Social media use, brand engagement, and tobacco product initiation among youth: Evidence from a prospective cohort study.

OBJECTIVE: To evaluate whether frequent social media use and liking/following tobacco brand accounts was associated with increased risk of tobacco and polytobacco initiation over approximately 1-year follow-up among youth with no prior tobacco use. METHODS: Associations between measures of social media engagement (daily social media use and liking/following tobacco brands) and tobacco initiation risk were examined using data from Waves 2 and 3 (2014-2015) of the US Population Assessment for Tobacco and Health study. Separate log-binomial models, accounting for missing data via multiple imputation and using propensity score adjustment to address confounding, estimated the adjusted relative risk (aRR) of any tobacco initiation and poly-use (2 + products) initiation at 1-year follow-up. RESULTS: Among the 8,672 youth with no prior tobacco use (49.3% female, mean [SD] age 14.1 [1.7]), 63.5% used social media at least daily, and 3.3% reported liking/following ≥ 1 tobacco brands on social media. Those reporting daily or more frequent social media use (compared to less) were at increased risk for tobacco (aRR 1.67; 95% CI 1.38-2.02) and polytobacco initiation (aRR 1.32; 95% CI 0.98-1.78). Although results were imprecise, liking/following ≥ 1 tobacco brands on social media (versus none) was associated with tobacco (aRR 1.34; 95% CI 0.95-1.89) or polytobacco initiation (aRR 1.60; 95% CI 0.99-2.60). In sensitivity analyses, liking/following cigarette or cigarillo brands was associated with polytobacco initiation. CONCLUSIONS: This study adds to a growing evidence-base describing the exposure of youth to tobacco-related social media content. Such content-often generated by tobacco companies-may contribute to youth tobacco initiation.

Racial Disparities in Accessing Care along the Continuum of Cancer Genetic Service Delivery.

BACKGROUND: Public health calls to ensure equity in genomics and precision medicine necessitate a closer examination of how these efforts might differentially affect access to genetic services across demographic subgroups. This study set out to examine racial/ethnic disparities along the cancer genetic service delivery continuum. METHODS: Retrospective data are drawn from 15 clinical sites across 6 U.S. States. Individuals who screened at-risk for hereditary cancer were: (i) referred/scheduled to see a genetic counselor (referral workflow), or (ii) offered genetic testing at the point-of-care (POC testing workflow). Logistic regression analyses evaluated the associations between race/ethnicity and several outcomes including appointment scheduling, genetic counseling, and genetic testing, controlling for demographics, clinical factors, and county-level covariates. RESULTS: A total of 14,527 patients were identified at-risk. Genetic testing uptake was significantly higher at POC sites than referral sites (34% POC vs. 11% referral, P < 0.001). Race/ethnicity was significantly associated with testing uptake among all sites, with non-Hispanic Blacks having lower odds of testing compared with non-Hispanic Whites [aOR = 0.84; 95% confidence interval (CI), 0.71-1.00; P = 0.049]. Moreover, this disparity was observed at referral sites, but not POC sites. Among patients scheduled, non-Hispanic Blacks had lower odds of counseling (aOR = 0.28; 95% CI, 0.17-0.47; P < 0.001). CONCLUSIONS: Findings suggest that factors influencing genetic counseling show rates may be driving disparities in genetic testing. IMPACT: Strategies to reduce barriers to seeing a genetic counselor, including modifications to clinical workflow, may help mitigate racial/ethnic disparities in genetic testing.

Compliance With the US Food and Drug Administration's Guidelines for Health Warning Labels and Engagement in Little Cigar and Cigarillo Content: Computer Vision Analysis of Instagram Posts.

