Perceived racism and discrimination and youth substance use in the United States - Intersections with sex and ethnicity.

OBJECTIVES: This study sought to examine associations between U.S. adolescents' perceived racism and discrimination (PRD) at school and current substance use. METHODS: Data were drawn from the Adolescent Behaviors and Experiences Survey (ABES), a probability sample of U.S. high school students in 2021 (n = 7705). Multivariable regression models were conducted to examine associations of PRD with current (past 30-day) use of tobacco products, marijuana, alcohol, and prescription opioid misuse. Interaction effects of PRD and demographic factors were tested. RESULTS: Among participants in the 2021 ABES, PRD was associated with higher odds of current use of tobacco (AOR = 1.3, p = 0.03), marijuana (AOR = 1.3, p = 0.03), alcohol (AOR = 1.2, p = 0.03), and misuse of prescription opioids (AOR = 1.6, p = 0.004). The effects of PRD on current tobacco and alcohol use differed by Hispanic and non-Hispanic adolescents (interaction effect = 0.007 and 0.01, respectively) with higher odds among Hispanic youth than among non-Hispanic counterparts. The associations of PRD and current tobacco use, marijuana use, alcohol use, and misuse of prescription opioids were moderated by sex with more pronounced effects on males than females. CONCLUSIONS: Efforts to promote awareness and create support environments that value diversity and inclusivity at school are needed to mitigate adolescent exposure to racism and discrimination.

Association of Race-Ethnicity Intersection with Disparities in Cigarette Smoking in US Adults.

BACKGROUND: Detailed estimates of disparities in cigarette smoking across single- and multi-race groups and their intersections with ethnicity are lacking. This study estimates the prevalence of self-reported current smoking among intersecting adult race-ethnicity groups in the United States. METHODS: The analysis uses 2018-2019 data from the Tobacco Use Supplement - Current Population Supplement (TUS-CPS; n=137,471). Self-reported Hispanic origin and race were recoded into 19 mutually-exclusive race by ethnicity intersecting groups. Weighted race-ethnicity group smoking prevalence were compared to the overall population prevalence and one another. RESULTS: Compared to the US population current smoking prevalence (11.4% [95% CI=11.2%-11.6%]), smoking was particularly higher in non-Hispanic American Indian/Alaska Native (AI/AN) groups (20.7% [95% CI=17.8%-24.0%]) and non-Hispanic multiracial AI/AN/White (24.4% [95% CI = 20.3%-29.1%]) and AI/AN/Black (22.4% [95% CI = 14.4%-33.2%]) groups. Non-Hispanic single-race Asian (5.0% [95% CI = 4.4%-5.6%]) and Hispanic single-race White (7.2% [95% CI = 6.7%-7.7%]) smoking prevalence undercut the overall US population prevalence. In pairwise comparisons, smoking prevalence was higher in various non-Hispanic single- and multi-race AI/AN groups than non-AI/AN groups and was lower in various Hispanic groups than non-Hispanic groups. CONCLUSION: Smoking prevalence disparities are not monolithic across complex diversity of race and ethnicity in the US. Accurate identification of priority populations in need of targeted tobacco control efforts may benefit by acknowledging multinomial heterogeneity across intersecting racial and ethnic identities. IMPLICATION: Understanding racial and ethnic disparities in cigarette smoking can inform national strategies for reducing health inequities. This study examines cigarette smoking disparities among 19 adult intersecting race-ethnicity groups in the United States using the 2018-2019 TUS-CPS data. Results show higher smoking rates in some non-Hispanic American Indian/Alaska Native and Black groups, while lower rates are seen in Asian and Hispanic individuals. These findings emphasize the need for disaggregated data to tackle smoking disparities and guide targeted prevention efforts.

Biomarkers of metal exposure in adolescent e-cigarette users: correlations with vaping frequency and flavouring.

BACKGROUND: Youth vaping poses a significant public health concern as metals have been detected in e-cigarette aerosols and liquids. This study investigated factors associated with biomarkers of metal exposure. METHODS: Data were drawn from Wave 5 of the Population Assessment of Tobacco and Health (PATH) Study Youth Panel, a nationally representative sample of US adolescents aged 13-17 years. Urinary biomarkers of exposure to cadmium, lead, and uranium were assessed by vaping frequency (occasional (1-5 days), intermittent (6-19 days), and frequent (20+ days)) in the past 30 days and flavour type (menthol/mint, fruit, and sweet). RESULTS: Among 200 exclusive e-cigarette users (median age 15.9 years, 62.9% female), 65 reported occasional use, 45 reported intermittent use, and 81 reported frequent use. The average number of recent puffs per day increased exponentially by vaping frequency (occasional: 0.9 puffs, intermittent: 7.9 puffs, frequent: 27.0 puffs; p=0.001). Both intermittent (0.21 ng/mg creatinine) and frequent users (0.20 ng/mg creatinine) had higher urine lead levels than occasional users (0.16 ng/mg creatinine). Frequent users also had higher urine uranium levels compared with occasional users (0.009 vs 0.005 ng/mg creatinine, p=0.0004). Overall, 33.0% of users preferred using menthol/mint flavours, 49.8% fruit flavours, and 15.3% sweet flavours. Sweet flavour users had higher uranium levels compared with menthol/mint users (0.009 vs 0.005 ng/mg creatinine, p=0.02). CONCLUSIONS: Vaping in early life could increase the risk of exposure to metals, potentially harming brain and organ development. Regulations on vaping should safeguard the youth population against addiction and exposure to metals.

