A Longitudinal Study of Perceptions of the Massachusetts Menthol Ban and Its Impact on Smoking Behaviors among Marginalized Individuals.

Menthol cigarettes have had a profound adverse effect on public health. On 1 June 2020, Massachusetts became the first state to ban the sale of menthol cigarettes. We explored how perceptions of the ban and smoking behaviors changed over time among a group of 27 individuals who smoked menthol cigarettes at our safety-net hospital. In a convergent mixed methods study, we administered questionnaires and interviews simultaneously at two timepoints: 1 month pre-ban and 6 months post-ban. Pre-ban, we assessed perceptions of the ban and anticipated smoking behaviors after the ban. Post-ban, we assessed participants' actual smoking behaviors and elicited suggestions to avoid unintended consequences that might undermine intended policy effects. Several respondents perceived the Massachusetts ban as positive because it could promote smoking cessation, prevent youth initiation, and mitigate unfair targeting of socioeconomically disadvantaged populations. Others perceived the ban as an overreach of government policy, financially motivated, and unfairly targeting the Black community. Many continued to smoke menthol cigarettes obtained outside Massachusetts. Individuals suggested promoting tobacco treatment for people affected by the ban and a national ban to circumvent out-of-state purchasing of menthol cigarettes. Our findings suggest that in order to be most effective, healthcare systems must promote tobacco treatment and ensure that treatment is accessible to all individuals affected by the ban.

COVID-19 Mortality by Race and Ethnicity in US Metropolitan and Nonmetropolitan Areas, March 2020 to February 2022.

Importance: Prior research has established that Hispanic and non-Hispanic Black residents in the US experienced substantially higher COVID-19 mortality rates in 2020 than non-Hispanic White residents owing to structural racism. In 2021, these disparities decreased. Objective: To assess to what extent national decreases in racial and ethnic disparities in COVID-19 mortality between the initial pandemic wave and subsequent Omicron wave reflect reductions in mortality vs other factors, such as the pandemic's changing geography. Design, Setting, and Participants: This cross-sectional study was conducted using data from the US Centers for Disease Control and Prevention for COVID-19 deaths from March 1, 2020, through February 28, 2022, among adults aged 25 years and older residing in the US. Deaths were examined by race and ethnicity across metropolitan and nonmetropolitan areas, and the national decrease in racial and ethnic disparities between initial and Omicron waves was decomposed. Data were analyzed from June 2021 through March 2023. Exposures: Metropolitan vs nonmetropolitan areas and race and ethnicity. Main Outcomes and Measures: Age-standardized death rates. Results: There were death certificates for 977 018 US adults aged 25 years and older (mean [SD] age, 73.6 [14.6] years; 435 943 female [44.6%]; 156 948 Hispanic [16.1%], 140 513 non-Hispanic Black [14.4%], and 629 578 non-Hispanic White [64.4%]) that included a mention of COVID-19. The proportion of COVID-19 deaths among adults residing in nonmetropolitan areas increased from 5944 of 110 526 deaths (5.4%) during the initial wave to a peak of 40 360 of 172 515 deaths (23.4%) during the Delta wave; the proportion was 45 183 of 210 554 deaths (21.5%) during the Omicron wave. The national disparity in age-standardized COVID-19 death rates per 100 000 person-years for non-Hispanic Black compared with non-Hispanic White adults decreased from 339 to 45 deaths from the initial to Omicron wave, or by 293 deaths. After standardizing for age and racial and ethnic differences by metropolitan vs nonmetropolitan residence, increases in death rates among non-Hispanic White adults explained 120 deaths/100 000 person-years of the decrease (40.7%); 58 deaths/100 000 person-years in the decrease (19.6%) were explained by shifts in mortality to nonmetropolitan areas, where a disproportionate share of non-Hispanic White adults reside. The remaining 116 deaths/100 000 person-years in the decrease (39.6%) were explained by decreases in death rates in non-Hispanic Black adults. Conclusions and Relevance: This study found that most of the national decrease in racial and ethnic disparities in COVID-19 mortality between the initial and Omicron waves was explained by increased mortality among non-Hispanic White adults and changes in the geographic spread of the pandemic. These findings suggest that despite media reports of a decline in disparities, there is a continued need to prioritize racial health equity in the pandemic response.

