Delaying high school start times impacts depressed mood among students: evidence from a natural experiment.

PURPOSE: Delaying high school start times prolongs weekday sleep. However, it is not clear if longer sleep reduces depression symptoms and if the impact of such policy change is the same across groups of adolescents. METHODS: We examined how gains in weekday sleep impact depression symptoms in 2,134 high school students (mean age 15.16 ± 0.35 years) from the Minneapolis metropolitan area. Leveraging a natural experiment design, we used the policy change to delay school start times as an instrument to estimate the effect of a sustained gain in weekday sleep on repeatedly measured Kandel-Davies depression symptoms. We also evaluated whether allocating the policy change to subgroups with expected benefit could improve the impact of the policy. RESULTS: Over 2 years, a sustained half-hour gain in weekday sleep expected as a result of the policy change to delay start times decreased depression symptoms by 0.78 points, 95%CI (-1.32,-0.28), or 15.6% of a standard deviation. The benefit was driven by a decrease in fatigue and sleep-related symptoms. While symptoms of low mood, hopelessness, and worry were not affected by the policy on average, older students with greater daily screen use and higher BMI experienced greater improvements in mood symptoms than would be expected on average, signaling heterogeneity. Nevertheless, universal implementation outperformed prescriptive strategies. CONCLUSION: High school start time delays are likely to universally decrease fatigue and overall depression symptoms in adolescents. Students who benefit most with respect to mood are older, spend more time on screens and have higher BMI.

American Indian Perspectives on Culturally Aligning a Digital Smoking Cessation Resource.

INTRODUCTION: Innovative smoking cessation approaches that overcome barriers such as traveling to program site or that require the staff and infrastructure for sustaining are likely needed to improve smoking quit rates among American Indian (AI) peoples in the United States. In this study, qualitative methods identified recommendations from AI peoples to guide alignment of an evidence-based smoking cessation smartphone app (i.e., QuitGuide) to the culture and needs of AI persons. METHODS: Semi-structured interviews were conducted with AI adults who smoke (n = 40) and with public health professionals (n = 6). Questions included: "The app asks if something triggered you to slip and lists several options. What options were you expecting to see on this list?" as well as how to make the app more engaging such as "What would make the app more helpful for AI peoples, like you, who want to quit smoking?." Constant comparative techniques were used to develop codes and themes. RESULTS: Loss, grief, and not accessing traditional tobacco were put forward as smoking triggers to be addressed in the app. Features that help users connect with and learn about AI cultures and promote healing, such as encouraging traditional tobacco use, being in community, embracing Native spirituality, and participating in cultural crafting were recommended. Some noted the need to motivate AI peoples to think about legacy and ability to care for younger generations and Indigenizing the app with Native imagery. CONCLUSIONS: Themes pointed towards promotion of strengths-based factors, such as healing, cultural connectedness and traditional tobacco use, in the app. IMPLICATIONS: Results will be used to culturally align a smartphone app for smoking cessation among AI peoples and may be insightful for other tribal, federal, and state public health efforts aimed at advancing health equity for AI peoples.

Structural Bias in the Completeness of Death Investigations for Sudden Unexpected Infant Deaths (SUIDs).

OBJECTIVE: To assess sudden unexpected infant death (SUID) investigations for structural inequities by race/ethnicity and geography. METHODS: The SUID Case Registry compiles data on death investigations. We analyzed cases from 2015 to 2018 (N = 3847) to examine likelihood of an incomplete death investigation, defined as missing autopsy, missing scene investigation, or missing detailed information about where and how the body was found. We also analyzed which specific components of death investigations led to the greatest number of incomplete investigations. RESULTS: Twenty-four percent of SUIDs had incomplete death investigations. Death scenes in rural places had 1.51 times the odds of incomplete death investigations (95% confidence interval [CI], 1.19-1.92) compared with urban areas. Scene investigations led by law enforcement were more likely to result in incomplete death investigations (odds ratio [OR] = 1.49; 95% CI, 1.18-1.88) than those led by medical examiners. American Indian/Alaska Native SUIDs were more likely than other racial groups to have an incomplete investigation (OR = 1.49; 95% CI, 0.92-2.42), more likely to occur in rural places ( P = .055), and more likely to be investigated by law enforcement ( P < .001). If doll reenactments had been performed, 358 additional cases would have had complete investigations, and if SUID investigation forms had been performed, 243 additional cases would have had complete investigations. American Indian/Alaska Native SUIDs were also more likely to be missing specific components of death investigations. CONCLUSION: To produce equitable public health surveillance data used in prevention efforts, it is crucial to improve SUID investigations, especially in rural areas and among American Indian/Alaska Native babies.

