Associations between vaping and self-reported respiratory symptoms in young people in Canada, England and the US.

BACKGROUND: Prevalence of youth nicotine vaping has increased, heightening concerns around negative health effects. This study aimed to compare self-reported respiratory symptoms among youth by vaping behaviours. METHODS: Participants (n = 39,214) aged 16-19 from the 2020 and 2021 International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Surveys (Canada, England, US). Weighted multivariable logistic regression assessed associations between reporting any of five respiratory symptoms in the past week (shortness of breath, wheezing, chest pain, phlegm, cough) and: past 30-day smoking and/or vaping; lifetime/current vaping. Among past-30-day vapers (n = 4644), we assessed associations between symptoms and vaping frequency, use of nicotine salts, usual flavour and device type(s). RESULTS: Overall, 27.8% reported experiencing any of the five respiratory symptoms. Compared with youth who had only vaped, those who had only smoked had similar odds of symptoms [adjusted odds ratio, OR (95% confidence interval, CI): 0.97 (0.85-1.10)], those who both smoked and vaped had higher odds [1.26 (1.12-1.42)], and those who had done neither, lower odds [0.67 (0.61-0.72)]. Compared with those who had never vaped, past use, experimentation and current regular or occasional use were all associated with higher odds. Reporting usually using nicotine salts was associated with higher odds of symptoms [1.43 (1.22-1.68)] than non-salt but was often uncertain. Compared with tobacco flavour (including with menthol), menthol/mint and sweets flavours were associated with similar odds; fruit [1.44 (1.07-1.93)], multiple [1.76 (1.30-2.39)] and 'other' [2.14 (1.45-3.16)] flavours with higher odds. All device types were associated with similar odds. CONCLUSIONS: Among youth, vaping was associated with increased reporting of past-week respiratory symptoms. Among those who vaped, some flavour types and potentially nicotine salts were associated with respiratory symptoms.

Use of Menthol Cigarettes and Accessories Among Youth Who Smoked After the Menthol Cigarette Ban in England and Canada, 2021: Implications for Health Equity.

INTRODUCTION: This study examined menthol cigarette use among youth who smoked, after menthol cigarette bans were implemented in England (May 2020) and Canada (October 2017). AIMS AND METHODS: Cross-sectional data come from 2021 ITC Youth Tobacco and Vaping Survey respondents aged 16-19 who smoked in the past 30 d in England (N = 715) and Canada (N = 419). Adjusted logistic regression models, estimated separately for each country, examined sociodemographic correlates of usually smoking menthol cigarettes (reporting currently most often smoking menthol cigarettes) overall, and by past 30-d use of any menthol accessories (e.g., filters, capsules). Youth reported the cigarette variety they smoked most often, coded as menthol or nonmenthol. RESULTS: Almost no youth who smoked in the past 30 d reported most often smoking a cigarette variety coded as menthol. However, 34.5% (95% CI: 30.4% to 38.9%) of youth who smoke in England and 30.9% (26.0%-36.3%) in Canada reported usually smoking menthol cigarettes, with greater odds of use among those identifying as black, or other race/ethnicity, respectively, compared to white in England (60.0%, aOR = 3.08, p = .001; 47.4%, aOR = 2.27, p = .011) and Canada (43.6%, aOR = 2.44, p = .046; 51.2%, aOR = 2.92, p = .001). Among those who reported usually smoking menthol cigarettes in England (N = 223) and Canada (N = 108), 71.7% (64.0%-78.2%) and 51.5% (41.1%-61.7%) reported using menthol accessories. CONCLUSIONS: After menthol cigarette bans in England and Canada, approximately one-third of youth who smoked reported usually smoking menthol cigarettes, with disproportionately higher use among those identifying as black and other race/ethnicity. Menthol accessories accounted for most menthol cigarette use. Closing regulatory loopholes is critical to advancing public health equity. IMPLICATIONS: Use of menthol cigarette accessories (eg, filters, cards, capsules) among youth who smoked was prevalent after implementation of menthol cigarette bans in England and Canada, and there was disproportionately higher use among those who identified as black and any other race/ethnicity. Efforts are therefore required to close regulatory loopholes of menthol cigarette bans. Findings further support countries, such as the United States, proposing menthol cigarette bans which extend coverage to accessories. More comprehensive menthol bans that also restrict accessories are likely to be more effective in reducing flavored tobacco use among young people and in advancing health equity.