Biomarkers of Toxic Exposure and Oxidative Stress Among U.S. Adult Users of Premium Cigar Versus Other Cigar Subtypes: 2013-2019.

INTRODUCTION: Cigars are currently the second-highest-used combustible tobacco product among U.S. adults, but knowledge about health effects of premium cigars versus other cigar subtype use is limited. AIMS AND METHODS: This study analyzed the biospecimen data (n = 31 875) from Waves 1-5 of the Population Assessment of Tobacco and Health Study, collected during 2013-2019. Multivariable generalized estimation equations, accounting for within-person clustering, were conducted to examine differences in urine biomarkers of exposure (BOE) from five classes of harmful and potentially harmful constituents along with a biomarker of oxidative stress (urine 8-isoprostane) among exclusive users of premium cigars versus other exclusive cigar subtypes (ie, non-premium large cigars, cigarillos, and filtered cigars), cigarettes, and non-tobacco users. RESULTS: In comparison to non-tobacco users, exclusive premium cigar users had higher geometric mean concentrations of the nicotine metabolite cotinine (5.8 vs. 0.5ng/mg, p < .0001), tobacco-specific nitrosamine (TSNA) (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL): 7.8 vs. 1.3pg/mg, p < .0001), and volatile organic compound (VOC) (N-Acetyl-S-(2-cyanoethyl)-L-cysteine (CYMA, acrylonitrile): 4.7 vs. 1.6ng/mg, p < .0001). Exclusive premium cigar users were less likely to be daily users than other tobacco user groups and had comparable BOEs with exclusive non-premium large cigar users but generally lower BOEs than exclusive cigarillo, filtered cigar, and cigarette smokers. Daily exclusive premium cigar users had similar nicotine and TSNA exposure but lower exposure to polycyclic aromatic hydrocarbons and volatile organic compounds than exclusive cigarillo and filtered cigar users. CONCLUSIONS: Premium cigar use exhibits different exposure to toxicants from other cigar subtype users. Regulations of premium cigars need to formalize product definition and take the population's health effects into consideration. IMPLICATIONS: This population study provides important information on BOE and potential harm with premium cigar use and its potential health effects. At present, premium cigars appear to pose a relatively low overall population health risk due to low frequency of use. However, future regulation of other tobacco products might change the landscape of premium cigar use and alter the overall health impact.

Reasons for E-cigarette Use, Vaping Patterns, and Cessation Behaviors Among US Adolescents.

INTRODUCTION: This study sought to examine reasons for youth e-cigarette use in association with vaping patterns and cessation behaviors. AIMS AND METHODS: A national representative sample of current (past 30-day) e-cigarette users in grades 6-12 was analyzed using the National Youth Tobacco Survey (NYTS), conducted from January to March 2020. An exploratory oblique factor analysis using a rotated pattern matrix to select salient variable-factor relationships yielded four subscales related to reasons for youth e-cigarette use. Multivariate logistic regressions were performed to assess the associations of each subscale with vaping patterns (frequent e-cigarette use, dual use of e-cigarettes and other tobacco products) and vaping cessation behaviors (intention to quit vaping and past-year quit attempts). RESULTS: The 2020 NYTS sampled 180 schools with 1769 current e-cigarette users. Four main reasons for vaping were identified through factor analysis, including (1) replacing cigarettes, (2) product characteristics [eg, flavors, concealability, and vape tricks], (3) family/friend use, and (4) curiosity. Curiosity was associated with lower odds of frequent e-cigarette use (adjusted odds ratio [AOR] = 0.5, p < .0001) and dual use of e-cigarettes and other tobacco products (AOR = 0.6, p = .01) but higher odds of intention to quit (AOR = 1.2, p = .26) and past year quit attempts (AOR =1.5, p = .01). Vaping due to product characteristics was associated with higher odds of frequent e-cigarette use (AOR = 1.7, p < .0001) and lower odds of intention to quit (AOR = 0.3, p < .0001) and past year quit attempts (AOR = 0.9, p = .01). CONCLUSIONS: Adolescents vape for various reasons that follow distinct patterns and user characteristics. Overall, interventions tailored to address heterogeneous reasons for vaping may help optimize the reduction in youth e-cigarette use. IMPLICATIONS: E-cigarettes have surpassed cigarettes and become the most commonly used tobacco product by US youths. Adolescents choose to vape for different reasons. This study examined reasons for youth e-cigarette use and their associations with vaping patterns and cessation behaviors. The product characteristics factor (eg, flavors, concealability, and vape tricks) was associated with more frequent e-cigarette use and lower odds of cessation behaviors, suggesting a need for flavor bans and product design regulation.