Increased all-cause mortality following occupational injury: a comparison of two states.

OBJECTIVES: To measure the impact of lost-time occupational injuries on all-cause mortality in Washington State and, using the same data elements and study design, to determine whether the estimated impact was similar to previous estimates for New Mexico. METHODS: We linked injuries in the Washington workers' compensation system with Social Security Administration data on earnings and mortality. We estimated Cox survival models of mortality for women and men with lost-time compared with medical-only injuries, adjusting for age, pre-injury earnings and industry. We used quantitative bias analysis to account for confounding by pre-injury smoking and obesity. RESULTS: The estimated mortality HR was 1.24 for women (95% CI 1.21 to 1.28) and 1.22 for men (95% CI 1.20 to 1.24). After adjusting for unmeasured pre-injury smoking and obesity, the estimated HR for women was 1.10, 95% simulation interval (SI) 1.00 to 1.21; for men, it was 1.15, 95% SI 1.04 to 1.27. CONCLUSIONS: All-cause mortality for Washington workers with lost-time injuries was higher than for those with medical-only injuries. Estimated HRs for Washington were consistent with those previously estimated for New Mexico, a less populous state with lower median wages and a different workers' compensation insurance mechanism. This suggests that the relationship between workplace injury and long-term mortality may be generalisable to other US states. These findings support greater efforts to enhance safety and to investigate factors that improve postinjury employment opportunities and long-term health. This association should be examined in additional locations, with different study conditions, or using additional data on pre-injury risk factors.

Dynamics of racial disparities in all-cause mortality during the COVID-19 pandemic.

As research documenting disparate impacts of COVID-19 by race and ethnicity grows, little attention has been given to dynamics in mortality disparities during the pandemic and whether changes in disparities persist. We estimate age-standardized monthly all-cause mortality in the United States from January 2018 through February 2022 for seven racial/ethnic populations. Using joinpoint regression, we quantify trends in race-specific rate ratios relative to non-Hispanic White mortality to examine the magnitude of pandemic-related shifts in mortality disparities. Prepandemic disparities were stable from January 2018 through February 2020. With the start of the pandemic, relative mortality disadvantages increased for American Indian or Alaska Native (AIAN), Native Hawaiian or other Pacific Islander (NHOPI), and Black individuals, and relative mortality advantages decreased for Asian and Hispanic groups. Rate ratios generally increased during COVID-19 surges, with different patterns in the summer 2021 and winter 2021/2022 surges, when disparities approached prepandemic levels for Asian and Black individuals. However, two populations below age 65 fared worse than White individuals during these surges. For AIAN people, the observed rate ratio reached 2.25 (95% CI = 2.14, 2.37) in October 2021 vs. a prepandemic mean of 1.74 (95% CI = 1.62, 1.86), and for NHOPI people, the observed rate ratio reached 2.12 (95% CI = 1.92, 2.33) in August 2021 vs. a prepandemic mean of 1.31 (95% CI = 1.13, 1.49). Our results highlight the dynamic nature of racial/ethnic disparities in mortality and raise alarm about the exacerbation of mortality inequities for Indigenous groups due to the pandemic.

Geographic and Temporal Patterns in Covid-19 Mortality by Race and Ethnicity in the United States from March 2020 to February 2022.