Use of 'Elf Bar' among youth and young adults who currently vape in England: cross-sectional associations with demographics, dependence indicators and reasons for use.

BACKGROUND AND AIMS: Elf Bar is currently the leading e-cigarette (vape) brand in Great Britain. This study examined youth and young adults' use of Elf Bar, socio-demographic characteristics and dependence indicators and reasons for use over other brands. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: Online 2022 International Tobacco Control Project Youth Tobacco and Vaping Survey (N = 1355 16-29-year-olds in England who had vaped in the past 30 days). MEASUREMENTS: Currently using Elf Bar most often (versus other brands) and associations with: socio-demographics, owning a vaping device, dependence indicators and reasons for brand choice. Logistic regressions were used. FINDINGS: Among 16-29-year-olds who vaped in the past 30 days, 48.4% (n = 732) reported Elf Bar as the brand they used most often. Among 16-17-year-olds, 40.7% used Elf Bar over other brands; this was lower than among 18-19-year-olds (60.1%) and 20-29-year-olds (47.4%) (P ≤ 0.002). Using Elf Bar over other brands was higher among those who were female (55.2 versus 41.5% male), identified as White (53.1 versus 30.9% other/mixed), a student (54.5 versus 44.3% not), did not own a vape (66.7 versus 44.4% who did) and typically vaped 5-8 hours after waking (62.7 versus 36.8% within 5 min) (P ≤ 0.044). Most who vaped but had never smoked used Elf Bar (64.3%), although use did not significantly differ from those who currently (45.4%), formerly (42.3%) or experimentally (48.7%) smoked (all P ≥ 0.060). Popular reasons for choosing Elf Bar over other brands were better flavour/taste (47.5%), less expensive (28.7%), easier to get (26.1%), smoother to inhale (24.0%) and popularity (23.1%). 'Better for quitting smoking' (10.1%) was least frequently selected reason for choosing Elf Bar over other brands. CONCLUSIONS: Elf Bar brand e-cigarettes were used by approximately half of 16-29-year-olds who vaped in England in 2022 and was mainly chosen over other brands for subjective responses (e.g. flavour/taste), rather than for quitting smoking.

Comparison of indicators of dependence for vaping and smoking: Trends between 2017 and 2022 among youth in Canada, England and the United States.

INTRODUCTION: The current study sought to examine trends in indicators of dependence for youth vaping and smoking during a period of rapid evolution in the e-cigarette market. METHODS: Data are from repeat cross-sectional online surveys conducted between 2017 and 2022 among youth aged 16-19 in Canada, England, and the USA. Participants were 23,145 respondents who vaped and/or smoked in the past 30 days. Four dependence indicators were assessed for smoking and vaping (perceived addiction, frequent strong urges, time to first use after waking, days used in past month) and two for vaping only (use events per day, E-cigarette Dependence Scale). Regression models examined differences by survey wave and country, adjusting for sex, age, race, and exclusive/dual use. RESULTS: All six indicators of dependence increased between 2017 and 2022 among youth who vaped in the past 30 days (p<.001 for all). For example, more youth reported strong urges to vape at least most days in 2022 than in 2017 (Canada: 26.5% to 53.4%; England: 25.5% to 45.4%; USA: 31.6% to 50.3%). In 2017, indicators of vaping dependence were substantially lower than for smoking; however, by 2022, youth vaping was associated with a greater number of days used in the past month (Canada, USA), shorter time to first use (all countries), and a higher likelihood of frequent strong urges (Canada, USA) compared to youth smoking. CONCLUSIONS: From 2017 to 2022, indicators of vaping dependence increased substantially. By 2022, vaping dependence indices were comparable to those of smoking. IMPLICATIONS: Indicators of vaping dependence among youth have increased substantially since 2017 to levels that are comparable to cigarette dependence among youth who smoke. Future research should examine factors underlying the increase in dependence among youth who vape, including changes to the nicotine profile and design of e-cigarette products.

Noticing education campaigns or public health messages about vaping among youth in the United States, Canada and England from 2018 to 2022.