Randomised experiment for the effect of 'Tobacco-Free Nicotine' messaging on current e-cigarette users' perceptions, preferences and intentions.

BACKGROUND: It is unclear whether emerging synthetic tobacco-free nicotine superiority messages such as 'better flavor and better experience' and 'no residual impurities of tobacco-derived nicotine' may impact consumer perception and product choice between synthetic and tobacco-derived nicotine vaping products. METHODS: Through a 2022 online survey of current e-cigarette users, we identified synthetic nicotine never users for randomisation into an embedded between-subjects experiment. The test group (n=186) viewed a tobacco-free nicotine message versus no message control (n=168). Multivariable regressions assessed messaging effects on three comparative measures between tobacco-free and tobacco-derived nicotine: harm perception, purchase intention and willingness to pay. RESULTS: Participants (n=354; age, mean (SD)=34.6 (11.1) years old) were recruited from geographically diverse regions with 27.7% rural residents. The overall sample comprised 44.1% females, 73.5% non-Hispanic white and 71.8% daily e-cigarette users. Sociodemographics and tobacco use status were not significantly different between two randomised groups. The test group (vs control) reported a higher intention to use tobacco-free than tobacco-derived nicotine vaping products (adjusted OR (AOR)=2.4, 95% CI 1.3 to 4.4, p=0.006) and willingness to pay more for tobacco-free nicotine vaping products (AOR=2.6, 95% CI 1.2 to 5.8, p=0.02). Urban (vs rural) synthetic-naïve vapers had lower harm perception (AOR=2.0, 95% CI 1.1 to 3.6, p=0.02) and higher intention to use tobacco-free than tobacco-derived nicotine vaping products (AOR=2.2, 95% CI 1.1 to 4.5, p=0.04); infrequent vapers were more willing to pay more for tobacco-free nicotine vaping products (AOR=1.1, 95% CI 1.03 to 1.17, p=0.002). CONCLUSION: Tobacco-free nicotine marketing message may prompt the transition to and promote a price premium for such products. With the proliferation of products in the market, comprehensive regulation of emerging synthetic vaping products is needed.

'Ice' flavoured e-cigarette use among young adults.

BACKGROUND: 'Ice' e-cigarette flavours-marketed as a combination of fruity/sweet and cooling flavours (eg, 'blueberry ice' or 'melon ice')-recently entered the US market. The prevalence and correlates of ice flavoured e-cigarette use in young adults are unknown. METHODS: This cross-sectional study of a Los Angeles, California, USA, cohort analysed data from the past 30-day e-cigarette (current) users (n=344; M (SD)=21.2 (0.4) years old) who completed web-based surveys from May-August 2020. The exposure variable was self-reported e-cigarette flavour used most often in the past month (menthol/mint, fruit/sweet or ice). Outcomes included self-reported combustible tobacco use, vaping dependence symptoms, frequency of use and device type used. RESULTS: Among current e-cigarette users, 48.8% reported using ice flavours most often, 33.7% predominately used fruit/sweet and 17.4% used menthol/mint. Using primarily ice-flavour was associated with reporting more past-30-day vaping days (vs menthol/mint: b=4.4, 95% CI (1 to 7.7); vs fruit/sweet: b=3.6, 95% CI (0.8 to 6.4)) and more episodes per vaping day versus fruit/sweet users (b=2.4, 95% CI (0.5 to 4.3)). Ice-flavour users were less likely than menthol/mint users to use JUUL/cartridge-based rechargeable (OR=0.1, 95% CI (0.03 to 0.45)) and more likely than sweet/fruit users to use disposable non-cartridge (OR=3.9, 95% CI (2.1 to 7.4)) devices than refillable/rechargeable tank/pen or other devices. Ice users had greater odds of past 30-day combustible tobacco use versus menthol/mint users (OR=2.7, 95% CI (1.3 to 5.7)) and vaping dependence symptoms than versus sweet/fruit users (OR=2.6, 95% CI (1.5 to 4.4)). CONCLUSION: Young adult use of ice flavoured e-cigarettes may be common and positively associated with combustible tobacco use, nicotine vaping frequency and dependence and use of disposable e-cigarette devices. Further study of the prevalence, determinants and health effects of ice flavoured e-cigarette use is warranted.

A review of bidimensional acculturation and STI/HIV-related sexual risk behaviours among Hispanic youth.