Prior research has established that American Indian, Alaska Native, Black, Hispanic, and Pacific Islander populations in the United States have experienced substantially higher mortality rates from Covid-19 compared to non-Hispanic white residents during the first year of the pandemic. What remains less clear is how mortality rates have changed for each of these racial/ethnic groups during 2021, given the increasing prevalence of vaccination. In particular, it is unknown how these changes in mortality have varied geographically. In this study, we used provisional data from the National Center for Health Statistics (NCHS) to produce age-standardized estimates of Covid-19 mortality by race/ethnicity in the United States from March 2020 to February 2022 in each metro-nonmetro category, Census region, and Census division. We calculated changes in mortality rates between the first and second years of the pandemic and examined mortality changes by month. We found that when Covid-19 first affected a geographic area, non-Hispanic Black and Hispanic populations experienced extremely high levels of Covid-19 mortality and racial/ethnic inequity that were not repeated at any other time during the pandemic. Between the first and second year of the pandemic, racial/ethnic inequities in Covid-19 mortality decreased-but were not eliminated-for Hispanic, non-Hispanic Black, and non-Hispanic AIAN residents. These inequities decreased due to reductions in mortality for these populations alongside increases in non-Hispanic white mortality. Though racial/ethnic inequities in Covid-19 mortality decreased, substantial inequities still existed in most geographic areas during the pandemic's second year: Non-Hispanic Black, non-Hispanic AIAN, and Hispanic residents reported higher Covid-19 death rates in rural areas than in urban areas, indicating that these communities are facing serious public health challenges. At the same time, the non-Hispanic white mortality rate worsened in rural areas during the second year of the pandemic, suggesting there may be unique factors driving mortality in this population. Finally, vaccination rates were associated with reductions in Covid-19 mortality for Hispanic, non-Hispanic Black, and non-Hispanic white residents, and increased vaccination may have contributed to the decreases in racial/ethnic inequities in Covid-19 mortality observed during the second year of the pandemic. Despite reductions in mortality, Covid-19 mortality remained elevated in nonmetro areas and increased for some racial/ethnic groups, highlighting the need for increased vaccination delivery and equitable public health measures especially in rural communities. Taken together, these findings highlight the continued need to prioritize health equity in the pandemic response and to modify the structures and policies through which systemic racism operates and has generated racial health inequities.

Assessment of Patterns in e-Cigarette Use Among Adults in the US, 2017-2020.