Public health campaigns have the potential to correct vaping misperceptions. However, campaigns highlighting vaping harms to youth may increase misperceptions that vaping is equally/more harmful than smoking. Vaping campaigns have been implemented in the United States and Canada since 2018 and in England since 2017 but with differing focus: youth vaping prevention (United States/Canada) and smoking cessation (England). We therefore examined country differences and trends in noticing vaping campaigns among youth and, using 2022 data only, perceived valence of campaigns and associations with harm perceptions. Seven repeated cross-sectional surveys of 16-19 year-olds in United States, Canada and England (2018-2022, n = 92 339). Over half of youth reported noticing vaping campaigns, and noticing increased from August 2018 to February 2020 (United States: 55.2% to 74.6%, AOR = 1.21, 95% CI = 1.18-1.24; Canada: 52.6% to 64.5%, AOR = 1.13, 1.11-1.16; England: 48.0% to 53.0%, AOR = 1.05, 1.02-1.08) before decreasing (Canada) or plateauing (England/United States) to August 2022. Increases were most pronounced in the United States, then Canada. Noticing was most common on websites/social media, school and television/radio. In 2022 only, most campaigns were perceived to negatively portray vaping and this was associated with accurately perceiving vaping as less harmful than smoking among youth who exclusively vaped (AOR = 1.46, 1.09-1.97). Consistent with implementation of youth vaping prevention campaigns in the United States and Canada, most youth reported noticing vaping campaigns/messages, and most were perceived to negatively portray vaping.

Impact of E-liquid Packaging on Vaping Product Perceptions Among Youth in England, Canada, and the United States: A Randomized Online Experiment.

INTRODUCTION: Vaping is not risk-free but can help those who smoke to reduce harm to health and stop smoking. However, packaging of vaping products, including e-liquids, appeals to youth and might facilitate vaping among nicotine-naïve people. Standardized packaging of vaping products could moderate the appeal of vaping among youth. This study assessed how youth interest in trying and perceived health harms of using e-liquids are associated with branded or standardized (white or olive) e-liquid packaging with different nicotine levels displayed. AIMS AND METHODS: A between-subject experiment with three packaging and two nicotine level conditions included youth (n = 13801) aged 16 to 19 from England, Canada, and the United States as a part of a cross-sectional online survey in August-September 2021. Participants' interest in trying and perceived harm of e-liquids were analyzed using logistic and multinomial regressions adjusted for age, sex, race or ethnicity, country, vaping, and smoking status. RESULTS: Compared with branded e-liquid packs, more youth reported no interest in trying e-liquids in white (aOR = 1.48, 95% CI = 1.34 to 1.64) or olive (aOR = 1.62, 95% CI: 1.47 to 1.80) standardized packs. Compared with branded e-liquid packs, more youth inaccurately perceived e-liquids in white (aOR = 1.22, 95% CI: 1.11 to 1.34) or olive (aOR = 1.29, 95% CI: 1.18 to 1.41) standardized packs as equally or more harmful than smoking. E-liquid nicotine levels displayed on packs were not associated with youth interest in trying or harm perceptions of using e-liquids. CONCLUSIONS: Among 16- to 19-year-old youth from England, Canada, and the United States, standardized packaging of e-liquids was associated with lower interest in trying and higher health risk perceptions. IMPLICATIONS: Branded packaging of vaping products appeal to youth and might prompt nicotine use among those who had never smoked. This study suggests that restricting branding elements on e-liquid packaging is associated with youth's lower interest in trying e-liquids and higher misperceptions that vaping is equally or more harmful than smoking. Standardized packaging might reduce appeal of vaping among youth, but its potential to discourage vaping for harm reduction should also be considered.

Reoperation for post hepatectomy complications.

BACKGROUND: Reoperation for post hepatectomy complications is associated with high rates of morbidity and mortality. We aim to describe the frequency, indications, and risk factors for reoperation after liver resection in a single centre. METHODS: Perioperative data of 464 patients, who underwent elective hepatectomy from 2001 to 2020 at The Queen Elizabeth Hospital in South Australia, were retrospectively analysed. The frequency and indications for reoperation for post hepatectomy complications were recorded. Binary logistic regression analysis was performed to determine variables associated with reoperation. RESULTS: A total of seven patients (1.5%) underwent reoperation post hepatectomy. The most common indications for reoperation were intra-abdominal abscess, post-operative haemorrhage, bile leak, and ischaemic bowel. Three out of the seven patients died. Patients were more likely to require reoperation if an additional major non-hepatic procedure was performed. CONCLUSION: Reoperation post hepatectomy is associated with morbidity and mortality and is more likely to occur in patients who have undergone a non-hepatic procedure at the same time as the primary hepatic resection. Surgeons should ensure these patients are appropriately monitored and be selective about performing complex, multiple procedures. When possible, procedures should be staged.