Background: Health warnings in tobacco advertisements provide health information while also increasing the perceived risks of tobacco use. However, existing federal laws requiring warnings on advertisements for tobacco products do not specify whether the rules apply to social media promotions. Objective: This study aims to examine the current state of influencer promotions of little cigars and cigarillos (LCCs) on Instagram and the use of health warnings in influencer promotions. Methods: Instagram influencers were identified as those who were tagged by any of the 3 leading LCC brand Instagram pages between 2018 and 2021. Posts from identified influencers, which mentioned one of the three brands were considered LCC influencer promotions. A novel Warning Label Multi-Layer Image Identification computer vision algorithm was developed to measure the presence and properties of health warnings in a sample of 889 influencer posts. Negative binomial regressions were performed to examine the associations of health warning properties with post engagement (number of likes and comments). Results: The Warning Label Multi-Layer Image Identification algorithm was 99.3% accurate in detecting the presence of health warnings. Only 8.2% (n=73) of LCC influencer posts included a health warning. Influencer posts that contained health warnings received fewer likes (incidence rate ratio 0.59, P<.001, 95% CI 0.48-0.71) and fewer comments (incidence rate ratio 0.46, P<.001, 95% CI 0.31-0.67). Conclusions: Health warnings are rarely used by influencers tagged by LCC brands' Instagram accounts. Very few influencer posts met the US Food and Drug Administration's health warning requirement of size and placement for tobacco advertising. The presence of a health warning was associated with lower social media engagement. Our study provides support for the implementation of comparable health warning requirements to social media tobacco promotions. Using an innovative computer vision approach to detect health warning labels in influencer promotions on social media is a novel strategy for monitoring health warning compliance in social media tobacco promotions.

Implementing digital systems to facilitate genetic testing for hereditary cancer syndromes: An observational study of 4 clinical workflows.

PURPOSE: National efforts have prioritized the identification of effective methods for increasing case ascertainment and delivery of evidence-based health care for individuals at elevated risk for hereditary cancers. METHODS: This study examined the uptake of genetic counseling and testing following the use of a digital cancer genetic risk assessment program implemented at 27 health care sites in 10 states using 1 of 4 clinical workflows: (1) traditional referral, (2) point-of-care scheduling, (3) point-of-care counseling/telegenetics, and (4) point-of-care testing. RESULTS: In 2019, 102,542 patients were screened and 33,113 (32%) were identified as at high risk and meeting National Comprehensive Cancer Network genetic testing criteria for hereditary breast and ovarian cancer, Lynch syndrome, or both. Among those identified at high risk, 5147 (16%) proceeded with genetic testing. Genetic counseling uptake was 11% among the sites with workflows that included seeing a genetic counselor before testing, with 88% of patients proceeding with genetic testing after counseling. Uptake of genetic testing across sites varied significantly by clinical workflow (6% referral, 10% point-of-care scheduling, 14% point-of-care counseling/telegenetics, and 35% point-of-care testing, P < .0001). CONCLUSION: Study findings highlight the potential heterogeneity of effectiveness attributable to different care delivery approaches for implementing digital hereditary cancer risk screening programs.

Associations between sociodemographic factors and receiving "ask and advise" services from healthcare providers in India: analysis of the national GATS-2 dataset.

BACKGROUND: India is home to about 12% of the world's tobacco users, with about 1.35 million tobacco-related deaths each year. The morbidity and mortality rates are socially patterned based on gender, rural vs. urban residence, education, and other factors. Following the World Health Organization's guidance, it is critical to offer tobacco users support for cessation as a complement to policy and environmental changes. Such guidance is typically unavailable in low-resource systems, despite the potential for population-level impact. Additionally, service delivery for tobacco control tends to be patterned by sociodemographic factors. To understand current activity in this area, we assessed the percentage of daily tobacco users being asked about tobacco use and advised to quit by a healthcare provider. We also examined social patterning of receipt of services (related to by rural vs. urban residence, age, gender, education, caste, and wealth). METHODS: We analyzed cross-sectional data from India's 2016-2017 Global Adult Tobacco Survey (GATS-2), a nationally representative survey. Among 74,037 respondents, about 25% were daily users of smoked and/or smokeless tobacco. We examined rates of being asked and advised about tobacco use overall and based on rural vs. urban residence, age, gender, education, caste, and wealth. We also conducted multivariate logistic regression to assess the association of demographic and socioeconomic conditions with participants' receipt of "ask and advise" services. RESULTS: Nationally, among daily tobacco users, we found low rates of individuals reporting being asked about tobacco use or advised to quit by a healthcare provider (22% and 19%, respectively). Being asked and advised about tobacco use was patterned by age, gender, education, caste, and wealth in our final regression model. CONCLUSIONS: This study offers a helpful starting point in identifying opportunities to address a critical service delivery gap in India. Given the existing burden on the public health and health systems, scale-up will require innovative, resource-appropriate solutions. The findings also point to the need to center equity in the design and scale-up of tobacco cessation supports so that marginalized and underserved groups will have equitable access to these critical services.