COVID-19 vaccine decision-making among Black women: A qualitative study.

OBJECTIVE: To understand COVID-19 vaccine decision-making among Black women in the United States. METHODS: We conducted qualitative interviews with 60 Black women (both African American and first- and second-generation immigrants originating from Africa and the Caribbean) living in the Minneapolis/St. Paul Metropolitan Area. RESULTS: Participants who were highly motivated to get vaccinated described their trust in science and a desire to protect themselves and those around them; while those who delayed vaccination reported doubts about vaccine safety. Many reported being influenced by targeted misinformation including the pervasive vaccine myths related to reproductive health. Historical trauma from unethical biomedical research and experiences of racism were also motivating factors. There were several concerns raised that were specific to ethnic groups. CONCLUSIONS: Current public health strategies that are intended to promote COVID vaccination are failing Black communities. Participants highlighted the need for clear and culturally appropriate communication about COVID-19 and the vaccines that is aligned with their communities' values and addresses misinformation. The critical insights we have gained by listening to these communities should be used to develop novel vaccination policy approaches.

Family deaths in the early life course and their association with later educational attainment in a longitudinal cohort study.

Due to structural racism and pathways between racism and health, Black and Native American people die at younger ages than white people. This means that those groups are likely to experience deaths of family members at younger ages. Evidence is mixed about whether family deaths affect educational attainment. We aim to 1) estimate the prevalence of family deaths by age and race 2) estimate the effect of a family death on later educational attainment and 3) analyze whether the effect of a family death varies by age, socioeconomic status, gender, and race. The National Longitudinal Study of Adolescent to Adult Health (Add Health) is a nationally representative sample of U.S. adolescents in grades 7-12 at baseline in 1994-1995. Add Health has a large and racially diverse sample and records family deaths across the entire life course starting from birth. Participants were included in this analysis if they reported their educational attainment in Wave IV (N = 14,796). The racial group with the lowest proportion experiencing a sibling or parent death in the first 23 years of their lives was white participants (11.7%), followed by Asian (12.5%), Hispanic (15.0%), Black (24.3%) and Native American participants (30.3%). In adjusted models, those who experienced a family death had 0.60 times the odds (95% CI 0.51-0.71) of achieving a bachelor's degree compared to those without a family death. Mother deaths, father deaths, and sibling deaths were each harmful for obtaining a college degree and their effects were similar in magnitude. The age range when the effect of a family death was strongest was 10-13 years old (OR = 0.52 95% CI 0.40-0.67). The effect of a family death on college degree attainment did not vary by baseline parent education, participant sex, or race/ethnicity.

Food security among SNAP participants 2019 to 2021: a cross-sectional analysis of current population survey food security supplement data.