Trends in vaping and nicotine product use among youth in Canada, England and the USA between 2017 and 2022: evidence to inform policy.

BACKGROUND: Preventing uptake of nicotine products among youth remains a central objective of tobacco control policy. Comparing trends in the use of nicotine across countries provides an opportunity to identify emergent product trends and to evaluate 'natural experiments' in policies. METHODS: Repeat cross-sectional data were analysed from eight waves of the International Tobacco Control Youth Tobacco and Vaping Survey, conducted between 2017 and 2022. Non-probability samples of youth aged 16-19 years in Canada, England and the USA (N=104 473) completed online surveys including measures on vaping, smoking and use of other nicotine products. This paper summarises findings across the 5-year period of the study, as part of a comprehensive report on key indicators of youth vaping in the three countries. RESULTS: The youth nicotine market has rapidly evolved across the three countries, with different patterns of combustible and non-combustible product use in Canada, the USA and England. These changes are primarily attributable to trends in youth vaping: following declines during the initial COVID-19 pandemic period, by 2022, vaping prevalence neared pre-pandemic levels in the USA and Canada, and reached record highs in England. Notable shifts also occurred in the types of vaping products used by youth, including increased use of disposable, nicotine salt-based products. Additional findings are reported on a range of policy-relevant indicators, including for vaping products, promotions and purchasing. CONCLUSIONS: Patterns of nicotine use among youth have rapidly evolved in recent years due to the proliferation of nicotine products, the COVID-19 pandemic and the emerging impact of policy measures.

A Case Study Implementing a Social Needs Screening Process and a Family Navigation Hub at Holland Bloorview Kids Rehabilitation Hospital.

Identifying and addressing clients' and families' most pressing social determinants of health needs are integral to quality healthcare. Healthcare leaders and front-line clinicians have long recognized the connection between unmet essential resource needs, such as food, housing and transportation and health outcomes. As a component of broader organizational efforts to improve equitable access to services, a social needs screening (SNS) initiative was introduced, along with a Family Navigation Hub providing navigation interventions. This paper describes the systematic approach taken to support the SNS initiative implementation and highlights evaluation results of the first year of activity.

Trends in E-Cigarette and Tobacco Cigarette Purchasing Behaviors by Youth in the United States, Canada, and England, 2017-2022.

Objectives: This paper describes trends in youth e-cigarette (EC) and tobacco cigarette (TC) purchasing behaviors in Canada, England, and the United States (US) in relationship to changing minimum legal age (MLA) laws. Methods: Data are from eight cross-sectional online surveys among national samples of 16- to 19-year-olds in Canada, England, and the US conducted from 2017 to 2022 (N = 104,467). Average wave percentage change in EC and TC purchasing prevalence and purchase locations were estimated using Joinpoint regressions. Results: EC purchasing increased between 2017 and 2022, although the pattern of change differed by country. EC purchasing plateaued in 2019 for the US and in 2020 for Canada, while increasing through 2022 for England. TC purchasing declined sharply in the US, with purchasing from traditional retail locations declining, while purchasing from social sources increased. Vape shops were the most common location for EC purchasing, although declining in England and the US. Conclusion: Trends in EC and TC purchasing trends in the US are consistent with the expected impact of the federal MLA law increasing the legal age to 21 years in December 2019.

Opioid prescribing, pain, and hospital stay of general surgery patients with oxycodone allergies in South Australia.