The Impact of Influencers on Cigar Promotions: A Content Analysis of Large Cigar and Swisher Sweets Videos on TikTok.

Little is known about the content, promotions, and individuals in cigar-related videos on TikTok. TikTok videos with large cigar and Swisher Sweets-related hashtags between July 2016 and September 2020 were analyzed. Follower count was used to identify influencers. We compared content characteristics and demographics of featured individuals between cigar types, and by influencer status. We also examined the association between content characteristics and video engagement. Compared to large cigar videos, Swisher Sweets videos were more likely to feature arts and crafts with cigar packages, cannabis use, and flavored products. In addition, Swisher Sweets videos were also more likely to feature females, Black individuals, and younger individuals. Both Swisher Sweets and large cigar influencers posted more videos of cigar purchasing behaviors than non-influencers, which was associated with more video views. None of the videos disclosed sponsorship with #ad or #sponsored. Videos containing the use of cigar packages for arts and crafts, and flavored products highlight the importance of colorful packaging and flavors in the appeal of Swisher Sweets cigars, lending support for plain packaging requirements and the prohibition of flavors in cigar products to decrease the appeal of cigars. The presence and broad reach of cigar promotions on TikTok requires stricter enforcement of anti-tobacco promotion policies.

Infectious diseases prevention and control using an integrated health big data system in China.

BACKGROUND: The Yinzhou Center for Disease Prevention and Control (CDC) in China implemented an integrated health big data platform (IHBDP) that pooled health data from healthcare providers to combat the spread of infectious diseases, such as dengue fever and pulmonary tuberculosis (TB), and to identify gaps in vaccination uptake among migrant children. METHODS: IHBDP is composed of medical data from clinics, electronic health records, residents' annual medical checkup and immunization records, as well as administrative data, such as student registries. We programmed IHBDP to automatically scan for and detect dengue and TB carriers, as well as identify migrant children with incomplete immunization according to a comprehensive set of screening criteria developed by public health and medical experts. We compared the effectiveness of the big data screening with existing traditional screening methods. RESULTS: IHBDP successfully identified six cases of dengue out of a pool of 3972 suspected cases, whereas the traditional method only identified four cases (which were also detected by IHBDP). For TB, IHBDP identified 288 suspected cases from a total of 43,521 university students, in which three cases were eventually confirmed to be TB carriers through subsequent follow up CT or T-SPOT.TB tests. As for immunization screenings, IHBDP identified 240 migrant children with incomplete immunization, but the traditional door-to-door screening method only identified 20 ones. CONCLUSIONS: Our study has demonstrated the effectiveness of using IHBDP to detect both acute and chronic infectious disease patients and identify children with incomplete immunization as compared to traditional screening methods.

Opioid analgesic use after ambulatory surgery: a descriptive prospective cohort study of factors associated with quantities prescribed and consumed.