Surveillance data indicate that food security rates increased among Supplemental Nutrition Assistance Program (SNAP) participants during the COVID-19 pandemic (2020 and 2021) compared with pre-pandemic (2019), but this could have been due to increased participation from better resourced households. Our objective was to examine if demographic differences between SNAP-participating households in each year were responsible for the increased prevalence of food secure households. We calculated the observed 30-d food security prevalence among SNAP-participating households for each year. We used indirect standardisation to produce expected 2020 and 2021 prevalences with 2019 as the standard population using household size, income, age, sex, race, Hispanic ethnicity, presence of children, single parent household, metropolitan status and census region. We calculated standardised prevalence ratios (SPRs) to understand if the observed prevalence was higher than expected given any changes in the demographic profile compared to 2019. The Current Population Survey data were collected by the United States Census Bureau and Department of Agriculture. Our sample included 5,245 SNAP-participating households. The observed prevalence of food secure households increased by 3⋅6 percentage points comparing 2019 to 2020 (SPR = 1⋅06, 95 % confidence interval = 1⋅00, 1⋅11) and by 8⋅6 percentage comparing 2019 to 2021 (SPR = 1⋅13, 95 % confidence interval = 1⋅07, 1⋅18). The greater prevalence of food secure SNAP households during the pandemic did not appear to be attributable to socio-demographic differences compared to pre-pandemic. Despite hesitance among policymakers to expand or enhance social safety net programmes, permanently incorporating COVID-19-related policy interventions could lessen food insecurity in years to come.

Impact of delaying high school start times on weight and related behaviors - the START study.

In the US, few adolescents get adequate school night sleep, largely due to early school start times. In the START study we aimed to test the following hypothesis: That following the implementation of later high school start times students have lesser longitudinal increases in body mass index (BMI) and shift to more healthful weight-related behaviors relative to students attending schools that retain early start times. The study enrolled a cohort of students (n = 2426) in five high schools in the Twin Cities, MN metro. Heights and weights were measured objectively, and surveys were administered annually from 9th through 11th grades (2016-2018). All study schools started early (either 7:30 am or 7:45 am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), two schools delayed their start times by 50-65 min, while three comparison schools started at 7:30 am throughout the observation period. Using a difference-in-differences natural experiment design, we estimated differences in changes in BMI and weight-related behaviors over time between policy change and comparison schools. Students' BMIs increased in parallel in both policy change and comparison schools over time. However relative to changes in comparison schools after the start time shift, students in policy change schools had a modestly more healthful profile of weight-related behaviors - for instance they had a relatively greater probability of eating breakfast, having supper with their family, getting more activity, eating fast food less frequently, and eating vegetables daily. Later start times could be a durable, population-wide strategy that promotes healthful weight behaviors.

Use of the Emergency Food System among Food Insecure, Low-income Households in the United States 2015 to 2020.

The emergency food system (EFS) is a critical part of the United States' social safety net. Using 2015-2020 Current Population Survey Food Security Supplement data, we identified trends in EFS use among food insecure, low-income households by estimating the probability of EFS use adjusting for demographics using multivariable logistic regression. From 2015-2019, between 31.0% and 34.4% of households received emergency food, while 42.4% did in 2020. EFS use did not increase in 2020 compared to prior years for older adults and non-metropolitan households. Targeted outreach should be used to expand the reach of this resource to underserved and marginalized populations."

The impact of delayed school start time on adolescent beverage consumption, findings from the START study.

OBJECTIVES: We sought to examine the effects of high school start time delay, a proven sleep-promoting intervention, on sugary beverage (SB) consumption among U.S. adolescents. METHODS: In the Spring of 2016 (baseline), the START study recruited 2134 ninth grade students who were enrolled high schools in the Twin Cities, MN metropolitan area. These participants were surveyed again in their 10th and 11th grade years, in Spring 2017 and 2018 (follow-ups 1 and 2). All five high schools started early (7:30 or 7:45 a.m.) at baseline. By follow-up 1, two "policy change" schools shifted their start times later (8:20 or 8:50 a.m.) and maintained these later start times through follow-up 2 while three "comparison schools" retained an early start time at all time points. Generalized estimating equations using a negative binomial distribution were used to obtain estimates of the number of sugary beverages consumed per day at each wave as well as the difference in difference (DiD) estimates between baseline and each follow-up period comparing policy change to comparison schools. RESULTS: Mean baseline sugary beverage consumption was 0.9 (1.5) beverages per day in policy change schools and 1.2 (1.7) beverages per day in the comparison schools. While there was no evidence of impact of start time change on total SB consumption, DiD estimates revealed a small decrease in the number of caffeinated sugary beverages consumed between baseline and the second follow-up period in students attending the policy change schools relative to comparison schools in both crude (0.11/day reduction, p-value = 0.048) and adjusted analyses (0.11/day reduction, p-value = 0.028). CONCLUSION: Although the differences in this study were quite modest, a population-wide reduction in sugary beverage consumption could have public health benefit.