BACKGROUND: The frequency of oxycodone adverse reactions, subsequent opioid prescription, effect on pain and patient care in general surgery patients are not well known. This study aimed to determine prevalence of documented oxycodone allergy and intolerances (independent variables) in a general surgical cohort, and association with prescribing other analgesics (particularly opioids), subjective pain scores, and length of hospital stay (dependent variables). METHODS: This retrospective cohort study included general surgery patients from two South Australian hospitals between April 2020 and March 2022. Multivariable logistic regression evaluated associations between previous oxycodone allergies and intolerances, prescription records, subjective pain scores, and length of hospital stay. RESULTS: Of 12 846 patients, 216 (1.7%) had oxycodone allergies, and 84 (0.7%) oxycodone intolerances. The 216 oxycodone allergy patients had lower odds of receiving oxycodone (OR 0.17, P < 0.001), higher odds of tramadol (OR 3.01, P < 0.001) and tapentadol (OR 2.87, P = 0.001), but 91 (42.3%) still received oxycodone and 19 (8.8%) morphine. The 84 with oxycodone intolerance patients had lower odds of receiving oxycodone (OR 0.23, P < 0.001), higher odds of fentanyl (OR 3.6, P < 0.001) and tramadol (OR 3.35, P < 0.001), but 42 (50%) still received oxycodone. Patients with oxycodone allergies and intolerances had higher odds of elevated subjective pain (OR 1.60, P = 0.013; OR 2.36, P = 0.002, respectively) and longer length of stay (OR 1.36, P = 0.038; OR 2.24, P = 0.002, respectively) than patients without these. CONCLUSIONS: General surgery patients with oxycodone allergies and intolerances are at greater risk of worse postoperative pain and longer length of stay, compared to patients without. Many still receive oxycodone, and other opioids that could cause cross-reactivity.

Surgery's Rosetta Stone: Natural language processing to predict discharge and readmission after general surgery.

BACKGROUND: This study aimed to examine the accuracy with which multiple natural language processing artificial intelligence models could predict discharge and readmissions after general surgery. METHODS: Natural language processing models were derived and validated to predict discharge within the next 48 hours and 7 days and readmission within 30 days (based on daily ward round notes and discharge summaries, respectively) for general surgery inpatients at 2 South Australian hospitals. Natural language processing models included logistic regression, artificial neural networks, and Bidirectional Encoder Representations from Transformers. RESULTS: For discharge prediction analyses, 14,690 admissions were included. For readmission prediction analyses, 12,457 patients were included. For prediction of discharge within 48 hours, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.86 and 0.86 for Bidirectional Encoder Representations from Transformers, 0.82 and 0.81 for logistic regression, and 0.82 and 0.81 for artificial neural networks. For prediction of discharge within 7 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.82 and 0.81 for Bidirectional Encoder Representations from Transformers, 0.75 and 0.72 for logistic regression, and 0.68 and 0.67 for artificial neural networks. For readmission prediction within 30 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.55 and 0.59 for Bidirectional Encoder Representations from Transformers and 0.77 and 0.62 for logistic regression. CONCLUSION: Modern natural language processing models, particularly Bidirectional Encoder Representations from Transformers, can effectively and accurately identify general surgery patients who will be discharged in the next 48 hours. However, these approaches are less capable of identifying general surgery patients who will be discharged within the next 7 days or who will experience readmission within 30 days of discharge.

Sociocultural and Demographic Factors Predict Readmissions for General Surgery Patients.

INTRODUCTION: Readmission is a poor outcome for both patients and healthcare systems. The association of certain sociocultural and demographic characteristics with likelihood of readmission is uncertain in general surgical patients. METHOD: A multi-centre retrospective cohort study of consecutive unique individuals who survived to discharge during general surgical admissions was conducted. Sociocultural and demographic variables were evaluated alongside clinical parameters (considered both as raw values and their proportion of change in the 1-2 days prior to admission) for their association with 7 and 30 days readmission using logistic regression. RESULTS: There were 12,701 individuals included, with 304 (2.4%) individuals readmitted within 7 days, and 921 (7.3%) readmitted within 30 days. When incorporating absolute values of clinical parameters in the model, age was the only variable significantly associated with 7-day readmission, and primary language and presence of religion were the only variables significantly associated with 30-day readmission. When incorporating change in clinical parameters between the 1-2 days prior to discharge, primary language and religion were predictive of 30-day readmission. When controlling for changes in clinical parameters, only higher comorbidity burden (represented by higher Charlson comorbidity index score) was associated with increased likelihood of 30-day readmission. CONCLUSIONS: Sociocultural and demographic patient factors such as primary language, presence of religion, age, and comorbidity burden predict the likelihood of 7 and 30-day hospital readmission after general surgery. These findings support early implementation a postoperative care model that integrates all biopsychosocial domains across multiple disciplines of healthcare.

Improving communication and patient information recall via a question prompt list: randomized clinical trial.