OBJECTIVES: To prospectively characterise: (1) postoperative opioid analgesic prescribing practices; (2) experience of patients undergoing elective ambulatory surgeries and (3) impact of patient risk for medication misuse on postoperative pain management. DESIGN: Longitudinal survey of patients 7 days before and 7-14 days after surgery. SETTING: Academic urban safety-net hospital. PARTICIPANTS: 181 participants recruited, 18 surgeons, follow-up data from 149 participants (82% retention); 54% women; mean age: 49 years. INTERVENTIONS: None. PRIMARY AND SECONDARY OUTCOME MEASURES: Total morphine equivalent dose (MED) prescribed and consumed, percentage of unused opioids. RESULTS: Surgeons postoperatively prescribed a mean of 242 total MED per patient, equivalent to 32 oxycodone (5 mg) pills. Participants used a mean of 116 MEDs (48%), equivalent to 18 oxycodone (5 mg) pills (~145 mg of oxycodone remaining per patient). A 10-year increase in patient age was associated with 12 (95% CI (-2.05 to -0.35)) total MED fewer prescribed opioids. Each one-point increase in the preoperative Graded Chronic Pain Scale was associated with an 18 (6.84 to 29.60) total MED increase in opioid consumption, and 5% (-0.09% to -0.005%) fewer unused opioids. Prior opioid prescription was associated with a 55 (5.38 to -104.82) total MED increase in opioid consumption, and 19% (-0.35% to -0.02%) fewer unused opioids. High-risk drug use was associated with 9% (-0.19% to 0.002%) fewer unused opioids. Pain severity in previous 3 months, high-risk alcohol, use and prior opioid prescription were not associated with postoperative prescribing practices. CONCLUSIONS: Participants with a preoperative history of chronic pain, prior opioid prescription, and high-risk drug use were more likely to consume higher amounts of opioid medications postoperatively. Additionally, surgeons did not incorporate key patient-level factors (eg, substance use, preoperative pain) into opioid prescribing practices. Opportunities to improve postoperative opioid prescribing include system changes among surgical specialties, and patient education and monitoring.

JUUL the heartbreaker: Twitter analysis of cardiovascular health perceptions of vaping.

INTRODUCTION: The public most frequently associates tobacco use solely with pulmonary health risks, despite heart disease being the leading cause of death in smokers. The health perceptions of e-cigarettes, especially cardiovascular health, have not been well studied. We aimed to evaluate the prevalence and health perceptions of tweets related to cardiovascular, pulmonary, and brain health - three organ systems for which tobacco use is a major disease risk factor. METHODS: We examined the cardiovascular, pulmonary, and brain health perceptions of vaping and JUUL on Twitter, followed by a content analysis of tweets pertaining to the cardiovascular risks. A Twitter firehose API scraped about 6.2 million publicly available tweets from 2015-2019 that contained vaping-related terms, and a separate dataset of about 1.9 million tweets that contained the term JUUL. A quantitative content analysis (n=2145) of tweets was subsequently conducted to assess the health perceptions of vaping and JUUL. Two trained coders independently assessed the posts and Twitter profiles to determine age (<18 or ≥18 years), sex, race, sentiment towards JUUL, and vaping-related topics. RESULTS: The majority of tweets containing vaping or JUUL-related terms did not also contain cardiovascular, pulmonary, or brain health terms (97.99% and 96.67%, respectively). Multiple linear regression analysis showed that youth (<18 years), females, non-White individuals, mention of a flavor, and mention of cardiovascular health harm words were associated with more positive sentiments towards JUUL. Pearson's chi-squared analyses indicated that youth were more likely to mention a JUUL flavor. Females and youth were more likely to reference cardiovascular terms with humor. CONCLUSIONS: The cardiovascular health risks of vaping are not fully recognized by the public. Vulnerable populations such as youth and females reference JUUL with cardiovascular-related words that downplay the severity of tobacco as a major risk factor for cardiovascular disease.

Patient navigation among recently hospitalized smokers to promote tobacco treatment: Results from a randomized exploratory pilot study.

INTRODUCTION: Adding screening for health-related social needs to tobacco treatment interventions initiated during hospitalizations may improve intervention effectiveness among vulnerable populations. Our objective was to examine the effect the acceptability and feasibility of a intervention in which a patient navigator screens for and addresses social needs to increase receipt of smoking cessation medication among recently hospitalized smokers at a safety-net hospital. METHODS: In a two-group randomized exploratory pilot study, we assigned hospitalized smokers to either the Enhanced Traditional Control (ETC) group (list of smoking cessation resources) or ETC + Patient Navigation (up to 10 h of navigation over a 3-month period, in which a navigator screens for and addresses health-related social needs). We assessed socio-demographics, smoking-related variables, and process data. RESULTS: Of 171 individuals screened, 44 (26%) were enrolled. Participants (mean age = 54.9 years, 61.4% non-Hispanic black, 68.2% high school education or less) smoked a mean of 11.4 cigarettes/day. 20 participants received a prescription for a cessation medication, 42.9% in the ETC group and 47.8% in the ETC + Patient Navigation group. 11 participants (47.8%) in the ETC + Patient Navigation group received the minimum intervention dose (completion of the social needs screener and at least one counseling session). Barriers to navigation were participants' medical illness and difficulty connecting with participants. CONCLUSIONS: Although nearly half of hospitalized smokers receiving support from a patient navigator received a prescription for a smoking cessation medication, the percentage did not differ by study arm. Refinement of the protocol to coordinate with hospital-wide tobacco treatment and social needs screening initiatives is needed.