A growing body of research suggests that acculturation may play a role in the disproportionate likelihood of sexual risk behaviour and STI/HIV infection among Hispanic youth in the USA. We systematically reviewed the relationship between acculturation and STI/HIV-related sexual risk behaviour among Hispanic youth aged 13-24 by reviewing studies that have used a bidimensional acculturation approach. Electronic databases were searched with the searches limited to articles published in 1992 when the concept of bidimensional acculturation was introduced or later. Two independent researchers screened the full data set to assess eligibility. Six studies were included. Three studies used cross-sectional data, while the other three used longitudinal data. We discovered that sexual risk behaviours differed by Hispanic youth acculturation types and were moderated by gender. We found that Hispanic acculturated youth had lower odds of having multiple sex partners than US acculturated youth. However, the relationship between acculturation and condom use yielded contradictory results and we could find no report on bi-culturation and sexual behaviour. Additional research is needed to explore whether adopting both US and Hispanic-heritage cultures at the same time may reduce or increase the odds of engaging in sexual risk behaviour among Hispanic youth in the USA.

Patterns and mediators of racial and ethnic disparities in COVID-19 vaccine hesitancy among young adults.

COVID-19 vaccines have been available for over a year, yet 26% of U.S. young adults remain unvaccinated. This study examines racial and ethnic disparities in young adult vaccine hesitancy and attitudes/beliefs that mediate disparities in vaccine hesitancy. Young adults (n = 2041;Mean[SD]:21.3[0.7] years-old) from a Los Angeles, CA, USA cohort were surveyed online in January-May 2021 and classified as vaccine hesitant (those who reported "Not at all likely"/"Not very likely" /"Slightly likely" to get vaccinated) versus non-hesitant (those who reported "Moderately likely"/"Very likely"/"Definitely likely" to get vaccinated or already vaccinated). Multivariable logistic regression was performed to examine racial/ethnic disparities in vaccine hesitancy. Factor analysis was conducted to create three subscales toward vaccination: positive, negative, and lack-of-access beliefs. Mediation analyses were performed to assess pathways from attitude/belief subscales to racial disparities in vaccine hesitancy. Overall 33.0% of respondents reported vaccine hesitancy. Black vs. White young adults had a higher prevalence of vaccine hesitancy (AOR[95%CI] = 4.3[2.4-7.8]), and Asians vs. Whites had a lower prevalence (AOR[95%CI] = 0.5[0.3-0.8]). Mediators explained 90% of the Black (vs. White) disparity in vaccine hesitancy, including significant indirect effects through positive belief-reducing (ß = 0.23,p < .001) and negative belief-enhancing (ß = 0.02,p = .04) effects. About 81% of the Asian (vs. White) disparity in vaccine hesitancy was explained by the three combined subscales, including significant positive belief-reducing (ß = -0.18,p < .001) indirect effect. Substantial racial and ethnic disparities in young adult COVID-19 vaccine hesitancy were found, which were mediated by differences in attitudes and beliefs toward vaccination. Targeted education campaigns and messages are needed to promote equitable utilization of the effective vaccine.

Effectiveness of incentives to improve the reach of health promotion programs- a systematic review and meta-analysis.

The reach (i.e., enrollment, engagement, and retention) of health promotion evidence-based programs (EBPs) at the participant level has been challenging. Incentives based on behavioral economics may be used to improve EBP reach. We aimed to systematically review and synthesize the evidence of the effectiveness of incentives as a dissemination strategy to increase EBP reach. We conducted a literature search in PubMed, SCOPUS, EMBASE, Cochrane Review and Cochrane CENTRAL for articles published between January 2000 and March 2020 to identify incentive strategies used to increase program reach among health promotion EBPs. Inclusion criteria included studies published in English, experimental or quasi-experimental designs, comparison of incentive to non-incentive or control strategies, and reported on reach (n = 35 health promotion studies). Monetary incentives using cash and a fixed schedule of reinforcement were the most used incentive schemes (71%). Incentives alone or combined with other strategies as a multicomponent approach were effective in improving program enrollment, engagement, and retention. Specifically, incentive strategies were associated with higher odds of program enrollment (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.82-4.24; n = 10) and retention (OR, 2.54, 95% CI, 1.34-4.85; n = 9) with considerable heterogeneity (I2 = 94% and 91%, respectively). Incentives are a promising individual-level dissemination strategy to improve the reach of health promotion EBPs. However, understanding the optimal amount, type, frequency, and target of incentives, and how incentives fit in a multicomponent approach in different contexts requires further research.

First E-Cigarette Flavor and Device Type Used: Associations With Vaping Persistence, Frequency, and Dependence in Young Adults.