BACKGROUND: Patient-surgeon communication is an important component of the success of a consultation and is known to impact patient outcomes. The aim of this study was to investigate whether a document called a question prompt list, containing suggested questions that a patient may like to ask their doctor, improved communication. METHODS: A prospective RCT was conducted from October 2021 to October 2022 at The Queen Elizabeth Hospital, Adelaide, Australia. Patients 16 years or older, seeing a general surgeon for a pre-surgical consultation, not requiring a translator, were randomized to receive a question prompt list (intervention) or standard care without a question prompt list (control). The primary outcomes were number of questions asked, talk time, and mutual eye gaze. Secondary outcomes were patient recall of information, anxiety, and consultation duration. Randomization was achieved using a computer program, with allocation concealment by opaque sequentially numbered envelopes. Patients were blinded to study group; surgeons were aware of study group, but blinded to outcomes. RESULTS: Patients (59) were randomly allocated to receive the question prompt list (31) or to the control group (28). A patient from the intervention group withdrew before consultation, resulting in 58 patients being included in the analysis. In the question prompt list consultations, 24 per cent more questions were asked (incidence rate ratio = 1.25, 95 per cent c.i. 1.10 to 1.42; P = 0.001). The intervention group recalled 9 per cent more items than the control group (incidence rate ratio = 1.09, 95 per cent c.i. 1.02 to 1.17; P = 0.012). The control group were 26 per cent less likely to correctly recall information about surgical treatment (OR = 0.26, 95 per cent c.i. 0.10 to 0.68; P = 0.006). No statistically significant differences between study arms for talk time, mutual eye gaze, anxiety, or consultation duration were demonstrated. CONCLUSION: The question prompt list was associated with increased question asking and greater patient recall of medical information. It did not increase patient anxiety or consultation duration. REGISTRATION NUMBER: ACTRN12623000089639 (http://www.ANZCTR.org.au).

Perceptions of cannabis use risk to mental health among youth in Canada, England and the United States from 2017 to 2021.

BACKGROUND: There is little research examining perceptions of cannabis use risk to mental health in countries with differing cannabis regulations. This study therefore examines such perceptions among youth between 2017 and 2021 in Canada (non-medical cannabis legalized in October 2018), England (highly-restricted medical cannabis legalized November 2018), and the US (non-medical cannabis legal in some states). METHODS: Seven repeat cross-sectional online surveys were conducted between July 2017 to August 2021 among youth aged 16-19 in Canada (N=29,420), England (N=28,155), and the US (N=32,974). Logistic regression models, stratified by country, were used to examine perceptions of cannabis use risk to mental health over time, adjusting for age group, sex, race/ethnicity, cannabis use and, for the US only, state-level cannabis legalization. RESULTS: Perceptions that cannabis use posed "no risk" to mental health decreased between July 2017 and August 2021 in Canada (6.1-4.4%; AOR=0.64, 95% CI=0.52-0.78) and the US (14.0-11.3%; AOR=0.74, 0.65-0.84) but not England (3.7-4.5%; AOR=1.21, 0.97-1.52). No significant changes were observed from immediately before (August 2018) to after (August 2019) legalization of non-medical cannabis in Canada (AOR=0.99, 0.83-1.20) or highly-restricted medical cannabis in England (AOR=0.90, 0.70-1.17). In the US, perceptions of "no risk" were more likely in states where cannabis use was illegal (15.0%) compared with legal non-medical (12.2%) (AOR=0.68, 0.63-0.74). CONCLUSION: There were modest decreases in perceptions that cannabis use poses no risk to mental health in Canada and the US between 2017 and 2021 but no clear association with cannabis legalization status.

Youth Use of e-Cigarette Flavor and Device Combinations and Brands Before vs After FDA Enforcement.