Process evaluation of counseling delivered by a patient navigator in an efficacious smoking cessation intervention among low-income primary care patients.

INTRODUCTION: This exploratory study examined the relationship between receipt of counseling by a patient navigator and socio-demographic characteristics of primary care patients enrolled in a smoking cessation trial. METHODS: We grouped intervention participants (n = 177) into two categories: 1) no or some contact with the navigator or 2) minimum counseling intervention dose or higher delivered. RESULTS: In logistic regression analyses, controlling for patient race/ethnicity, education, age, gender, household annual income, stress/chaos/hassles composite score, heavy smoking, and substance use, non-Hispanic white participants had lower odds (aOR 0.30; 95% CI 0.13-0.70, p < 0.01) of receiving the minimum intervention dose or higher compared to all other race/ethnicity categories. There was also effect modification such that patients aged 50 or younger who were non-Hispanic white were less likely (aOR 0.09, 95% CI: 0.02-0.54, p < 0.01) to receive the minimum intervention dose compared to older patients from all other race/ethnicity groups. CONCLUSIONS: Future research should explore issues such as acceptability of the intervention to white and younger age participants, and the potential impact of co-occurring substance use disorders on intervention uptake.

The Relationship Between the U.S. State Alcohol Policy Environment and Individuals' Experience of Secondhand Effects: Alcohol Harms Due to Others' Drinking.

BACKGROUND: Although restrictive state alcohol policy environments are protective for individuals' binge drinking, research is sparse on the effect of alcohol policies on alcohol's harms to others (AHTO). We examined the lagged associations between efficacy of U.S. state alcohol policies and number of harms from others' drinking 1 year later. METHODS: Individuals with AHTO data in a nationally representative sample of U.S. adults (analytic sample n = 26,744) that pooled the 2000, 2005, 2010, and 2015 National Alcohol Surveys and a 2015 National Alcohol's Harm to Others Survey were linked with prior-year state policy measures. We used 2 measures from the Alcohol Policy Scale (APS)-effectiveness in reducing (i) binge drinking and (ii) impaired driving, based on experts' efficacy judgments regarding 29 state alcohol policies. Three 12-month AHTO measures (due to another drinker) were experiencing: (i) either family/marriage difficulties or financial troubles; (ii) being assaulted or vandalized; and (iii) passenger with drunk driver or traffic accident. Multilevel models accounting for clustering within states and stratified by age-groups (<40 vs. ≥40) examined associations between the APS and AHTO measures, controlling for individual covariates (gender, race, education, employment and marital status, family problem-drinking history) of the victim. RESULTS: Only for those aged <40, the lagged APS-Binge drinking and APS-Impaired driving scores were each inversely associated with aggression-related harms and, separately, with drunk driving-related harm from someone else's drinking (ps < 0.05 to < 0.01). Family/financial harms were not associated with APS scores for either age-group. Composite AHTO measures (any of 3 harm-types) also were inversely associated with stronger state alcohol policy environments (ps < 0.05 to <0.01). CONCLUSIONS: State alcohol policies may be effective in reducing, to a meaningful degree, aggression-related harms and vehicular hazards due to other drinkers, but mainly in those under 40.

Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study.

