Changes in substance use among adolescents before and during the COVID-19 pandemic in Guatemala.

Objectives: Due to the COVID-19 pandemic, on March 16th, schools had to be closed in Guatemala and went to online teaching. We sought to analyze the change in substance use among high school students in Guatemala associated with the lockdown. Methods: Data from two surveys (2019, n=2096, and 2020, n=1606) of a student cohort in private high schools in Guatemala City was used. Logistic models for past 30-day cigarette, e-cigarette, marijuana, and alcohol (including binge drinking) were used, regressing these on survey wave, while adjusting for sex, scholastic performance, high school year of student, parental education, substance use, and household member tobacco use. Results: Prevalence declined for smoking (10% to 3%, p<0.001), e-cigarette (31% to 14%, p<0.001), marijuana (4.3% to 1.9%, p<0.001), and alcohol use (47% to 38.5%, p<0.001), and binge drinking (24% to 13%, p<0.001). Adjusted models showed wave 2 associated with lower odds of using cigarettes (AOR=0.44, 95%CI=0.32-0.62), e-cigarettes (AOR=0.41, 95% CI=0.35-0.49, p<0.001), and binge drinking (AOR=0.73, 95%CI=0.59-0.89; p=0.002). Conclusion: Among Guatemalan adolescents, COVID-19 restrictions were associated with a significant decrease in smoking, e-cigarette use, and binge drinking.

Factors Associated With the Changes in Smoking and Electronic cigarette use in Adolescents During the COVID-19 Pandemic: A Longitudinal Analysis.

PURPOSE: Explore the factors associated with the changes in smoking and electronic cigarette (e-cigarette) use and susceptibility among adolescents during the COVID-19 pandemic. METHODS: We surveyed a cohort of students (7th-12th grade) from private schools in Guatemala. Baseline (May-September 2019) was conducted in-person and follow-up (June-November 2020) online during the lockdown. Separate Generalized Estimating Equations logistic models regressed current smoking (n = 3,729), current e-cigarette use (n = 3,729), smoking susceptibility among never-smokers (n = 2,596), and susceptibility to e-cigarette use among never-users (n = 1,597) on online ad exposure, visiting stores, social network smoking/e-cigarette use, substance use (alcohol, marihuana, and cigarette or e-cigarette), perceived harm of using cigarettes/e-cigarettes, sociodemographic characteristics, and survey wave. Interactions were assessed between time and ad exposures, friends smoking and e-cigarette use. RESULTS: Frequency of store visits, exposure to online ads, and the use of cigarette and e-cigarette lowered at follow-up. Online e-cigarette ads, having family and friends who smoke, and current e-cigarette use increased the likelihood of being a current smoker. Frequent exposure to online e-cigarette ads, having family who use e-cigarettes, and being a current smoker were associated with higher likelihood of current e-cigarette use. Exposure to either online ads or having friends that smoke or use e-cigarettes, increased susceptibility to using either product. Interaction results showed that high exposure to online e-cigarette ads overtime increased the susceptibility to use e-cigarettes. DISCUSSION: Exposure to online ads and friends and family cigarette and e-cigarette use increased adolescent consumption and susceptibility during the pandemic.

Chemicals in cigarette flavor capsules from Guatemala and Mexico.

