9%) for system-wide HSS, mostly for infrastructure, and US$0.6 billion (2.5%) for system-wide health security. US$567.1 million (2.4%) was invested in supporting these activities at the global level. If responses to individual health emergencies are included, 7.5% of total DAH (US$1.7B) was for health security. We found a correlation between DAH for HSS and maternal mortality rates, and we interpret this as evidence that HSS aid generally flowed to countries with greater need. Conclusions : Achieving UHC by 2030 will require greater investments in system-wide HSS and proactive health emergency preparedness. It may be appropriate for donors to more prominently consider country needs and global functions when investing in health security and HSS.

Electronic cigarette and combustible cigarette use following a campus-wide ban: Prevalence of use and harm perceptions.

The current study examined changes in prevalence of e-cigarette use and perceptions of the harmfulness of e-cigarette and combustible cigarettes following a campus-wide tobacco ban. Undergraduate students completed surveys of tobacco use and perceived product harmfulness. Four samples were collected: in 2013 prior to the ban (n = 792) and in fall 2014 (n = 310), 2015 (n = 208), and 2016 (n = 417). E-cigarette use increased in the years following the ban (p = .01) while combustible cigarette use decreased from 2013 to 2016 (p = .02). Men were more likely than women to use both products (ps < .05). Students' perceptions of the harmfulness of combustible and electronic cigarettes remained stable in the years following the ban (p > .05). This study is the first to examine the impact of including e-cigarettes in tobacco free policies. Combustible cigarette use declined, but e-cigarette use increased in the years following the e-cigarette ban. Prospective research is needed to understand the long-term impacts of e-cigarette bans.

Geographical and Temporal Variation in the Incidence and Mortality of Hepato-Pancreato-Biliary Primary Malignancies:1990-2017.

BACKGROUND: Hepatic, pancreas, and biliary (HPB) cancers pose serious challenges to global health care systems. These malignancies demonstrate great geographical variations with shifting trends over time. The aim of the present study was to determine the recent trends in incidence, prevalence, and mortality of primary HPB malignancies to guide the further development of effective strategies for prevention, screening, and treatment. METHODS: The Global Burden of Disease (GBD) dataset 1990-2017 was interrogated for end point variables by age, sex, year, and geography. Epidemiologic data were modeled in DisMod-MR 2.1, a Bayesian meta-regression tool that pools data points from different sources and adjusts for known sources of variability. Global Burden of Disease data were extracted from 284 country-year, and 976 subnational-year combinations from 27 countries in North America, Latin America, Europe, India, and New Zealand. RESULTS: Although the global incidence of primary HPB malignancies increased by 1.43% from 1990 to 2017 (1,400,739 cases), the incidence of extrahepatic biliary and gallbladder malignancies decreased by -0.32% (210,878 cases) over the same period. There was significant variability in the incidence, prevalence, and mortality of HPB cancers by the sociodemographic index (SDI), as well as by geography. The largest incidence increase of primary liver and pancreas cancers was seen in the high-income Asia-Pacific group, followed by the high-income North America and Western Europe groups. The highest incidences and prevalence of extrahepatic biliary and gallbladder malignancies were observed in Asia-Pacific, Southern Latin American, and Andean Latin American regions. In general, mortality rates of HPB malignancies were larger in the low SDI when compared with the high SDI group in all geographical regions. CONCLUSIONS: The global incidence and prevalence of primary liver and pancreatic malignancies continue to increase with great geographical variation. The mortality trends mirror those of the incidence. Although the global incidence and prevalence of extrahepatic biliary and gallbladder malignancies has decreased, the mortality rate has not significantly changed. The results of this article can assist local and regional authorities in policy development to improve health care access for screening, early detection, and treatment of HPB malignancies.

Economic effects of the double burden of malnutrition.

Observations from many countries indicate that multiple forms of malnutrition might coexist in a country, a household, and an individual. In this Series, the double burden of malnutrition (DBM) encompasses undernutrition in the form of stunting, and overweight and obesity. Health effects of the DBM include those associated with both undernutrition, such as impaired childhood development and greater susceptibility to infectious diseases, and overweight, especially in terms of increased risk of added visceral fat and increased risk of non-communicable diseases. These health effects have not been translated into economic costs for individuals and economies in the form of lost wages and productivity, as well as higher medical expenses. We summarise the existing approaches to modelling the economic effects of malnutrition and point out the weaknesses of these approaches for measuring economic losses from the DBM. Where population needs suggest that nutrition interventions take into account the DBM, economic evaluation can guide the choice of so-called double-duty interventions as an alternative to separate programming for stunting and overweight. We address the evidence gap with an economic analysis of the costs and benefits of an illustrative double-duty intervention that addresses both stunting and overweight in children aged 4 years and older by providing school meals with improved quality of diet. We assess the plausibility of our method and discuss how improved data and models can generate better estimates. Double-duty interventions could save money and be more efficient than single-duty interventions.

The Attitudinal and Motivational Effects of Anti-waterpipe Messages.