School start time delays and high school educational outcomes: Evidence from the START/LEARN study.

INTRODUCTION: Delaying high school start times extends adolescents' nightly sleep, but it is less clear how it affects educational outcomes. We expect links between school start time delays and academic performance because getting enough sleep is a key input to the cognitive, health, and behavioral factors necessary for educational success. Thus, we evaluated how educational outcomes changed in the 2 years following a school start time delay. METHODS: We analyzed 2153 adolescents (51% male, 49% female; mean age 15 at baseline) from START/LEARN, a cohort study of high school students in the Minneapolis-St. Paul, MN, USA metropolitan area. Adolescents experienced either a school start time delay ("policy change schools") or consistently early school start times ("comparison schools"). We compared patterns of late arrivals, absences, behavior referrals, and grade point average (GPA) 1 year before (baseline, 2015-2016) and 2 years after (follow-up 1, 2016-2017 and follow-up 2, 2017-2018) the policy change using a difference-in-differences analysis. RESULTS: A school start time delay of 50-65 min led to three fewer late arrivals, one fewer absence, a 14% lower probability of behavior referral, and 0.07-0.17 higher GPA in policy change schools versus comparison schools. Effects were larger in the 2nd year of follow-up than in the 1st year of follow-up, and differences in absences and GPA emerged in the second year of follow-up only. CONCLUSIONS: Delaying high school start times is a promising policy intervention not only for improving sleep and health but for improving adolescents' performance in school.

Association of Smokeless Tobacco Use With Incident Peripheral Artery Disease: Results From the Atherosclerotic Risk in Communities Study.

INTRODUCTION: Cigarette smoking is associated with an increased risk for peripheral artery disease. It is unknown whether smokeless tobacco, a noncombustible form of tobacco exposure, is also associated with increased peripheral artery disease risk. Using data from the Atherosclerosis Risk in Communities study, we tested the hypothesis that the use of smokeless tobacco is associated with a higher risk of developing peripheral artery disease. METHODS: Participants with peripheral artery disease at baseline were excluded. Smokeless tobacco use was assessed 3 times from 1987 to 1995, and peripheral artery disease events accrued from 1987 to 2018. Smokeless tobacco was modeled as a time-dependent exposure in Cox regression models. Analyses were completed in 2021. RESULTS: This study included 14,344 participants with a baseline mean (SD) age of 54.1 (5.7) years; 54.8% were female, and 26.4% were Black. There were 635 incident peripheral artery disease events over a median follow-up of 27.6 years (maximum of 32.1 years). The peripheral artery disease incidence rate was 4.44 per 1,000 person-years among those who used smokeless tobacco compared with 1.74 per 1,000 person-years for those who did not. The hazard ratio for current versus never smokeless tobacco use was 1.94 (95% CI=1.31, 2.88) after adjustment for sociodemographic characteristics and cigarette smoking. Peripheral artery disease incidence rate among those currently using smokeless tobacco was similar to that of those who currently smoke cigarette (3.39 per 1,000 person-years). CONCLUSIONS: Current smokeless tobacco use was associated with high rates of peripheral artery disease, similar to cigarette smoking. Future research should evaluate the effect of cessation of noncombustible tobacco on incident peripheral artery disease.

Impact of smoking cessation on household food security.