BACKGROUND: The global market share for cigarettes with flavor capsules has grown exponentially over the last decade, particularly in Latin America. When smoking, consumers crush a liquid capsule in the filter that flavors the smoke. Little is known about the chemical constituents of the liquids in capsules or their potential health risks. METHODS: Based on consumer data and availability in Mexico and Guatemala, 31 flavor capsule brands were purchased (19 and 12, respectively) in 2020. Since some cigarettes included multiple capsules in a stick (up to 2) or pack (up to 4), the final analytic sample included 50 capsules. We conducted qualitative and quantitative analysis using gas chromatography with mass spectrometry (GC-MS, Agilent Technologies, Inc.). RESULTS: The qualitative analysis detected 296 compounds (range=9 to 67 per capsule), and all capsules contained menthol. Among the compounds detected in more than half the sample were limonene, menthone, benzaldehyde, eucalyptol and triacetin. Traces of nicotine were found in 22% of the capsules. In the quantitative analysis, menthol concentrations were 33 times greater than the next most common compound (limonene). Benzyl alcohol and vanillin were also found in high concentrations. Comparing same brand varieties across countries showed substantial variability in the concentration of menthol and other compounds. CONCLUSION: Menthol is an omnipresent constituent in capsule cigarettes, perhaps because of its anesthetizing and reinforcing addictive properties. Other compounds found are toxic, potentially carcinogenic, and may enhance addictiveness. Variance in the presence and concentrations of such compounds highlights the importance of product standards to regulate capsule content. IMPLICATIONS: This study evaluated the chemical content of capsule cigarettes from two Latin American countries that have two of the highest market shares for capsule cigarettes worldwide. Compared to other studies, our assessment included brand varieties from two countries to compare the differences in chemical content by country. Our results yield that menthol is found in all capsules, and that other chemicals found may prolong nicotine exposure and therefore reinforce the addictive properties of cigarettes.

Latin America and the Caribbean Code Against Cancer 1st edition: Tobacco and nicotine-related products, secondhand smoke, and alcohol and cancer.

Tobacco, secondhand smoke (SHS), and alcohol, all carcinogens, are leading preventable cancer risk factors in Latin America and the Caribbean (LAC). Since 2000, smoking and SHS exposure have significantly decreased in the region. Yet alcohol consumption remains high. The entry of nicotine-related products such as electronic cigarettes (e-cigs) threatens achievements made in tobacco control and chronic diseases prevention, including cancer. E-cigs use is likely associated with smoking initiation among adolescents who had never smoked and dual use with combustible tobacco products. Therefore, the LAC Code Against Cancer recommends to the public actions they can take to reduce their risk of cancer: 1. Don't smoke or use any type of tobacco. If you do, quitting is possible, with professional help if needed. Don't use e-cigarettes either, as they lead to tobacco use. 2. Make your home a smoke-free place. Respect and promote laws that ensure smoke-free spaces to protect our health. and 3. Avoid drinking alcoholic beverages. This helps prevent several types of cancer. The Code recommends to policymakers a package of cost-effective policies based on the MPOWER and SAFER to prevent cancer at the population level. It also recommends that primary care health professionals: 1. Ask all their patients and their families whether they smoke or vape, inform them about the harms of smoking and vaping, and promote tobacco and nicotine related products cessation strategies among users. 2. Inform about the harms of exposure to SHS, especially among children, and promote smoke-free environments, and 3. Prevent alcohol use by their patients and their families, use tools to assess use, intensity, and frequency, and apply brief counseling intervention to support alcohol abstinence in primary care.

Latin American and the Caribbean Code Against Cancer 1st edition: Weight, physical activity, diet, breastfeeding, and cancer.

In Latin America and the Caribbean a considerable proportion of the population have excess body weight, do not meet the recommendations of physical activity and healthy diet, and have suboptimal rates of breastfeeding. Excess body weight is associated with at least 15 cancer sites, physical activity protects against three cancers, with some evidence suggesting a protective effect for eight more cancer sites, and sedentary behavior probably increases the risk of five cancer sites. Fiber and wholegrains protect against colorectal cancer, high intake of fruits and vegetables could reduce the risk of aerodigestive cancers; processed and red meat increase the risk of colorectal cancer; and very hot beverages are associated with esophageal cancer. Moreover, sugar-sweetened beverages and ultra-processed foods are a convincing cause for excess body weight, increasing cancer risk through this pathway, with some emerging evidence suggesting also direct pathways. Breastfeeding protects against breast cancer, and could protect against ovarian cancer. Taking this evidence into account, the Latin America and the Caribbean Code Against Cancer recommends the general public to maintain a healthy body weight, be physically active and limit sedentary behavior, eat a healthy diet (eat plenty of vegetables, fruits, wholegrains and legumes; avoid sugar-sweetened beverages and processed meat; and limit ultra-processed foods, red meat and very hot beverages), and breastfeed. Moreover, the Latin America and the Caribbean Code Against Cancer also includes a set of public policy recommendations for cancer prevention to inform policy makers and civil society about the need of policies to shape healthy environments and create opportunities to facilitate the adoption of the recommendations directed to the public.