Importance: Updated data on the patterns of e-cigarette use among adults in the US are needed. Objective: To examine recent patterns in current and daily e-cigarette use among US adults. Design, Setting, and Participants: This repeated cross-sectional study used data from the 2017, 2018, and 2020 Behavioral Risk Factor Surveillance System, a nationally representative state-based survey of noninstitutionalized US adults. A total of 994 307 adults 18 years and older who were living in states and territories that provided data on e-cigarette use in 2017 (53 states and territories), 2018 (36 states and Guam), and 2020 (42 states and Guam) were included. Main Outcomes and Measures: The weighted prevalence of current (past 30 days) and daily e-cigarette use was estimated for each year, and changes in prevalence from 2017 to 2020 were assessed, first overall and then stratified by participant characteristics, including state or territory of residence. Results: Among 994 307 adults from states with data on e-cigarette use, 429 370 individuals (weighted 51.3% female) were participants in the 2017 survey, 280 184 (weighted 52.1% female) were participants in the 2018 survey, and 284 753 (weighted 52.1% female) were participants in the 2020 survey. The weighted proportions of young adults aged 18 to 24 years were 12.6% in 2017, 11.8% in 2018, and 11.9% in 2020. Across all 3 years, 17 035 participants (weighted, 1.0%) were American Indian or Alaska Native, 22 313 (weighted, 4.6%) were Asian, 75 780 (weighted, 12.2%) were Black, 72 190 (weighted, 15.1%) were Hispanic, 4817 (weighted, 0.2%) were Native Hawaiian, 757 140 (weighted, 65.1%) were White, 20 332 (weighted, 1.3%) were multiracial, and 6245 (weighted, 0.5%) were of other races and/or ethnicities. The prevalence of current e-cigarette use was 4.4% (95% CI, 4.3%-4.5%) in 2017, which increased to 5.5% (95% CI, 5.4%-5.7%) in 2018 and decreased slightly to 5.1% (95% CI, 4.9%-5.3%) in 2020. The recent decrease, though modest, was observed mainly among young adults aged 18 to 20 years (from 18.9% [95% CI, 17.2%-20.7%] to 15.6% [95% CI, 14.1%-17.1%]; P = .004). However, the prevalence of daily e-cigarette use increased consistently from 1.5% (95% CI, 1.4%-1.6%) in 2017 to 2.1% (95% CI, 2.0%-2.2%) in 2018 and 2.3% (95% CI, 2.2%-2.4%) in 2020. Among young adults aged 21 to 24 years, there was a slight, albeit insignificant, increase in the prevalence of current e-cigarette use (from 13.5% [95% CI, 12.3%-14.7%] to 14.5% [95% CI, 13.2%-15.9%]; P = .28) but a significant increase in the prevalence of daily e-cigarette use (from 4.4% [95% CI, 3.8%-5.1%] to 6.6% [95% CI, 5.6%-7.6%]; P < .001) between 2018 and 2020. State-level patterns in the prevalence of current e-cigarette use were heterogeneous, with states like Massachusetts (from 5.6% [95% CI, 4.8%-6.5%] to 4.1% [95% CI, 3.1%-5.3%]; P = .03) and New York (from 5.4% [95% CI, 4.9%-5.9%] to 4.1% [95% CI, 3.5%-4.7%]; P = .001) recording significant decreases between 2018 and 2020. In contrast, Guam (from 5.9% [95% CI, 4.5%-7.9%] to 11.4% [95% CI, 8.7%-14.8%]; P = .002) and Utah (from 6.1% [95% CI, 5.5%-6.7%] to 7.2% [95% CI, 6.5%-8.0%]; P = .02) recorded significant increases in current e-cigarette use over the same period. Conclusions and Relevance: In this study, a slight decrease in the prevalence of current e-cigarette use was found between 2018 and 2020; this decrease was mainly observed among young adults aged 18 to 20 years. In contrast, daily e-cigarette use consistently increased, particularly among young adults aged 21 to 24 years. This increase in daily use suggests greater nicotine dependence among those who use e-cigarettes, warranting continued surveillance.

"Pandemic of the unvaccinated"? At midlife, white people are less vaccinated but still at less risk of Covid-19 mortality in Minnesota.

Introduction: Recent research underscores the exceptionally young age distribution of Covid-19 deaths in the United States compared with international peers. This brief characterizes how high levels of Covid mortality at midlife ages (45-64) are deeply intertwined with continuing racial inequity in Covid-19 mortality. Methods: Mortality data from Minnesota in 2020-2022 were analyzed in June 2022. Death certificate data and published vaccination rates in Minnesota allow vaccination and mortality rates to be observed with greater age and temporal precision than national data. Results: Black, Hispanic, and Asian adults under age 65 were all more highly vaccinated than white populations of the same ages during most of Minnesota's substantial and sustained Delta surge and all of the subsequent Omicron surge. However, white mortality rates were lower than those of all other groups. These disparities were extreme; at midlife ages (ages 45-64), during the Omicron period, more highly-vaccinated populations had COVID-19 mortality that was 164% (Asian-American), 115% (Hispanic), or 208% (Black) of white Covid-19 mortality at these ages. In Black, Indigenous, and People of Color (BIPOC) populations as a whole, Covid-19 mortality at ages 55-64 was greater than white mortality at 10 years older. Conclusions: This discrepancy between vaccination and mortality patterning by race/ethnicity suggests that, if the current period is a "pandemic of the unvaccinated," it also remains a "pandemic of the disadvantaged" in ways that can decouple from vaccination rates. This result implies an urgent need to center health equity in the development of Covid-19 policy measures.

Associations of Smokeless Tobacco Use With Cardiovascular Disease Risk: Insights From the Population Assessment of Tobacco and Health Study.