Background: Opioid overdose survivors have an increased risk for death. Whether use of medications for opioid use disorder (MOUD) after overdose is associated with mortality is not known. Objective: To identify MOUD use after opioid overdose and its association with all-cause and opioid-related mortality. Design: Retrospective cohort study. Setting: 7 individually linked data sets from Massachusetts government agencies. Participants: 17 568 Massachusetts adults without cancer who survived an opioid overdose between 2012 and 2014. Measurements: Three types of MOUD were examined: methadone maintenance treatment (MMT), buprenorphine, and naltrexone. Exposure to MOUD was identified at monthly intervals, and persons were considered exposed through the month after last receipt. A multivariable Cox proportional hazards model was used to examine MOUD as a monthly time-varying exposure variable to predict time to all-cause and opioid-related mortality. Results: In the 12 months after a nonfatal overdose, 2040 persons (11%) enrolled in MMT for a median of 5 months (interquartile range, 2 to 9 months), 3022 persons (17%) received buprenorphine for a median of 4 months (interquartile range, 2 to 8 months), and 1099 persons (6%) received naltrexone for a median of 1 month (interquartile range, 1 to 2 months). Among the entire cohort, all-cause mortality was 4.7 deaths (95% CI, 4.4 to 5.0 deaths) per 100 person-years and opioid-related mortality was 2.1 deaths (CI, 1.9 to 2.4 deaths) per 100 person-years. Compared with no MOUD, MMT was associated with decreased all-cause mortality (adjusted hazard ratio [AHR], 0.47 [CI, 0.32 to 0.71]) and opioid-related mortality (AHR, 0.41 [CI, 0.24 to 0.70]). Buprenorphine was associated with decreased all-cause mortality (AHR, 0.63 [CI, 0.46 to 0.87]) and opioid-related mortality (AHR, 0.62 [CI, 0.41 to 0.92]). No associations between naltrexone and all-cause mortality (AHR, 1.44 [CI, 0.84 to 2.46]) or opioid-related mortality (AHR, 1.42 [CI, 0.73 to 2.79]) were identified. Limitation: Few events among naltrexone recipients preclude confident conclusions. Conclusion: A minority of opioid overdose survivors received MOUD. Buprenorphine and MMT were associated with reduced all-cause and opioid-related mortality. Primary Funding Source: National Center for Advancing Translational Sciences of the National Institutes of Health.

A multi-decade joinpoint analysis of firearm injury severity.

BACKGROUND: Non-fatal firearm injuries constitute approximately 70% of all firearm trauma injuries in the United States. Patterns of severity of these injuries are poorly understood. We analyzed the overall, age-, sex- and intent-specific temporal trends in the injury severity of firearm hospitalizations from 1993 to 2014. METHODS: We assessed temporal trends in the severity of patients hospitalized for firearm using Nationwide Inpatient Sample (NIS) data over a 22 year period. Firearm hospitalization was identified using assault (E965x), unintentional (E922x), intentional self-harm (E955x), legal (E970) and undetermined (E985x) International Classification of Diseases, Ninth Revision, Clinical Modification (ICD9) codes. Injury severity was measured using the computed New Injury Severity Score (NISS). We used survey weighted means, SD and annual percent change (APC), and joinpoint regression to analyze temporal trends. RESULTS: A weighted total of 648 662 inpatient admissions for firearm injury were analyzed. Firearm injury severity demonstrated a significant annual increase of 1.4% (95% CI=1.3 to 1.6), and was driven by annual increases among young adults (APC=1.4%, 95% CI=1.3 to 1.5), older adults (APC=1.5%, 95% CI=1.3 to 1.6), female (APC=1.5%, 95% CI=1.3 to 1.6) and male (APC=1.4%, 95% CI=1.3 to 1.6) hospitalizations. The annual increase among assault/legal injuries was 1.4% (95% CI=1.3 to 1.5), similar to unintentional (APC=1.4%, 95% CI=1.3 to 1.6), intentional self-harm (APC=1.5%, 95% CI=1.4 to 1.6) and undetermined (APC=1.4%, 95% CI=1.3 to 1.6). CONCLUSIONS: The severity of hospitalized firearm injuries increased significantly from 1993 to 2014. This annual increase reflects a move towards hospitalization of more serious injuries, and outpatient management of less serious injuries across the board, suggesting a mounting burden on the US healthcare system. LEVEL OF EVIDENCE: Level IV.

State Firearm Laws and Interstate Transfer of Guns in the USA, 2006-2016.