First tobacco product tried and current use of cigarettes and electronic cigarettes among adolescents from Guatemala City.

OBJECTIVE: To assess how first experimenting with ciga-rettes or e-cigarettes is associated with current use in Gua-temala, a middle-income country with weak tobacco control and no e-cigarette regulations. MATERIALS AND METHODS: We surveyed students from private schools in Guatemala City, limiting analyses to ever users (n=1 026). Multinomial logistic models regressed current product use on first product used, adjusting for sociodemographics and friends and family use. RESULTS: The most common first product used was e-cigarettes (56%), followed by flavored cigarettes (24%) and regular cigarettes (20%). At the time of the survey, 4% were exclusive smokers, 37% were exclusive e-cigarette users, 18% dual users, and 40% had ever tried either but were not current users. Compared to those who first tried cigarettes, students who first tried e-cigarettes were less likely to be current smokers (RR=0.19 [CI: 0.11,0.31]) or dual users (RR=0.26 [CI: 0.14,0.49]) and students who first tried flavored cigarettes were more likely to be current smokers (RR=1.66 [CI=1.13,2.42]). CONCLUSIONS: In our sample, Guatemalan adolescents from private schools more frequently experiment and continue to use e-cigarettes than cigarettes. There is urgent need to implement e-cigarette restrictions in addition to tobacco control policy implementation.

Prevalence of Hypertension, Diabetes, and Other Cardiovascular Disease Risk Factors in Two Indigenous Municipalities in Rural Guatemala: A Population-Representative Survey.

Background: Nearly 50% of Guatemalans are Indigenous Maya, yet few studies have examined the prevalence of modifiable cardiovascular disease (CVD) risk factors in Indigenous Maya populations. Therefore, we sought to estimate the prevalence of modifiable CVD risk factors in two Indigenous Maya areas in Guatemala. Methods: We conducted, between June 2018 and October 2019, a population-representative survey of adults aged 18 years and older in two rural Indigenous Maya municipalities in Guatemala. Our primary outcomes were five modifiable CVD risk factors: diabetes, hypertension, obesity, smoking, and alcohol use. We estimated the crude and age-standardized prevalence of each outcome. We also constructed multivariable logistic regression models to assess prevalence over covariates including age, sex, education level, ethnicity, and poverty. Sampling weights adjusted for nonresponse, and appropriate survey commands were used in all analyses. Results: The crude prevalence of diabetes was 12.5% (95% confidence Interval [CI] 9.6% to 16.1%), hypertension 20.3% (95% CI 17.1% to 23.9%), obesity 23.7% (95% CI 19.4% to 28.6%), smoking 10.7% (95% CI 7.8% to 14.5%), and high alcohol use 0.9% (95% CI 0.5% to 1.6%). Age-standardized prevalence of each outcome was similar to the crude prevalence. The prevalence of multiple CVD risk factors increased between the age groups 18-29 years and 50-59 years before decreasing among older age groups. Men had twenty-fold higher smoking prevalence than women (20.5% vs. 1.2%, respectively) and women had nearly double the age-adjusted prevalence of obesity as men (30.1% vs. 17.0%, respectively). Conclusion: There is a substantial prevalence of modifiable CVD risk factors in rural, Indigenous populations in Guatemala, in particular hypertension, diabetes, obesity (among women), and smoking (among men). These findings can help catalyze policy and clinical investments to improve the prevention, management, and control of CVD risk factors in these historically marginalized communities.