INTRODUCTION: Cigarette smoking is strongly associated with the development of cardiovascular disease (CVD). However, evidence is limited as to whether smokeless tobacco (ST) use is associated with CVD. AIMS AND METHODS: Using data from 4347 adults in the Population Assessment of Tobacco and Health Study (2013-2014), we compared geometric mean concentrations of CVD-related harm biomarkers and biomarkers of exposure among exclusive ST users and exclusive cigarette smokers-in relation to recent nicotine exposure-and never tobacco users, adjusting for age, sex, race/ethnicity, income, body mass index, and CVD. Biomarker levels among exclusive ST users who were former established cigarette smokers were compared with exclusive cigarette smokers. RESULTS: Compared with cigarette smokers, ST users had significantly higher concentrations of total nicotine equivalents (TNE) but lower concentrations of inflammatory (high-sensitivity C-reactive protein, interleukin-6, intercellular adhesion molecule, fibrinogen) and oxidative stress (8-isoprostane) biomarkers (all p < .05). Biomarker levels among ST users were similar to never smokers. ST users who were former cigarette smokers had lower levels of inflammatory and oxidative stress biomarkers and biomarkers of exposure (cadmium, lead, 1-hydroxypyrene, acrylonitrile, and acrolein), compared with cigarettes smokers (p < .05), despite having higher TNE levels (p < .05). Among cigarette smokers, but not among ST users, inflammatory biomarkers and TNE were highly correlated. CONCLUSIONS: ST use is not associated with increases in biomarkers of CVD-related harm and exposure, compared with never smokers, despite exposure to nicotine at levels higher than those observed among cigarette smokers. These findings support the concept that increases in CVD risk among cigarette smokers is caused primarily by constituents of tobacco smoke other than nicotine. IMPLICATIONS: Despite having higher levels of nicotine and compared with exclusive cigarette smokers, exclusive ST users (including those who were former cigarette smokers) had significantly lower concentrations of inflammatory and oxidative stress biomarkers, comparable to levels observed among never tobacco users. These findings suggest that increases in CVD risk among cigarette smokers is caused primarily by tobacco constituents other than nicotine and that switching to ST is likely associated with lower CVD risk.

The unequal burden of the Covid-19 pandemic: Capturing racial/ethnic disparities in US cause-specific mortality.

Despite a growing body of literature focused on racial/ethnic disparities in Covid-19 mortality, few previous studies have examined the pandemic's impact on 2020 cause-specific mortality by race and ethnicity. This paper documents changes in mortality by underlying cause of death and race/ethnicity between 2019 and 2020. Using age-standardized death rates, we attribute changes for Black, Hispanic, and White populations to various underlying causes of death and show how these racial and ethnic patterns vary by age and sex. We find that although Covid-19 death rates in 2020 were highest in the Hispanic community, Black individuals faced the largest increase in all-cause mortality between 2019 and 2020. Exceptionally large increases in mortality from heart disease, diabetes, and external causes of death accounted for the adverse trend in all-cause mortality within the Black population. Within Black and White populations, percentage increases in all-cause mortality were similar for men and women, as well as for ages 25-64 and 65+. Among the Hispanic population, however, percentage increases in mortality were greatest for working-aged men. These findings reveal that the overall impact of the pandemic on racial/ethnic disparities in mortality was much larger than that captured by official Covid-19 death counts alone.

Association of E-Cigarettes With Erectile Dysfunction: The Population Assessment of Tobacco and Health Study.