INTRODUCTION: Type of e-cigarette flavoring and device during first use might differentiate later e-cigarette use and dependence. This retrospective cross-sectional study examined associations of recalled first nicotine vaping device and flavor used with current vaping frequency/dependence. AIMS AND METHODS: A young adult cohort from Los Angeles, California, USA completed web-based surveys (N = 2553). Using cross-sectional data from 971 reporting ever vaping nicotine, multivariable hurdle regressions tested associations between recalled first flavor (fruit/sweet, menthol/mint, other) and device (Juul, disposable, mod, box, pod, pen, other) vaped with past-30-day vaping status (yes/no) and frequency (1-30 days), and with any vaping dependence symptoms (yes/no) and count (1-10 symptoms). RESULTS: The most common first-flavor was sweet (71%); the most common first-device was a vape pen (37%), then Juul (22%). First-flavor of mint/menthol (vs. other; adjusted odds ratio [AOR]: 2.22[95% CI = 1.16 to 4.25]), and first-device mod (AOR = 2.40[95% CI = 1.34 to 4.31]) and non-Juul pod (2.64[95% CI = 1.41 to 4.92]) (vs. pen) were associated with past-30-day vaping, and twice as many vaping days (adjusted rate ratios [ARRs] range: 1.96-2.12; ps < .05). First flavor of mint/menthol (vs. other; AOR: 1.95[95% CI = 1.003 to 3.79) and first device mod, box, non-Juul pod, and other (AORs range: 2.36-4.01; ps < .05) were associated with nicotine dependence. First device Juul, mod, box, and non-Juul pod were also associated with more dependence symptoms (ARRs range:1.38-1.59; ps < .05). CONCLUSIONS: Exposure to mint/menthol and certain devices (mod, box, Juul, and non-Juul pods) at first e-cigarette use may be associated with more frequent e-cigarette use and nicotine dependence symptoms in young adulthood. Mint/menthol and certain devices warrant consideration in regulation of e-cigarettes based on product characteristics. IMPLICATIONS: Characteristics (flavor and device type) of first e-cigarette product used were associated with higher usage and more dependence. Pending replication with prospective designs, the findings suggest certain flavors (mint/menthol) and devices (pods, mods) merit consideration in regulation because of their possible link with continued use and dependence among young people.

Disposable E-Cigarette Use Prevalence, Correlates, and Associations With Previous Tobacco Product Use in Young Adults.

INTRODUCTION: Novel, inexpensive disposable e-cigarettes widely sold in attractive flavors might be exempt from US federal regulations. To inform regulatory and public health priorities, this study examined young adult disposable e-cigarette use uptake among existing tobacco users versus non-users and possible use correlates that could be potential regulatory targets. AIMS AND METHODS: Prospective cohort data were analyzed in 2021. Among baseline (2018-2019) never disposable e-cigarette users (n = 1903; mean [SD]: 19.3 [0.8] years-old), we tested prospective associations of baseline tobacco product use with follow-up (2020) disposable e-cigarette use initiation, followed by stratified analyses distinguishing baseline exclusive and dual e-cigarette/combustible tobacco use. Exploratory cross-sectional associations of tobacco-related correlate with vaping frequency among current disposable users (n = 266) were tested. RESULTS: Follow-up ever disposable e-cigarette use initiation was higher among baseline former (22.1%) and current (50.2%) versus never (6.3%) rechargeable (non-disposable) e-cigarette users. In stratified analyses, follow-up disposable e-cigarette use initiation was 0% in baseline never-vaping exclusive current smokers, higher in baseline never-vaping former smokers versus never users of any tobacco product (18.2% vs. 5.7%; adjusted odds ratio [95% CI] = 3.9 [2.1-7.5]), and higher among baseline current dual users versus never-smoking exclusive current vapers (61.3% vs. 42.2%; adjusted odds ratio [95% CI] = 3.0 [1.5-6.0]). Among follow-up current disposable e-cigarette users (overall prevalence = 10.9%), using ice-flavored (vs. fruit/sweet-flavored) e-cigarettes (adjusted rate ratio [95% CI] = 1.5 [1.0-2.1]) and vaping dependence symptoms (adjusted rate ratio [95% CI] = 2.2 [1.5-3.2]) were cross-sectionally associated with more past-month disposable e-cigarette use days. CONCLUSIONS: Young adult disposable e-cigarette use was of appreciable prevalence, including among tobacco product never users and former smokers. Regulation of disposable e-cigarettes, including ice-flavored products, might benefit young adult health. IMPLICATIONS: Sales of disposable e-cigarette products increased significantly in the United States from 2019 to 2020. These products contain high nicotine concentrations and various flavors that may appeal to young people. This study provides the first evidence that disposable e-cigarette use may be common among young adults, including among tobacco product never users and former smokers. Frequency of disposable e-cigarette use was positively associated with using ice-flavored e-cigarettes and vaping dependence. Regulatory policies and enforcement strategies addressing disposable e-cigarettes merit consideration in young adult health policy and prevention priorities.

Online popularity of JUUL and Puff Bars in the USA: 2019-2020.