SARS-CoV-2 seroprevalence in healthcare workers in a high-volume ophthalmology centre in Guatemala.

PURPOSE: To determine the seroprevalence of SARS-CoV-2 antibodies in eye healthcare workers (EHCW) in the largest ophthalmology centre in Guatemala and factors associated with antibody positivity. METHODS: We conducted a cross sectional sero-survey in all the staff at the largest ophthalmology centre in Guatemala. Serum samples were collected and tested for total antibodies against SARS-CoV-2 employing Roche Elecsys Anti-SARS-CoV-2 Immunoassay. Results were reported as reactive or non-reactive. According to patient exposure the staff were divided into low risk (technicians, domestic and administrative staff) and high risk (nurses, ophthalmologists, anaesthesiologists, and optometrists). Among those with positive antibodies, they were given a survey that included demographic characteristics, COVID-19 exposure, and related symptomatology. Logistic regression was used to determine the factors associated with antibody positivity. RESULTS: On November 25th a total of 94 healthcare workers were sero-surveyed, mean age was 34.15 years (±8.41), most (57.44%) were females. Seroprevalence was 18%, the majority (77%) were in the low-risk group; while 64% at high-risk, tested negative. Those at low exposure, were five times more likely to have antibodies than those at high exposure (OR:5.69; 95% CI 1.69-19.13). Age and gender were not associated to seropositivity. CONCLUSIONS: We found a similar seroprevalence of SARS-CoV-2 antibodies in EHCW to what has been reported in other healthcare groups. Seropositivity was higher among HCW with fewer patient exposure, hence the probability of community transmission.Key messagesEven though eye healthcare workers are believed to be at higher risk of infection, the prevalence of antibodies against SARS-CoV-2 in this group is comparable to what has been reported previously in other healthcare groups.

Spinal metastasis at the cervicothoracic junction from acinic cell carcinoma of the parotid gland: Case report.

BACKGROUND: Acinic cell carcinoma (ACC) accounts for only 1% of all parotid neoplasms. Spinal metastases of these tumor are extremely rare. CASE DESCRIPTION: A 21-year-old patient had two prior partial resections of an ACC of the parotid gland followed by radiotherapy. Two years later, the patient presented with a 3-month history of cervicothoracic pain. The cervical spine magnetic resonance imaging revealed a pathological vertebral fracture secondary to metastatic infiltration of the D1 and D2 vertebral bodies contributing to spinal cord compression. The patient underwent a two-staged approach to resect the D1/D2 infiltrated vertebral bodies and to stabilize the cervicothoracic junction. The histopathological diagnosis was consistent with metastatic ACC. The patient subsequently received 10 cycles of adjuvant radiotherapy. Six months later, the patient was neurologically intact and radiographically exhibited adequate fusion without new tumor recurrence. At the telemedicine follow-up 35 months postoperatively, the patient was doing well without axial pain or any neurological symptoms. CONCLUSION: A 23-year-old patient following circumferential decompression/fusion of a D1/D2 metastatic parotid carcinoma ACC was neurologically symptom free and radiographically stable without evidence of residual/ recurrent tumor.

Cross-sectional study examining the accuracy of self-reported smoking status as compared to urinary cotinine levels among workers at risk for chronic kidney disease of unknown origin in Guatemala.