Objectives: Waterpipe smoking can lead to negative health outcomes. In this study, we examined responses to anti-waterpipe smoking public service announcements (PSAs). Methods: In a pilot study, current waterpipe smokers (N = 20) and susceptible waterpipe never smokers (N = 25) were randomized to view either 3 anti-waterpipe PSAs, created by the Truth campaign, or 3 control videos. Participants answered questions pertaining to message acceptance at 3 time-points and perceived risk and motivation to quit or avoid waterpipe at 4 time-points. Results: Participants were recruited from the community (N = 45; Mage = 22.4 years). Whereas waterpipe smokers and never smokers who viewed the PSAs significantly increased in acceptance of (p < .05) and positive attitudes towards (p < .05) the messages with increased viewing of the mes- sages, waterpipe never smokers did so at a significantly higher rate (p < .05). Waterpipe never smokers who viewed the PSAs had increased perceived severity and susceptibility of health harms of waterpipe compared to the control (ps < .05). We also found gender differences. Conclusions: The 3 tested PSAs from the Truth campaign show evidence of effectiveness against waterpipe use.

Investing in non-communicable disease risk factor control among adolescents worldwide: a modelling study.

INTRODUCTION: Exposure to non-communicable disease (NCD) risk factors is increasing among adolescents in most countries due to demographic, economic and epidemiological forces. We sought to analyse the potential health impact and costs of implementing NCD risk reduction interventions among adolescents worldwide. METHODS: We identified six interventions targeted at adolescent tobacco smoking, heavy episodic drinking and obesity and supported by effectiveness and cost-effectiveness evidence. Based on a population-level cohort of adolescents in 70 representative countries, we assessed the global mortality consequences of fully implementing these interventions over 2020-2070 using the potential impact fraction approach. We calculated the economic benefits of reduced mortality and estimated the required financial costs, discounting both at 3% annually. We also conducted best-case and worst-case scenario analyses. RESULTS: Full implementation of these interventions worldwide could avert nearly 10% of premature deaths among this cohort, translating to about US$400 billion in cumulative economic benefits. Cumulatively, the required costs would be about US$85 billion, suggesting that every US$1 of public money invested would generate US$5 in increased human capital. Tobacco taxes generally conferred the highest economic returns; however, an in-depth analysis of three countries illustrated the potential for different priorities, such as alcohol control, to emerge. CONCLUSION: From a life course perspective, implementation of a package of interventions to reduce NCD risk among adolescents worldwide would substantially reduce premature mortality at reasonable costs. Our analysis illustrates the importance of integrating NCD prevention policies into the emerging global agenda for adolescent health and well-being.

Vaccine hesitancy among parents of adolescents and its association with vaccine uptake.

BACKGROUND: Addressing parental vaccine hesitancy may increase adolescent vaccination acceptance. However, no validated measure exists to identify parents hesitant toward adolescent vaccines. OBJECTIVE: To determine if a modified version of the Parent Attitudes about Childhood Vaccines (PACV) survey, a previously validated tool to identify parental hesitancy toward vaccines in infants, predicts adolescent vaccine uptake at office visits. METHODS: We modified the PACV for use in the adolescent setting and distributed it to a convenience sample of parents of adolescents aged 11 to 17 presenting for care at a diverse group of six pediatric practices in Oklahoma and South Carolina. We determined the vaccination status of the parents' adolescents for 3 vaccines (Tetanus-diphtheria-acellular pertussis [Tdap], meningococcal conjugate [MCV4], and human papillomavirus [HPV] vaccines). We used Fisher's exact tests to compare vaccination status with each survey item and with an overall general hesitancy scale that we constructed. RESULTS: We analyzed 363 surveys. At the time of the visit, vaccination coverage was 84% for Tdap, 73% for MCV, and 45% for any dose of HPV. Thirty-nine percent of parents expressed concern about vaccine efficacy and 41% expressed concern about side effects. Forty-five percent of parents disagreed with the statement that "teens can get all of the vaccines that are due at a single visit." Two individual items were associated with not receiving a dose of HPV vaccine that was due. The overall modified PACV score failed to predict adolescent vaccine uptake at an office visit. CONCLUSION: Several individual items were associated with vaccine uptake. The cumulative modified PACV, a general measure of vaccine hesitancy, was not associated with vaccination status despite illuminating parental hesitancy. We need to better understand vaccine-specific concerns for the adolescent population.

Trends in obesity prevalence and disparities among low-income children in Oklahoma, 2005-2010.