BACKGROUND: The US Food and Drug Administration (FDA) announced a flavour ban on cartridge-based e-cigarettes in January 2020. It is unclear whether e-cigarette users will switch to disposable vaping products with a variety of kids-appealing flavours available. METHODS: We performed piece-wise regression and autoregressive integrated moving average (ARIMA) algorithms to compare the relative search volume (RSV) of JUUL and Puff Bar (a disposable vaping product) using the 1-year Google Trends data from 24 February 2019 to 20 February 2020, separated by three events that may have spurred changes in RSV for each product. RESULTS: The RSV for JUUL was relatively stable before Trump Administration announced plans to ban flavoured e-cigarettes. After that, the RSV for JUUL dropped sharply (rate of change=-8.8 per week) from 11 September 2019 to 17 October 2019 when JUUL Labs announced to halt online sales of some flavoured products, and the RSV resumed the decreasing trend after FDA announced enforcement policy of cartridge-based e-cigarettes on 2 January 2020. In comparison, the RSV for Puff Bar started to increase after 11 September 2019 with a low rate of change (0.6) until 17 October 2019. After that, the increase in RSV for Puff Bar accelerated. The RSV of puff bars surpassed that of JUUL during the week of 2 February 2020. CONCLUSION: The popularity of Puff Bar on Google Search suggests that users may replace cartridge-based vaping products with disposable e-cigarettes in the circumvention of the partial flavour ban. Continuous surveillance and further assessment are needed to prevent potential loopholes in tobacco regulation.

Using place-based characteristics to inform FDA tobacco sales inspections: results from a multilevel propensity score model.

BACKGROUND: Conducting routine inspections for compliance with age-of-sale laws is essential to reducing underage access to tobacco. We seek to develop a multilevel propensity score model (PSM) to predict retail violation of sales to minors (RVSM). METHODS: The Food and Drug Administration compliance check of tobacco retailers with minor-involved inspections from 2015 to 2019 (n=683 741) was linked with multilevel data for demographics and policies. Generalised estimating equation was used to develop the PSM using 2015-2016 data to predict the 2017 RVSM. The prediction accuracy of the PSM was validated by contrasting PSM deciles against 2018-2019 actual violation data. RESULTS: In 2017, 44.3% of 26 150 zip codes with ≥1 tobacco retailer had 0 FDA underage sales inspections, 11.0% had 1 inspection, 13.5% had 2-3, 15.3% had 4-9, and 15.9% had 10 or more. The likelihood of having an RVSM in 2017 was higher in zip codes with a lower number of inspections (adjusted OR (aOR)=0.988, 95% CI (0.987 to 0.990)) and penalties (aOR=0.97, 95% CI (0.95 to 0.99)) and a higher number of violations (aOR=1.07, 95% CI (1.06 to 1.08)) in the previous 2 years. Urbanicity, socioeconomic status, smoking prevalence and tobacco control policies at multilevels also predicted retail violations. Prediction accuracy was validated with zip codes with the highest 10% of the PSM 3.4 times more likely to have retail violations in 2019 than zip codes in the bottom decile. CONCLUSION: The multilevel PSM predicts the RVSM with a good rank order of retail violations. The model-based approach can be used to identify hot spots of retail violations and improve the sampling plan for future inspections.

The Effects of the Affordable Care Act on Health Access Among Adults Aged 18-64 Years With Chronic Health Conditions in the United States, 2011-2017.

CONTEXT: The 2010 Patient Protection and Affordable Care Act (ACA) eliminated the restrictions on preexisting conditions for health care coverage. Little is known about the effects of the ACA on health care access among individuals with chronic health conditions. OBJECTIVE: To determine how the implementations of the ACA affected health care access for adults with chronic health conditions. DESIGN, SETTING, AND PARTICIPANTS: Data from respondents aged 18 to 64 years to the 2011-2017 nationally representative Behavioral Risk Factor Surveillance System (BFRSS) who reported preexisting chronic health conditions (n = 1 133 609). Multivariable logistic regression models were used to examine the changes in health care access from 2011-2013 (before the ACA) to 2015-2017 (after the ACA), overall and by sociodemographic groups. MAIN OUTCOMES MEASURES: Self-reported access to health care coverage, skipped doctor visits because of cost issues, and having a routine checkup in the past 12 months. RESULTS: The percentage of adults with chronic health conditions having no health care coverage declined from 19.7% before the ACA to 11.9% after the ACA (adjusted odds ratio [AOR] = 0.5], P < .001), the percentage of skipped doctor visits because of cost declined from 24.6% to 20.0% (AOR = 0.8, P < .001), and the percentage with an annual routine checkup increased from 69.6% to 72.5% (AOR = 1.1, P < .001). The improvements in health care access were pronounced across sociodemographic groups after the ACA, especially among some disadvantaged groups (ie, young adults, non-Hispanic Blacks and Hispanics, and those with low income and low education). However, substantial disparities in health care access persisted, especially among individuals with low socioeconomic status. CONCLUSIONS: This study identifies substantial improvements in health care access among adults with chronic health conditions after ACA implementation, especially among disadvantaged populations.

Racial Disparities of E-Cigarette Use Among US Youths: 2014‒2019.