OBJECTIVES: There is a lack of information on cotinine levels in rural populations in low-income and middle-income countries like Guatemala. Therefore, there is a need to explore smoking status and biomarkers of tobacco use in epidemiological research in rural, low-income populations, in particular those at-risk for chronic kidney disease of unknown origin (CKDu). DESIGN: We evaluated self-reported smoking status against urinary cotinine levels, the gold standard biomarker of tobacco smoke exposure, among agricultural workers at four separate cross-sectional time points. SETTING: Guatemala. PARTICIPANTS: 283 sugarcane workers. PRIMARY OUTCOME MEASURES: Compared self-reported smoking status and urinary cotinine levels in two agricultural worker studies. RESULTS: Self-reported smoking prevalence was 12% among workers. According to cotinine levels (≥50 ng/mL), the smoking prevalence was 34%. Self-reported smoking status had 28% sensitivity and 96% specificity. Urinary cotinine levels show that smoking prevalence is underestimated in this worker population. CONCLUSIONS: According to our findings, smoking status should be objectively measured with biomarkers rather than self-reported in CKDu epidemiological research. Self-reported smoking status is likely an underestimate of the true smoking prevalence among agricultural workers. Research on the CKDu epidemic in Central America and other parts of the world might be underestimating tobacco exposure as a potential contributor to the development of CKDu.

Effects of tobacco product type and characteristics on appeal and perceived harm: Results from a discrete choice experiment among Guatemalan adolescents.

Guatemala is one of the few countries where both heated tobacco products (HTPs) and electronic cigarettes (e-cigarettes) remain unregulated. We used a discrete choice experiment (DCE) administered to 2038 high school students to assess how tobacco product attributes influence their appeal among Guatemalan adolescents. Participants were randomly assigned to evaluate 4 of 32 contrasting sets, each containing 3 packs (1 of each product type). Experimental manipulations included: product type, brand, nicotine content and flavor. Participants then indicated which product they were most and least interested in trying and would be most and least harmful to their health. Conditional logistic regression models were used to assess the impact of product characteristics on choice. Product type accounted for almost 90% of variation in choices. Respondents were less interested in trying HTPs (B = -0.93; p < 0.001) and viewed them as more harmful (B = 2.77; p < 0.001) compared to cigarettes. They were more interested in trying e-cigarettes (B = 1.22; p < 0.001), which were also perceived as less harmful (B = -1.47; p < 0.001) compared to cigarettes. Products without nicotine were of more interest for trying (B = 0.14; p < 0.001) and perceived as more harmful (B = 0.20; p < 0.001) than those with. Students were more interested in trying a flavor compared to regular tobacco and among the flavors, berry was the highest rated one (B = 0.28; p < 0.001). Finally, in this country with weak tobacco control, e-cigarettes appear to be more appealing and perceived as less harmful than HTPs and cigarettes. Packaging and flavoring regulations are urgently needed on these products as they are a marketing strategy targeting adolescents.

New tobacco products, old advertising strategies: point-of-sale advertising in Guatemala.

OBJECTIVE: Capsule cigarettes, electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) are now readily available in Guatemala. As in most countries, the point-of-sale (POS) remains an important marketing channel for the tobacco industry. Therefore, we sought to characterise the POS marketing of these products in the two largest cities in Guatemala. METHODS: Convenience stores were randomly surveyed in mid and high socioeconomic status (SES) neighbourhoods in Guatemala City (n=60) and Quetzaltenango (n=15) in 2019. We adapted a previously implemented checklist to assess the availability of interior advertising of capsule cigarettes, e-cigarettes and HTP. Data entry was done in Kobo toolbox and analysis in STATA. RESULTS: All stores sold conventional and flavoured capsule cigarettes, 78% e-cigarettes and 68% HTP. Most cigarette advertising was for capsule cigarettes. E-cigarettes were more likely to be sold in Guatemala City (96%) than in Quetzaltenango (13%). HTPs were only found in Guatemala City (85%), with no difference between high and medium SES neighbourhoods. Median number of ads for cigarettes and capsule cigarettes was higher in the high SES neighbourhood. Most e-cigarettes (83%) and HTP (74%) were found <50 cm from candy. E-cigarettes and HTP were available in a wide range of flavours. All stores that sold HTP had flavoured HEETS (amber, bronze, turquoise, yellow, blue and purple). CONCLUSION: We found a high prevalence of advertising for capsule cigarettes, e-cigarettes and HTP at the POS. The POS, a crucial advertising channel for the tobacco industry, is now being used for new products and therefore needs to be urgently regulated.