INTRODUCTION: Smoking is independently associated with erectile dysfunction and cardiovascular disease. Given existing similarities in the constituents of e-cigarettes or ENDS and cigarettes, this study examines the association between ENDS use and erectile dysfunction. METHODS: Data from Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health study were analyzed in 2020. Male participants aged ≥20 years who responded to the erectile dysfunction question were included. Multivariable logistic regression models examined the association of ENDS use with erectile dysfunction within the full sample and in a restricted sample (adults aged 20-65 years with no previous cardiovascular disease diagnosis) while adjusting for multiple risk factors. RESULTS: The proportion of erectile dysfunction varied from 20.7% (full sample) to 10.2% (restricted sample). The prevalence of current ENDS use within the full and restricted samples was 4.8% and 5.6%, respectively, with 2.1% and 2.5%, respectively, reporting daily use. Current daily ENDS users were more likely to report erectile dysfunction than never users in both the full (AOR=2.24, 95% CI=1.50, 3.34) and restricted (AOR=2.41, 95% CI=1.55, 3.74) samples. In the full sample, cardiovascular disease history (versus not present) and age ≥65 years (versus age 20-24 years) were associated with erectile dysfunction (AOR=1.39, 95% CI=1.10, 1.77; AOR= 17.4, 95% CI=12.15, 24.91), whereas physical activity was associated with lower odds of erectile dysfunction in both samples (AOR range=0.44-0.58). CONCLUSIONS: The use of ENDS seems to be associated with erectile dysfunction independent of age, cardiovascular disease, and other risk factors. While ENDS remain under evaluation for harm reduction and smoking-cessation potential, ENDS users should be informed about the possible association between ENDS use and erectile dysfunction.

Widening Socioeconomic Disparities in Pain and Physical Function Among Americans Are Linked with Growing Obesity.

Objectives: We investigate whether obesity accounts for widening socioeconomic disparities in pain. Methods: Based on nationally representative samples of Americans aged 25-74 in 1995-1996 and 2011-2014, we use logistic regression to model period change in headaches, backaches, and joint aches as well as physical limitations and to determine whether those changes vary by a multidimensional measure of socioeconomic status. Results: Prevalence of backaches, joint aches, physical limitations, and obesity increased between the mid-1990s and the early 2010s, particularly among more disadvantaged Americans. Socioeconomic disparities in frequent backaches, frequent joint pain, and physical limitations more than doubled over this period. We estimate that obesity and health conditions may account for nearly a quarter of the widening disparity in frequent backaches and about half of the widening disparity in frequent joint pain and physical limitations. Discussion: Widening disparities in backaches, joint pain, and physical limitations have coincided with growing obesity.

Mortality following workplace injury: Quantitative bias analysis.

PURPOSE: Recent studies have shown increased all-cause mortality among workers following disabling workplace injury. These studies did not account for 2 potentially important confounders, smoking and obesity. We estimated injury-related mortality accounting for these factors. METHODS: We followed workers receiving New Mexico workers' compensation benefits (1994-2000) through 2013. Using data from the Panel Study of Income Dynamics, we derived the joint distribution of smoking status and obesity for workers with and without lost-time injuries. We conducted a quantitative bias analysis (QBA) to determine the adjusted relationship of injury and mortality. RESULTS: We observed hazard ratios after adjusting for smoking and obesity of 1.13 for women (95% simulation interval (SI) 0.97 to 1.31) and 1.12 for men (95% SI 1.00 to 1.27). The estimated fully adjusted excess hazard was about half the estimates not adjusted for these factors. CONCLUSIONS: Using QBA to adjust for smoking and obesity reduced the estimated mortality hazard from lost-time injuries and widened the simulation interval. The adjusted estimate still showed more than a 10 percent increase for both women and men. The change in estimates reveals the importance of accounting for these confounders. Of course, the results depend on the methods and assumptions used.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association.

BACKGROUND: The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS: The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS: Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS: The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Assessing the Impact of the Covid-19 Pandemic on US Mortality: A County-Level Analysis.