In a cross-sectional, panel study, we examined the relationship between state firearm laws and the extent of interstate transfer of guns, as measured by the percentage of crime guns recovered in a state and traced to an in-state source (as opposed to guns recovered in a state and traced to an out-of-state source). We used 2006-2016 data on state firearm laws obtained from a search of selected state statutes and 2006-2016 crime gun trace data from the Bureau of Alcohol, Tobacco, Firearms, and Explosives. We examined the relationship between state firearm laws and interstate transfer of guns using annual data from all 50 states during the period 2006-2016 and employing a two-way fixed effects model. The primary outcome variable was the percentage of crime guns recovered in a state that could be traced to an original point of purchase within that state as opposed to another state. The main exposure variables were eight specific state firearm laws pertaining to dealer licensing, sales restrictions, background checks, registration, prohibitors for firearm purchase, and straw purchase of guns. Four laws were independently associated with a significantly lower percentage of in-state guns: a waiting period for handgun purchase, permits required for firearm purchase, prohibition of firearm possession by people convicted of a violent misdemeanor, and a requirement for relinquishment of firearms when a person becomes disqualified from owning them. States with a higher number of gun laws had a lower percentage of traced guns to in-state dealers, with each increase of one in the total number of laws associated with a decrease of 1.6 percentage points in the proportion of recovered guns that were traced to an in-state as opposed to an out-of-state source. Based on an examination of the movement patterns of guns across states, the overall observed pattern of gun flow was out of states with weak gun laws and into states with strong gun laws. These findings indicate that certain state firearm laws are associated with a lower percentage of recovered crime guns being traced to an in-state source, suggesting reduced access to guns in states with those laws.

Past 15-year trends in lifetime cocaine use among US high school students.

BACKGROUND: Most recent research on adolescent drug use has focused on alcohol, tobacco, and marijuana. Less is known about the recent epidemiology of adolescent cocaine use, which has serious health consequences. PURPOSE: To describe recent trends in cocaine use by U.S. high school students, and identify differences in lifetime and repeated use across sex and racial/ethnic groups. METHODS: We used data from the national Youth Risk Behavior Surveys (YRBS) from 1999 to 2015. We estimated the prevalence of lifetime cocaine use (LCU) and repeated lifetime cocaine use (RLCU) across years by race/ethnicity and sex and tested for linear and quadratic trends. RESULTS: The prevalence of LCU decreased from 1999 to 2015 (9.54%-5.19%). RLCU also decreased (5.13%-2.84%). Despite the overall decline, LCU and RLCU both rose between 2009-2015 (LCU:2.78%-5.19%, RLCU:1.58%-2.84%). Boys had higher rates of LCU and RLCU than girls (LCU:6.42% vs 4.65%; RLCU:3.69% vs 2.18%). American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, and Hispanic adolescents had the highest overall prevalence of LCU. Black adolescents' LCU patterns differed from other racial/ethnic groups. The prevalence of LCU among Black boys increased over time, while the prevalence for Black girls remained consistently low. CONCLUSIONS: Adolescent cocaine use is less common today than in the 1990s. However, rates of adolescent cocaine use have risen across all racial/ethnic groups in the past few years. Public health efforts should address at risk groups with particularly high or rising rates of cocaine use.

Effect of Patient Navigation and Financial Incentives on Smoking Cessation Among Primary Care Patients at an Urban Safety-Net Hospital: A Randomized Clinical Trial.