Importance: The US Food and Drug Administration's Center for Tobacco Products (CTP) prioritized its enforcement efforts against nontobacco, nonmenthol (ie, sweet)-flavored cartridge e-cigarettes in February 2020. Within-person e-cigarette initiation, continuation, and switching behaviors among youth are unknown following CTP's prioritized enforcement efforts. Objective: To describe transitions in youths' e-cigarette flavor/device combination use, brand use, nicotine use, and frequency of use following CTP's e-cigarette enforcement prioritization. Design, Setting, and Participants: The US population-based, nationally representative Population Assessment of Tobacco and Health cohort study included data collected in 2019 and 2021 from youth aged 12 to 17 years. The data were analyzed from February to June 2023. Exposure: e-cigarette use (past 30 days), flavor/device combination used, brand used, nicotine use, and frequency of use. Main Outcomes and Measures: Transitions in e-cigarette use, flavor/device combination used, brand used, nicotine use, and frequency of use between 2019 and 2021 among 9088 youth aged 12 to 17 years in 2019; prevalence of e-cigarette use, flavor/device combination used, and brand used in 2019 (n = 8771) and 2021 (n = 5574) among youth aged 14 to 17 years in each year. Results: The 2019 sample included 8771 youth. The population of those aged 12 to 17 years was 49.0% female (95% CI, 48.7%-49.3%) and 51.0% male (95% CI, 50.8%-51.3%). Participants were 15.4% Black (95% CI, 15.0%-15.7%), 24.1% Hispanic (95% CI, 23.9%-24.4%), 75.9% non-Hispanic (95% CI, 75.6%-76.1%), 69.1% White (95% CI, 68.5%-69.8%), and 15.5% another race (95% CI, 14.9%-16.1%). Among youth ages 12 to 17 years who did not use e-cigarettes in 2019, 531 (6.5%) initiated use in 2021 (95% CI, 5.9%-7.1%); among them, 415 (76.8%) initiated with a combination other than a sweet cartridge (95% CI, 72.2%-80.8%). Among youth ages 12 to 17 who used e-cigarettes in 2019, 360 (47.8%) continued use in 2021 (95% CI, 44.0%-51.1%). Continuation rates were similar for those who used sweet-cartridge e-cigarettes (144 [51.5%]; 95% CI, 45.7%-57.3%) and those who used other combinations (204 [47.6%]; 95% CI, 42.8%-52.4%) in 2019. Among those who continued e-cigarette use in 2021, 121 (84.0%) of those who used sweet-cartridge e-cigarettes in 2019 switched to a different combination (95% CI, 77.0%-89.2%). Overall, among youth who used e-cigarettes in 2021, 177 (53%) used a sweet-disposable combination, 32 (11%) used a sweet-cartridge, and no individual brand was used by more than 10%. Conclusions and Relevance: The results of this longitudinal cohort study of youth in the US suggest that most youth who initiated or continued e-cigarette use in 2021 used flavor/device combinations that were excluded from CTP's enforcement priorities. Restrictions and enforcement efforts that only cover a subset of products may be ineffective at preventing youth flavored e-cigarette use.

Vital signs and medical emergency response (MER) activation predict in-hospital mortality in general surgery patients: a study of 15 969 admissions.

BACKGROUND: The applicability of the vital signs prompting medical emergency response (MER) activation has not previously been examined specifically in a large general surgical cohort. This study aimed to characterize the distribution, and predictive performance, of four vital signs selected based on Australian guidelines (oxygen saturation, respiratory rate, systolic blood pressure and heart rate); with those of the MER activation criteria. METHODS: A retrospective cohort study was conducted including patients admitted under general surgical services of two hospitals in South Australia over 2 years. Likelihood ratios for patients meeting MER activation criteria, or a vital sign in the most extreme 1% for general surgery inpatients (<0.5th percentile or > 99.5th percentile), were calculated to predict in-hospital mortality. RESULTS: 15 969 inpatient admissions were included comprising 2 254 617 total vital sign observations. The 0.5th and 99.5th centile for heart rate was 48 and 133, systolic blood pressure 85 and 184, respiratory rate 10 and 31, and oxygen saturations 89% and 100%, respectively. MER activation criteria with the highest positive likelihood ratio for in-hospital mortality were heart rate ≤ 39 (37.65, 95% CI 27.71-49.51), respiratory rate ≥ 31 (15.79, 95% CI 12.82-19.07), and respiratory rate ≤ 7 (10.53, 95% CI 6.79-14.84). These MER activation criteria likelihood ratios were similar to those derived when applying a threshold of the most extreme 1% of vital signs. CONCLUSIONS: This study demonstrated that vital signs within Australian guidelines, and escalation to MER activation, appropriately predict in-hospital mortality in a large cohort of patients admitted to general surgical services in South Australia.

Use of Electronic Nicotine Delivery Systems or Cigarette Smoking After US Food and Drug Administration-Prioritized Enforcement Against Fruit-Flavored Cartridges.