Objectives To evaluate disparities in youth e-cigarette use patterns and flavor use by race/ethnicity over time. Methods We used data from the US 2014-2019 National Youth Tobacco Survey (NYTS) to examine trends in dual use (co-use of e-cigarettes and cigarettes or other tobacco products), occasional (≤ 5 days) versus frequent use (≥ 20 days) in the past 30 days, and flavor use among current (past-30-day) e-cigarette users (n = 13 178) across racial/ethnic groups (non-Hispanic Whites, non-Hispanic Blacks, Hispanics/Latinos, and non-Hispanic others). Results Among current e-cigarette users, dual use and occasional use decreased significantly from 2014 to 2019 across racial and ethnic groups except for non-Hispanic Blacks; frequent use and flavored e-cigarette use increased among non-Hispanic Whites, Hispanics/Latinos, and non-Hispanic others but not among non-Hispanic Blacks. In 2019, non-Hispanic Black e-cigarette users were more likely to report dual use (adjusted odds ratio [AOR] = 2.2; 95% confidence interval [CI] = 1.5, 3.2; P < .001) and occasional use of e-cigarettes (AOR = 3.7; 95% CI = 2.3, 5.9; P < .001) but less likely to report frequent use (AOR = 0.2; 95% CI = 0.1, 0.4; P < .001) and flavored e-cigarette use (AOR = 0.4; 95% CI = 0.3, 0.5; P < .001) than their White peers. Conclusions Youth e-cigarette use patterns differed considerably across racial/ethnic groups, and tailored strategies to address disparities in e-cigarette use are needed. (Am J Public Health. 2021;111(11):2050-2058. https://doi.org/10.2105/AJPH.2021.306448).

Youth Knowledge of Tobacco 21 and its Association With Intention to Use Tobacco.

BACKGROUND: Raising the minimum legal age (MLA) of tobacco sales from 18 to 21 (Tobacco 21 [T21]) has recently been implemented nationwide as a method to reduce tobacco use, but empirical data on youth knowledge of T21 policies and related pathways to tobacco use are limited. METHODS: Data were collected from the 2018 Kansas Communities That Care Student Survey. Knowledge of the MLA was compared between T21 and non-T21 regions using a quasi-experimental design. Logistic regression and mediation analysis were conducted to assess the association between knowledge of the MLA, influencing factors, and intention to use tobacco. RESULTS: Of 16 949 students (aged between 11 and 18) completing the T21 survey, fewer students responded correctly about the MLA in T21 than in non-T21 regions (37.4% vs. 46.3% responded correctly, 27.6% vs. 24.2% responded incorrectly, respectively). In T21 regions, Hispanics and students who support T21 were more likely to respond correctly about the MLA. Among current non-tobacco users in T21 regions, students who responded correctly about the MLA were less likely to report intention to use tobacco (adjusted odds ratio [AOR] = 0.7, 95% confidence interval [CI]: [0.6-0.8]) than those who responded incorrectly. The pathway from knowledge of the MLA to intention to use tobacco was significantly mediated by increased support for T21 (p = .002), perceived difficulty in accessing cigarettes (p = .042), and reduced susceptibility to peer influence (p = .027). CONCLUSIONS: Knowledge of the MLA was inversely associated with intention to use tobacco among youth. Educational campaigns to raise awareness and support for T21 among youth may improve the impact of T21 policies. IMPLICATIONS: This study examined youth knowledge of the MLA to purchase tobacco products, and whether knowledge of the MLA was associated with reduced intention to use tobacco. It also examined other influencing factors (eg, perceived support for T21) and potential mediation pathways linking knowledge of the MLA with intention to use tobacco. Given the nationwide adoption of T21, educational campaigns to promote knowledge of the policy may improve its impact.

A cluster-randomized field trial to reduce cesarean section rates with a multifaceted intervention in Shanghai, China.

BACKGROUND: Cesarean section (CS) rate has risen dramatically and stayed at a very high level in China over the past two to three decades. Given the short- and long-term adverse effects of CS, effective strategies are needed to reduce unnecessary CS. We aimed to evaluate whether a multifaceted intervention would decrease the CS rate in China. METHODS: We carried out a cluster-randomized field trial with a multifaceted intervention in Shanghai, China, from 2015 to 2017. A total of 20 hospitals were randomly allocated into an intervention or a control group. The intervention consisted of more targeted health education to pregnant women, improved hospital CS policy, and training of midwives/doulas for 8 months. The study included a baseline survey, the intervention, and an evaluation survey. The primary outcome was the changes of overall CS rate from the pre-intervention to the post-intervention period. A subgroup analysis stratified by the Robson classification was also conducted to examine the CS change among women with various obstetric characteristics. RESULTS: A total of 10,752 deliveries were randomly selected from the pre-intervention period and 10,521 from the post-intervention period. The baseline CS rates were 42.5% and 41.5% in the intervention and control groups, respectively, while the post-intervention CS rates were 43.4% and 42.4%, respectively. Compared with the control group, the intervention did not significantly reduce the CS rate (adjusted OR = 0.92; 95% CI 0.73, 1.15). Similar results were obtained in subgroup analyses stratified by the risk level of pregnancy, maternal age, number of previous CS, or parity. Scarred uterus and maternal request remained the primary reasons for CS after the interventions in both groups. The intervention did not alter the perinatal outcomes (adjusted change of risk score = - 0.06; 95%CI - 0.43, 0.31). CONCLUSIONS: A multifaceted intervention including more targeted prenatal health education, improved hospital CS policy, and training of midwives/doulas, did not significantly reduce the CS rate in Shanghai, China. However, our experience in implementing a multifaceted intervention may provide useful information to other similar areas with high CS use. TRIAL REGISTRATION: This trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn) (ChiCTR-IOR-16009041) on 17 August 2016.