La escala de afluencia familiar en la investigación sobre inequidades sociales en salud en adolescentes latinoamericanos / The family affluence scale for research on social inequities in Latin American adolescents health

Resumen: Objetivo: Evaluar la escala de afluencia familiar (EAF), que consiste en el autorreporte sobre número de computadoras y automóviles del hogar, dormitorio propio y vacaciones, como indicador de nivel socioeconómico (NSE) familiar en adolescentes escolarizados de tres países latinoamericanos. Material y métodos: Fueron encuestados 14 717 estudiantes de secundaria de Argentina, México y Guatemala. Se evaluó la asociación de la EAF con otros indicadores de NSE a nivel familiar (nivel educativo parental, posesión de bienes y servicios tecnológicos) y de entorno escolar (índice de marginación, escuela pública o privada y matrícula escolar). Resultados: La EAF mostró menos datos faltantes que los otros indicadores familiares de NSE. Además, mostró asociaciones en la dirección esperada con los otros indicadores de NSE. Conclusiones: La EAF parece constituir un indicador válido tanto de la riqueza material familiar como del NSE a nivel de la escuela, útil para estudios sobre inequidades en salud en adolescentes latinoamericanos.

Abstract: Objective: To assess the family affluence scale (FAS), which consists of self-reported number of computers and cars in the home, having one's own bedroom and holidays, as a family socioeconomic status (SES) indicator for adolescents in three Latin American countries. Materials and methods: 14 717 secondary students from Argentina, Mexico and Guatemala were surveyed. The association between FAS and other SES indicators at familiar level (parent education and owning of technological goods and services) and school level (marginalization index, public or private school, and school fee) were evaluated. Results: The FAS was associated in the expected direction with all other NSE indicators. Conclusions: The FAS seems to be a valid indicator of the material wealth of adolescent families, as well as of school SES, and it can be used in studies on health inequities in Latin American adolescents.

Cross-sectional study on the awareness, susceptibility and use of heated tobacco products among adolescents in Guatemala City, Guatemala.

OBJECTIVES: Heated tobacco products (HTPs) are increasingly marketed worldwide, yet limited research on HTPs has been conducted in low and middle-income countries (LMICs) or among adolescents. Guatemala is one of the few LMICs where HTPs are available. This study examined prevalence and correlates of HTP awareness, susceptibility and use among adolescents in Guatemala. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional survey on HTP awareness, susceptibility and use was conducted among 2870 students between the ages of 13 and 17 in private schools in Guatemala City, Guatemala. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was susceptibility to future use of HTP among school-aged current and never smokers in Guatemala. We also explored awareness and use of HTPs. Multivariate binomial regression models were used to explore associations between these outcomes and both sociodemographic factors and established smoking correlates. RESULTS: Of all students (n=2870), about half were aware of HTPs (52.4%) and susceptible to future or continued use (52.4%). Whereas 8.4% of students had tried HTPs in the lifetime (but not in the last month), only 2.9% used HTPs in the past month. Independent correlates of HTP susceptibility and ever-use included: use of other tobacco products (current smoking: adjusted OR (AOR)=10.53 and 6.63, respectively; current e-cigarette use: AOR=21.87 and 10.40, respectively), moderate alcohol consumption (AOR=1.49 and 1.19, respectively), marijuana use in the past 30 days (AOR=3.49 and 2.29, respectively) and having friends who use HTPs (AOR=1.83 and 7.28, respectively). CONCLUSIONS: Among this sample of adolescents in Guatemala City, where tobacco control is weak, the prevalence of HTP use was low but susceptibility to future use was high. Tobacco prevention and intervention strategies for cigarettes and e-cigarettes should now also include HTPs, which tend to be used by similar adolescent populations (ie, those who use other substances or are exposed to tobacco through family and friends).