Importance: The Center for Tobacco Products (CTP) of the US Food and Drug Administration prioritized its enforcement efforts against non-tobacco-, non-menthol- (fruit-) flavored cartridge electronic nicotine delivery systems (ENDS) in February 2020. Objective: To evaluate adults' use of ENDS and cigarette smoking following the CTP's prioritized enforcement efforts against fruit-flavored cartridge ENDS. Design, Setting, and Participants: In this population-based, nationally representative US cohort study, data were collected from the Population Assessment of Tobacco and Health Study from December 2018 to November 2019 (hereafter referred to as 2019) and/or from September 2020 to December 2020 (Adult Telephone Survey, hereafter referred to as 2020). Adults (aged ≥21 years) who used ENDS in the past 30 days and smoked cigarettes in the past 30 days or quit smoking cigarettes in the past year (n = 3173) were evaluated. Data were analyzed from January 1, 2022, to May 2, 2023. Exposure: ENDS flavor-device combinations used. Main Outcomes and Measures: Outcome measures were cross-sectional prevalence of ENDS flavor-device combinations used in 2019 (n = 2654) and 2020 (n = 519) and longitudinal transitions in cigarette smoking (cessation [no smoking in the past 30 days in 2020 among those who smoked in 2019; n = 876] and relapse [smoking in the past 30 days in 2020 among those who recently quit in 2019; n = 137]) as a function of ENDS flavor-device combination used in 2019. Results: The sample in 2019 included 2654 individuals (55% male [95% CI, 53%-58%]). Among those who used ENDS and smoked cigarettes, fruit-flavored cartridge ENDS use decreased from 13.9% (95% CI, 12.1%-15.9%) in 2019 to 7.9% (95% CI, 5.1%-12.1%) in 2020 (P = .01), whereas fruit-flavored disposable ENDS use increased from 4.0% (95% CI, 3.1%-5.1%) in 2019 to 14.5% (95% CI, 11.6%-18.0%) in 2020 (P < .001). Patterns were similar among those who recently quit smoking. Neither cigarette cessation nor relapse rates differed between those who used ENDS that were vs were not prioritized for enforcement efforts (cessation: 23.4% [95% CI, 18.1%-29.7%] vs 26.4% [95% CI, 22.4%-30.8%]; adjusted odds ratio, 1.12; 95% CI, 0.57-2.21; relapse: 32.7% [95% CI, 17.1%-53.4%] vs 29.8% [95% CI, 20.3%-41.3%]; adjusted odds ratio, 0.96; 95% CI, 0.24-3.84). Conclusions and Relevance: In this nationally representative US cohort study of adults who smoked cigarettes and used ENDS, fruit-flavored cartridge ENDS use was nearly halved between 2019 and 2020. Cigarette cessation and relapse rates did not differ between those who used ENDS targeted by CTP and those who used other ENDS.

Awareness and use of short-fill e-liquids by youth in England in 2021: findings from the ITC Youth Tobacco and Vaping Survey.

BACKGROUND: Refillable e-cigarettes were popular among youth in England in 2021. The UK Tobacco and Related Products Regulations (TRPR) limits e-liquids to 20 mg/mL of nicotine in a 10 mL bottle. Short-fill e-liquids, which are not covered by TRPR regulations, are typically nicotine-free and come in larger, underfilled bottles allowing customisation with the addition of 'nicotine shots'. This paper investigates awareness, use, and reasons for use of short-fill e-liquids among youth in England. METHODS: Data are from the online 2021 International Tobacco Control Youth Survey, comprising 4224 youth (aged 16-19 years) in England. Weighted logistic regression models investigated associations between awareness and past 30-day use of short-fills by smoking status, vaping status, nicotine strength vaped and participant demographics. Reasons for use were also reported. RESULTS: Approximately one-quarter (23.0%) of youth in England reported awareness of short-fill e-liquids. Among youth who had vaped in the past 30 days, 22.1% had used short-fills in the past 30 days; use was most prevalent among those who were also smoking (43.2%) and those who reported usually vaping nicotine concentrations of 2.1% (21 mg/mL) or more (40.8%). 'Convenience of a bigger bottle' was the most selected reason for use (45.0%), followed by 'less expensive than regular e-liquids' (37.6%). CONCLUSIONS: Awareness of short-fills was common among youth in 2021, including among those who had never vaped or smoked. Among youth who vaped in the past 30 days, short-fill use was more prevalent among those who also smoked and those who vaped nicotine-containing e-liquids. Integration of short-fill products into existing e-cigarette regulations should be considered.