PURPOSE: Smokers can spend a substantial amount on cigarettes, potentially constraining their ability to purchase food. We tested the association of smoking cessation and household food security. METHODS: Using the Current Population Survey (2001-2019), we longitudinally linked the Tobacco Use Supplement and the Food Security Supplement (n = 71,278). Among adult smokers (n = 13,144), we used modified Poisson regression to model household food insecurity as a function of quit status (continuing smokers vs. recent quitters), adjusting for sex, age, household size, children in the household, and other household smokers. We also used multinomial logistic regression to examine more detailed food security status (high, marginal, low, very low). RESULTS: The adjusted probability of household food insecurity at follow-up was 11% (95% CI: 8.7%-13%) for recent quitters and 20% (95% CI: 19%-21%) for continuing smokers. Continuing smokers had a lower adjusted probability of high food security (69% vs. 80%) and a higher adjusted probability of marginal (11% vs. 9.8%), low (12% vs. 7%), and very low food security (7.8% vs. 3.6%) compared to recent quitters. CONCLUSIONS: Cigarette cessation is associated with a lower risk of household food insecurity. Therefore, promoting tobacco cessation alongside food assistance and poverty reduction policies may help alleviate food insecurity.

Cancer pain and alcohol self-medication.

BACKGROUND: Cancer survivors are at increased risk of pain due to their either cancer and/or treatments. Substances like alcohol may be used to self-medicate cancer pain; however, these substances pose their own health risks that may be more pronounced for cancer survivors. METHODS: We used cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS) 2012-2019 to quantify the association between cancer pain and alcohol use. We used negative binomial regression, with interaction terms added to examine variations across age, sex, and race. We also examined whether alcohol use relates to cancer pain control status. RESULTS: Cancer survivors with cancer pain were more likely to be younger, female, Black, and to have been diagnosed with breast cancer. Cancer pain was associated with lower alcohol consumption (incidence rate ratio (IRR): 0.88, confidence interval (CI): 0.77, 0.99). This association was primarily among people 65 and older, women, and white and Hispanic people. Cancer pain control status was not related to alcohol use. CONCLUSIONS: Lower alcohol use among cancer survivors with pain has many possible explanations, including several alternative pain management strategies or a decrease in social engagement. Our findings of racial and gender disparities in cancer pain are consistent with the broader evidence on disparities in pain. IMPLICATIONS FOR CANCER SURVIVORS: Cancer pain management for marginalized groups should be improved. Healthcare providers should screen cancer survivors for both pain and substance use, to prevent unhealthy self-medication behaviors.

Estimating the Long-Term Causal Effects of Attending Historically Black Colleges or Universities on Depressive Symptoms.

Racism is embedded in society, and higher education is an important structure for patterning economic and health outcomes. Historically Black Colleges and Universities (HBCUs) were founded on antiracism while predominantly White institutions (PWIs) were often founded on white supremacy. This contrast provides an opportunity to study the association between structural racism and health among Black Americans. We used the National Longitudinal Study of Adolescent to Adult Health (Add Health) to estimate the long-term causal effect of attending an HBCU (vs. PWI) on depressive symptoms among Black students in the United States from 1994-2018. While we found no overall association with attending an HBCU (vs. PWI) on depressive symptoms, we found that this association varied by baseline mental health and region, and across time. For example, among those who attended high school outside of the South, HBCU attendance was protective against depressive symptoms 7 years later, and the association was strongest for those with higher baseline depressive symptoms. We recommend equitable state and federal funding for HBCUs, and that PWIs implement and evaluate antiracist policies to improve mental health of Black students.

Invited Commentary: Use of Epidemiologic Methods to Guide Comprehensive and Equitable Approaches to Policy.

Despite a dramatic reduction in the prevalence of commercial cigarette smoking in the United States, children are still commonly exposed to secondhand smoke (SHS), which is a cause of various pediatric health problems. Further, SHS exposure is patterned by race and class, exacting an inequitable toll on children from families with lesser social and economic advantage. In this issue of the Journal, Titus et al. (Am J Epidemiol. 2023;192(1):25-33) use natural experiment evaluation methods (difference-in-differences) to test whether the recently implemented US Department of Housing and Urban Development policy that forbade smoking in and around New York City Housing Authority buildings affected child respiratory health. The results from their work remind us that policies do not always impact outcomes as we might expect. Given that policy is one of the most potent tools for population health promotion, this work underlines the need for epidemiologists to engage in policy evaluation at all stages of the policy life cycle, in order to discover comprehensive approaches to policy development and implementation that prioritize equity and address structural racism.