BACKGROUND: National WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children) data indicate a decrease in obesity prevalence among most low-income preschool-aged children. Though racial/ethnic disparities exist, studies examining obesity trends among various racial/ethnic groups are lacking. The aims of this study were to identify racial/ethnic disparities in obesity among low-income preschool children in Oklahoma and describe trends in obesity prevalence among four major racial/ethnic groups. METHODS: Subjects included 218,486 children 2-4 years of age who participated in WIC in Oklahoma from 2005 to 2010. Logistic regression was performed to identify disparities and trends in obesity among American Indian, Hispanic, White, and African American children. RESULTS: Racial/ethnic disparities in obesity were evident, with prevalence highest in Hispanics and lowest in African Americans. Obesity increased among girls for all racial/ethnic groups from 2005 to 2010 (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.01, 1.03). Among boys, obesity increased in African Americans (OR, 1.04; 95% CI, 1.01, 1.07), but remained stable in other racial/ethnic groups. CONCLUSIONS: In Oklahoma, in contrast to recent national studies, obesity is increasing among certain groups of low-income preschool children. These findings suggest geographic diversity in obesity and that state-specific obesity surveillance is important to help target interventions to those at highest risk.

Pediatric behavioral health screening in primary care: a preliminary analysis of the pediatric symptom checklist-17 with functional impairment items.

BACKGROUND: Roughly 21% of youth in the United States meet criteria for a mental health diagnosis, but only one-fifth of those children obtain help. The Pediatric Behavioral Health Screen (PBHS) utilizes the Pediatric Symptom Checklist-17 (PSC-17) and functional impairment items to assess behavioral health concerns. METHODS: Data were obtained from a systematic chart review for children 6 to 16 years old. Descriptive analyses and a confirmatory factor analysis were used to evaluate the clinical performance and utility of the PBHS. RESULTS: A positive screen was endorsed for 26.7% of the sample, of whom 68% also experienced functional impairment. Clinicians appropriately administered the screen 73.5% of the time. The 3-factor model of the PSC-17 exhibited a good model fit. CONCLUSIONS: Prevalence rates of psychosocial concerns and functional impairment affirm the need for routine behavioral health screening in the pediatric primary care setting. The PBHS exhibited good psychometric performance and clinical utility.

Pilot investigation of changes in readiness and confidence to quit smoking after E-cigarette experimentation and 1 week of use.

INTRODUCTION: This study examined changes in smokers' readiness and confidence to quit smoking, smoking behavior, nicotine withdrawal symptoms, and tobacco product preference following electronic cigarette (EC) experimentation and 1 week of ad libitum use. METHODS: Current cigarette smokers, with no prior use of ECs and uninterested in quitting, completed 3 study phases: baseline assessment (N = 20), experimentation (N = 19), and ad libitum use (N = 16). Baseline assessment consisted of completion of assessment measures and exhaled carbon monoxide measurements. Experimentation phases consisted of four, 75-min sessions in which participants completed assessment measures and sampled 3 EC brands and their own brand of cigarette (OBC). Ad libitum use included participants selecting and being provided their preferred EC brand from the experimentation phase to be used "as you want" for 1 week. Outcome measures included readiness and confidence to quit smoking, nicotine withdrawal symptoms, product preference/satisfaction, and smoking behavior items. RESULTS: Readiness and confidence to quit increased significantly during the experimentation period and continued to increase during ad libitum use. There were no significant differences in reported effectiveness in reducing smoking urges and cravings between OBC and EC though OBC were rated as more enjoyable and satisfying. During ad libitum use, regular cigarette smoking decreased by approximately 44% from baseline levels with overall tobacco use (EC + OBC) remaining the same. CONCLUSIONS: Among a small convenience sample of unmotivated cigarette smokers, EC experimentation and 1 week of ad libitum use increased readiness and confidence to quit regular cigarettes and reduced regular cigarette smoking.

Reasons for not vaccinating adolescents: National Immunization Survey of Teens, 2008-2010.

OBJECTIVE: To determine the reasons adolescents are not vaccinated for specific vaccines and how these reasons have changed over time. METHODS: We analyzed the 2008-2010 National Immunization Survey of Teens examining reasons parents do not have their teens immunized. Parents whose teens were not up to date (Not-UTD) for Tdap/Td and MCV4 were asked the main reason they were not vaccinated. Parents of female teens Not-UTD for human papillomavirus vaccine (HPV) were asked their intent to give HPV, and those unlikely to get HPV were asked the main reason why not. RESULTS: The most frequent reasons for not vaccinating were the same for Tdap/Td and MCV4, including "Not recommended" and "Not needed or not necessary." For HPV, the most frequent reasons included those for the other vaccines as well as 4 others, including "Not sexually active" and "Safety concerns/Side effects." "Safety concerns/Side effects" increased from 4.5% in 2008 to 7.7% in 2009 to 16.4% in 2010 and, in 2010, approaching the most common reason "Not Needed or Not Necessary" at 17.4% (95% CI: 15.7-19.1). Although parents report that health care professionals increasingly recommend all vaccines, including HPV, the intent to not vaccinate for HPV increased from 39.8% in 2008 to 43.9% in 2010 (OR for trend 1.08, 95% CI: 1.04-1.13). CONCLUSIONS: Despite doctors increasingly recommending adolescent vaccines, parents increasingly intend not to vaccinate female teens with HPV. The concern about safety of HPV grew with each year. Addressing specific and growing parental concerns about HPV will require different considerations than those for the other vaccines.