A Longitudinal Study of Exposure to Tobacco-Related Toxicants and Subsequent Respiratory Symptoms Among U.S. Adults with Varying E-cigarette Use Status.

BACKGROUND: The link between e-cigarette use and subsequent development of respiratory diseases remains an open question. AIMS AND METHODS: A subset of a probability sample of U.S. adults from the Population Assessment of Tobacco and Health Study Waves 1 and 2 were selected for biospecimen analysis (n = 4614). Subjects were divided into three mutually exclusive groups at baseline: nonusers (n = 2849), exclusive e-cigarette users (n = 222), and poly e-cigarette/tobacco users (n = 1,543). Geometric mean concentrations of baseline biomarkers from five classes of harmful and potentially harmful constituents were reported. Multivariable linear regressions were conducted to examine the relationship between baseline biomarkers and subsequent respiratory symptoms among user groups. RESULTS: Baseline exclusive e-cigarette users (33.6%[confidence interval, CI: 26.7% to 41.4%]) and poly e-cigarette/tobacco users (50.8%[CI: 47.4% to 54.2%]) had higher prevalence of subsequent respiratory symptoms than nonusers (21.7%[19.2% to 24.4%]). As compared with nonusers, poly e-cigarette/tobacco users had higher concentrations in clinically relevant biomarkers at baseline than exclusive e-cigarette users. Among poly e-cigarette/tobacco users, baseline nicotine metabolites (TNE2, cotinine), tobacco-specific nitrosamine (NNAL), PAH (1-NAP, 3-FLU), and volatile organic compound (N-Acetyl-S-(2-carboxyethyl)-l-cysteine, N-acetyl-S-(2-cyanoethyl)-l-cysteine) were significantly higher among those reporting subsequent respiratory symptoms than those who did not. Among exclusive e-cigarette users, baseline NNAL was significantly higher among those reporting subsequent respiratory symptoms than those who did not. Within subjects with subsequent respiratory symptoms, NNAL was 2.5 times higher in exclusive e-cigarette users (10.7[6.5 to 17.5]) and 63.4 times higher in poly e-cigarette/tobacco users (199.6[176.7 to 225.4]) than nonusers (3.1[2.4 to 3.9]). CONCLUSIONS: E-cigarette use is associated with higher concentrations of known tobacco-related toxicants and risks of subsequent respiratory symptoms than nonusers. Poly e-cigarette/tobacco users exhibit higher risk than exclusive e-cigarette users. IMPLICATIONS: This longitudinal study identified positive associations between baseline urinary biomarkers of exposure to tobacco-related toxicants and increased risks of subsequent respiratory symptoms across varying e-cigarette use groups. E-cigarette use is associated with increased exposure to known tobacco-related toxicants, and certain toxicant exposure increases the risk of respiratory symptoms.

Hierarchical and Mediation Analysis of Disparities in Very Short Sleep among Sexual Minority Youth in the U.S., 2015.

BACKGROUND: Insufficient sleep is associated with increased risk of chronic diseases, substance use, and unintentional injuries. Little is known about the disparities in short sleep among sexual minority youth. METHODS: A nationally representative sample of U.S. students in grades 9-12 (n = 14,703) from the 2015 Youth Risk Behavior Survey was analyzed to examine the prevalence and risk factors of short sleep. Self-reported sleep duration (very short: ≤5 h, short: 6-7 h, normal: ≥8 h per day) were compared by sex group (male vs. female) and sexual orientation (heterosexual, gay, lesbian, bisexual, and unsure). RESULTS: Of all respondents, 88.8% were heterosexual/straight, 2.0% were lesbian or gay, 6.0% were bisexual, and 3.2% were unsure about their sexual identity. Bisexual and unsure girls (36.2%, 95% CI [31.3-41.0] and 33.7%, CI [25.6-41.8], respectively) had a higher prevalence of very short sleep duration than straight girls (19.8%, CI [18.3-21.4]). Gay and unsure boys (38.5%, CI [25.6-51.5] and 33.3%, CI [23.5-32.1], respectively) had a higher prevalence of very short sleep duration than straight boys (16.5%, CI [15.1-17.9]). The effects of sexual minority status on very short sleep duration attenuated when incrementally adjusting for influencing factors, and further analysis identified that feeling sad/hopeless had the largest standardized mediation effect. CONCLUSIONS AND RELEVANCE: Sexual minority adolescents had a higher prevalence of reporting very short sleep duration as compared to their straight peers, and the effects were mediated by influencing variables including demographic factors, substance use, excessive media use, and experiences of victimization/mental health problems.