BACKGROUND: Covid-19 excess deaths refer to increases in mortality over what would normally have been expected in the absence of the Covid-19 pandemic. Several prior studies have calculated excess deaths in the United States but were limited to the national or state level, precluding an examination of area-level variation in excess mortality and excess deaths not assigned to Covid-19. In this study, we take advantage of county-level variation in Covid-19 mortality to estimate excess deaths associated with the pandemic and examine how the extent of excess mortality not assigned to Covid-19 varies across subsets of counties defined by sociodemographic and health characteristics. METHODS AND FINDINGS: In this ecological, cross-sectional study, we made use of provisional National Center for Health Statistics (NCHS) data on direct Covid-19 and all-cause mortality occurring in U.S. counties from January 1 to December 31, 2020 and reported before March 12, 2021. We used data with a ten week time lag between the final day that deaths occurred and the last day that deaths could be reported to improve the completeness of data. Our sample included 2,096 counties with 20 or more Covid-19 deaths. The total number of residents living in these counties was 319.1 million. On average, the counties were 18.7% Hispanic, 12.7% non-Hispanic Black and 59.6% non-Hispanic White. 15.9% of the population was older than 65 years. We first modeled the relationship between 2020 all-cause mortality and Covid-19 mortality across all counties and then produced fully stratified models to explore differences in this relationship among strata of sociodemographic and health factors. Overall, we found that for every 100 deaths assigned to Covid-19, 120 all-cause deaths occurred (95% CI, 116 to 124), implying that 17% (95% CI, 14% to 19%) of excess deaths were ascribed to causes of death other than Covid-19 itself. Our stratified models revealed that the percentage of excess deaths not assigned to Covid-19 was substantially higher among counties with lower median household incomes and less formal education, counties with poorer health and more diabetes, and counties in the South and West. Counties with more non-Hispanic Black residents, who were already at high risk of Covid-19 death based on direct counts, also reported higher percentages of excess deaths not assigned to Covid-19. Study limitations include the use of provisional data that may be incomplete and the lack of disaggregated data on county-level mortality by age, sex, race/ethnicity, and sociodemographic and health characteristics. CONCLUSIONS: In this study, we found that direct Covid-19 death counts in the United States in 2020 substantially underestimated total excess mortality attributable to Covid-19. Racial and socioeconomic inequities in Covid-19 mortality also increased when excess deaths not assigned to Covid-19 were considered. Our results highlight the importance of considering health equity in the policy response to the pandemic.

Racial/Ethnic Differences in Associations of Non-cigarette Tobacco Product Use With Subsequent Initiation of Cigarettes in US Youths.

INTRODUCTION: Understanding which non-cigarette tobacco products precede smoking in youth across different racial/ethnic groups can inform policies that consider tobacco-related health disparities. METHODS: We used nationally representative, longitudinal data from the Population Assessment of Tobacco and Health Study waves 1-4. The sample was a dynamic cohort of cigarette-naïve youth aged 12-17 years. Mixed-effects models were used to assess non-cigarette product (e-cigarette, cigar product, or other product) use with cigarette use over 1-year intervals. RESULTS: Of the 28 788 observations pooled across waves 1-4, respondents were 48.7% non-Hispanic white, 13.9% non-Hispanic black, and 23.1% Hispanic. Odds of cigarette initiation over 1-year follow-up were higher among youth with prior use of e-cigarettes (odds ratio [OR], 2.76; 95% confidence interval [CI], 2.21-3.45), cigars (OR, 2.00; 95% CI, 1.42-2.80), or other products (OR, 1.66; 95% CI, 1.28-2.14) compared to never users. At the population level, 20.6% of cigarette initiation was attributable to e-cigarette use among white youth and 21.6% among Hispanic youth, while only 3.5% of cigarette initiation was attributable to e-cigarette use among black youth. In contrast, 9.1% of cigarette initiation for black youth was attributable to cigar use compared to only 3.9% for both white and Hispanic youth. CONCLUSIONS: Prior use of e-cigarettes, cigars, and other non-cigarette products were all associated with subsequent cigarette initiation. However, white and Hispanic youth were more likely to initiate cigarettes through e-cigarette use (vs. cigar or other product use), while black youth were more likely to initiate cigarettes through cigar use (vs. e-cigarette or other product use). IMPLICATIONS: Our findings suggest that previous studies on effects of non-cigarette tobacco products may overlook the critical role of cigar products as a pathway into cigarette smoking among US youth, particularly black youth. While our data support the importance of e-cigarette use as a pathway into smoking, regulatory actions aimed at addressing youth e-cigarette use alone may contribute to disparities in black versus white tobacco use and further exacerbate inequities in tobacco-related disease. Thus, contemporary policy development and discourse about the effects of non-cigarette tobacco products on cigarette initiation should consider cigar and other non-cigarette products as well as e-cigarettes.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data.