Weekend night vs. school night sleep patterns, weight status, and weight-related behaviors among adolescents.

OBJECTIVE: In this study, we examine associations between objectively measured weekend night vs. school night sleep patterns, weight status, and weight-related behaviors among adolescents. DESIGN: Cross-sectional study. SETTING: Five Minnesota high schools that started early (7:30 or 7:45 AM) in Spring 2016. PARTICIPANTS: Ninth grade students, ages 14.5-16 years (n = 284). MEASUREMENTS: Students completed surveys, had body measurements taken, and wore sleep (wrist) actigraphs for 1 week (n = 284). We examined weekend night-school night differences in sleep duration and sleep timing. We then assessed whether these factors were related to weight status and weight-related behaviors (eating behaviors, food consumption, physical activity, beverage consumption) using generalized linear mixed models. RESULTS: On average, students slept 1.5 hours (95% confidence interval 1.3-1.7) more and had a sleep midpoint 1.9 hours (1.8-2.1) later on weekend nights compared to school nights. Female students had larger increases in sleep duration on weekend nights than males but similar timing differences. Sleep duration differences were uncorrelated with sleep timing differences (r = 0.01). Neither duration nor timing differences were associated with overweight, obesity, or any of the eating behaviors we examined. However, sleeping longer on weekend nights than on school nights was associated with lower probability of being active 6-7 days per week (p = .02). CONCLUSIONS: Adolescents have substantial sleep duration and sleep timing differences on weekend nights vs. school nights. While these differences may not be associated with weight status or weight-related behaviors, they reflect the reality that most adolescents have schedules that restrict their sleep.

Barriers to Accessing Healthy Food and Food Assistance During the COVID-19 Pandemic and Racial Justice Uprisings: A Mixed-Methods Investigation of Emerging Adults' Experiences.

BACKGROUND: A steep rise in food insecurity is among the most pressing US public health problems that has resulted from the COVID-19 pandemic. OBJECTIVE: This study aimed to (1) describe how food-insecure emerging adults are adapting their eating and child-feeding behaviors during COVID-19 and (2) identify barriers and opportunities to improve local food access and access to food assistance. DESIGN: The COVID-19 Eating and Activity Over Time study collected survey data from emerging adults during April to October 2020 and completed interviews with a diverse subset of food-insecure respondents. PARTICIPANTS/SETTING: A total of 720 emerging adults (mean age: 24.7 ± 2.0 years; 62% female; 90% living in Minnesota) completed an online survey, and a predominately female subsample (n = 33) completed an interview by telephone or videoconference. MAIN OUTCOME MEASURES: Survey measures included the short-form of the US Household Food Security Survey Module and 2 items to assess food insufficiency. Interviews assessed eating and feeding behaviors along with barriers to healthy food access. ANALYSES PERFORMED: Descriptive statistics and a hybrid deductive and inductive content analysis. RESULTS: Nearly one-third of survey respondents had experienced food insecurity in the past year. Interviews with food-insecure participants identified 6 themes with regard to changes in eating and feeding behavior (eg, more processed food, sporadic eating), 5 themes regarding local food access barriers (eg, limited enforcement of COVID-19 safety practices, experiencing discrimination), and 4 themes regarding barriers to accessing food assistance (eg, lack of eligibility, difficulty in locating pantries). Identified recommendations include (1) expanding the distribution of information about food pantries and meal distribution sites, and (2) increasing fresh fruit and vegetable offerings at these sites. CONCLUSIONS: Interventions of specific relevance to COVID-19 (eg, stronger implementation of safety practices) and expanded food assistance services are needed to improve the accessibility of healthy food for emerging adults.

Assessing Changes in Adolescents' Sleep Characteristics and Dietary Quality in the START Study, a Natural Experiment on Delayed School Start Time Policies.