Importance: While the proportion of adults who smoke cigarettes has declined substantially in the past decade, socioeconomic disparities in cigarette smoking remain. Few interventions have targeted low socioeconomic status (SES) and minority smokers in primary care settings. Objective: To evaluate a multicomponent intervention to promote smoking cessation among low-SES and minority smokers. Design, Setting, and Participants: For this prospective, unblinded, randomized clinical trial conducted between May 1, 2015, and September 4, 2017, adults 18 years and older who spoke English, smoked 10 or more cigarettes per day in the past week, were contemplating or preparing to quit smoking, and had a primary care clinician were recruited from general internal medicine and family medicine practices at 1 large safety-net hospital in Boston, Massachusetts. Interventions: Patients were randomized to a control group that received an enhancement of usual care (n = 175 participants) or to an intervention group that received up to 4 hours of patient navigation delivered over 6 months in addition to usual care, as well as financial incentives for biochemically confirmed smoking cessation at 6 and 12 months following enrollment (n = 177 participants). Main Outcomes and Measures: The primary outcome determined a priori was biochemically confirmed smoking cessation at 12 months. Results: Among 352 patients who were randomized (mean [SD] age, 50.0 [11.0] years; 191 women [54.3%]; 197 participants who identified as non-Hispanic black [56.0%]; 40 participants who identified as Hispanic of any race [11.4%]), all were included in the intention-to-treat analysis. At 12 months following enrollment, 21 participants [11.9%] in the navigation and incentives group, compared with 4 participants [2.3%] in the control group, had quit smoking (odds ratio, 5.8; 95% CI, 1.9-17.1; number needed to treat, 10.4; P < .001). In prespecified subgroup analyses, the intervention was particularly beneficial for older participants (19 [19.8%] vs 1 [1.0%]; P < .001), women (17 [16.8%] vs 2 [2.2%]; P < .001), participants with household yearly income of $20 000 or less (15 [15.5%] vs 3 [3.1%]; P = .003), and nonwhite participants (21 [15.2%] vs 4 [3.0%]; P < .001). Conclusions and Relevance: In this study of adult daily smokers at 1 large urban safety-net hospital, patient navigation and financial incentives for smoking cessation significantly increased the rates of smoking cessation. Trial Registration: clinicaltrials.gov Identifier: NCT02351609.

Broadening the Perspective on Gun Violence: An Examination of the Firearms Industry, 1990-2015.

INTRODUCTION: Firearm violence injures or kills 100,000 Americans each year. This paper applies the Host-Agent-Vector-Environment model to this issue. Research on firearm violence tends to focus on two elements-the host (i.e., victims of firearm violence) and the environment (i.e., gun policies)-but little attention has been paid to the agent (the gun and ammunition) or the vector (firearm manufacturers, dealers, and the industry lobby). METHODS: Using Bureau of Alcohol, Tobacco, Firearms and Explosives data, trends in firearm manufacturing were investigated from 1990 to 2015. Outcome measures included: (1) trends in domestic gun manufacturing by weapon type; (2) trends in production by firearm caliber; and (3) 2015 market share by type of firearm and company. Data were collected and analyzed in 2016. RESULTS: Overall domestic firearms production decreased slightly from 1996 through 2004, and then steadily increased from 1.7% in 2005 to 13.8% in 2013, when >10 million firearms were produced for the domestic market. The increase in total firearm production was driven by the increased production of pistols and rifles. Within the pistol category, increased production was attributable to an increase in higher caliber weapons. Similar trends were observed in gun purchases and recovered and traced crime guns. CONCLUSIONS: Trends in firearm manufacturing reveal a shift toward more-lethal weapons, and this trend is also observed in gun purchases and crime gun traces. This may reflect a societal shift in cultural practices and norms related to guns and could inform strategies to reduce firearm violence.

Past 15-year trends in adolescent marijuana use: Differences by race/ethnicity and sex.

BACKGROUND: The potential for increases in adolescent marijuana use is an important concern given recent changes in marijuana policy. The purpose of this study was to estimate trends in marijuana use from 1999 to 2013 among a national sample of US high school students. We examine changes over time by race/ethnicity and sex. METHODS: Data are from the National Youth Risk Behavior Survey (YRBS), which involves biennial, school-based surveys that generate nationally representative data about 9th-12th grade students in the United States. Students self-reported sex, race/ethnicity, and marijuana use (i.e., lifetime use, past 30-day use, any use before age 13). We generated national estimates of the prevalence of marijuana use for the time period, and also tested for linear and quadratic trends (n=115,379). RESULTS: The prevalence of lifetime marijuana use decreased modestly from 1999 to 2009 (44% to 37%), and has increased slightly since 2009 (41%). Other marijuana use variables (e.g., past 30-day use) followed a similar pattern over time. The prevalence of past 30-day use from 1999 to 2013 for all groups and both sexes was 22.5%, and it was lowest among Asians and highest among American Indian/Alaska Natives. Although boys have historically had a higher prevalence of marijuana use, results indicate that male-female differences in marijuana use decreased over time. CONCLUSION: Despite considerable changes in state marijuana policies over the past 15 years, marijuana use among high school students has largely declined. Continued surveillance is needed to assess the impact of policy changes on adolescent marijuana use.