BACKGROUND: Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. METHODS AND FINDINGS: We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. CONCLUSION: In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

Association of body mass index and osteoarthritis with healthcare expenditures and utilization.

OBJECTIVE: Osteoarthritis is highly prevalent and, on aggregate, is one of the largest contributors to US spending on hospital-based health care. This study sought to examine body mass index (BMI)-related variation in the association of osteoarthritis with healthcare utilization and expenditures. METHODS: This is a retrospective study using administrative insurance claims linked to electronic health records. Study patients were aged ≥ 18 years with ≥1 BMI measurement recorded in 2014, with the first (index) BMI ≥ 25 kg m-2. Study outcomes and covariates were measured during a 1-year evaluation period spanning 6 months before and after index. Multivariable regression analyses examined the association of BMI with osteoarthritis prevalence, and the combined associations of osteoarthritis and BMI with osteoarthritis-related medication utilization, all-cause hospitalization, and healthcare expenditures. RESULTS: A total of 256 459 patients (median age = 56 y) met study eligibility criteria; 14.8% (38 050) had osteoarthritis. In multivariable analyses, the adjusted prevalence of osteoarthritis increased with increasing BMI (12.7% in patients who were overweight [25.0-29.9 kg m-2] to 21.9% in patients with class III obesity [BMI ≥ 40 kg m-2], P < .001). Among patients with osteoarthritis, increasing BMI (from overweight to class III obesity) was associated with increased (all P < .01): utilization rates for analgesic medications (41.5-53.5%); rates of all-cause hospitalization (26.3%-32.0%); and total healthcare expenditures ($18 204-$23 372). CONCLUSION: The prevalence and economic burden of osteoarthritis grow with increasing BMI; primary prevention of weight-related osteoarthritis and secondary weight management may help to alleviate this burden.

Diabetes Prevalence and Its Relationship With Education, Wealth, and BMI in 29 Low- and Middle-Income Countries.

OBJECTIVE: Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs), but empirical data on its prevalence and relationship to socioeconomic status are scarce. We estimated diabetes prevalence and the subset with undiagnosed diabetes in 29 LMICs and evaluated the relationship of education, household wealth, and BMI with diabetes risk. RESEARCH DESIGN AND METHODS: We pooled individual-level data from 29 nationally representative surveys conducted between 2008 and 2016, totaling 588,574 participants aged ≥25 years. Diabetes prevalence and the subset with undiagnosed diabetes was calculated overall and by country, World Bank income group (WBIG), and geographic region. Multivariable Poisson regression models were used to estimate relative risk (RR). RESULTS: Overall, prevalence of diabetes in 29 LMICs was 7.5% (95% CI 7.1-8.0) and of undiagnosed diabetes 4.9% (4.6-5.3). Diabetes prevalence increased with increasing WBIG: countries with low-income economies (LICs) 6.7% (5.5-8.1), lower-middle-income economies (LMIs) 7.1% (6.6-7.6), and upper-middle-income economies (UMIs) 8.2% (7.5-9.0). Compared with no formal education, greater educational attainment was associated with an increased risk of diabetes across WBIGs, after adjusting for BMI (LICs RR 1.47 [95% CI 1.22-1.78], LMIs 1.14 [1.06-1.23], and UMIs 1.28 [1.02-1.61]). CONCLUSIONS: Among 29 LMICs, diabetes prevalence was substantial and increased with increasing WBIG. In contrast to the association seen in high-income countries, diabetes risk was highest among those with greater educational attainment, independent of BMI. LMICs included in this analysis may be at an advanced stage in the nutrition transition but with no reversal in the socioeconomic gradient of diabetes risk.