BACKGROUND: Sleep duration, quality, and timing may influence dietary quality. In adults, poor dietary quality is a risk factor for numerous chronic diseases. It is unclear how these various sleep domains influence adolescents' diets because prior population-based studies have not effectively manipulated sleep, did not include objective sleep measures, and had short follow-up times. OBJECTIVES: The objectives of this study were to examine 1) how adolescent sleep characteristics relate to dietary quality; and 2) how delay in high school start times (which lengthened sleep duration) affects dietary quality over 2 y. METHODS: In the START study, adolescents (grades 9-11, n = 423) attending 5 high schools in the Minneapolis, Minnesota metropolitan area were annually assessed in 3 waves (2016-2018). At Baseline, all schools started "early" (07:30 or 07:45). From Follow-up 1 through Follow-up 2, 2 "policy change schools" shifted to later start times (to 08:20 and 08:50). Three "comparison schools" maintained their early start throughout. Sleep characteristics were measured with actigraphy. Mixed-effect regression models were used to examine cross-sectional and longitudinal associations of sleep characteristics with dietary quality, and school start time policy change with dietary quality change. RESULTS: Cross-sectionally, later sleep midpoint and onset were associated with dietary quality scores 1.6-1.7 lower (both P < 0.05). However, no prospective associations were observed between sleep characteristics and dietary quality in longitudinal models. Shifting to later school start time tended to be associated with a 2.4-point increase in dietary quality score (P = 0.09) at Follow-up 1, but was not associated with change in dietary quality scores at Follow-up 2 (P = 0.35). CONCLUSIONS: High school students attending delayed-start schools maintained better dietary quality than students in comparison schools; however, differences were not statistically significant. Overall study findings highlight the complexity of the relation between sleep behavior and diet in adolescence.

Association of Delaying School Start Time With Sleep-Wake Behaviors Among Adolescents.

PURPOSE: Few adolescents spend enough time asleep on school nights. This problem could be addressed by delaying high school start times, but does this translate to reduced prevalence of sleep-wake problems like awakening too early or feeling sleepy during the day? METHODS: The START study (n = 2,414) followed a cohort of students from five Minnesota high schools to evaluate impacts of school start time delays. Participants were enrolled in ninth grade (Baseline) when all schools started early (7:30 or 7:45 a.m.). At Follow-Up 1 (10th grade) and Follow-Up 2 (11th grade), two schools had delayed their start times by 50 and 65 minutes while three comparison schools started at 7:30 a.m. Six sleep-wake behaviors were assessed at all three time points via survey. Generalized estimating equation models were used to investigate changes in sleep-wake problems between policy change and comparison schools. RESULTS: The prevalence of sleep-wake problems at Baseline ranged from 11% for being late to class due to oversleeping to 48% for needing to be told to wake multiple times in the morning. Compared to students from comparison schools, students at policy change schools reported smaller increases in the prevalence of feeling sleepy daily and oversleeping and being late to class between 9th and 11th grade. After implementation of the delayed start, awakening too early was more common among students at policy change schools compared to the comparison schools. CONCLUSIONS: This longitudinal study provides evidence that delaying high school start times reduces daytime sleepiness and school tardiness.

E-Cigarettes and Cardiopulmonary Health.

E-cigarettes have surged in popularity over the last few years, particularly among youth and young adults. These battery-powered devices aerosolize e-liquids, comprised of propylene glycol and vegetable glycerin, typically with nicotine, flavors, and stabilizers/humectants. Although the use of combustible cigarettes is associated with several adverse health effects including multiple pulmonary and cardiovascular diseases, the effects of e-cigarettes on both short- and long-term health have only begun to be investigated. Given the recent increase in the popularity of e-cigarettes, there is an urgent need for studies to address their potential adverse health effects, particularly as many researchers have suggested that e-cigarettes may pose less of a health risk than traditional combustible cigarettes and should be used as nicotine replacements. This report is prepared for clinicians, researchers, and other health care providers to provide the current state of knowledge on how e-cigarette use might affect cardiopulmonary health, along with research gaps to be addressed in future studies.