Regional and Country Prevalence Estimates of Unsafe Sex Among Adolescents in 68 Low-Income and Middle-Income Countries.

Prioritizing adolescent health is a public health priority to achieve the sustainable development goals, including reducing the risk of unsafe sex. Data on unsafe sex have remained scarce among adolescents in low-and middle-income countries (LMICs). To estimate the prevalence of unsafe sex in LMICs, we conducted secondary data analysis on the Global School-based Student Health Surveys among 244,863 students aged 13-17 years from 68 countries across five World Health Organization regions. The overall prevalence of ever had sex was 16.2%. The highest to lowest regional prevalence estimation of ever had sex was 30.5% (28.9-32.1) in the Americas, 28.6% (26.8-30.4) in Africa, 10.9% (9.2-12.6) in the Eastern Mediterranean, 9.6% (8.8-10.5) in South-East Asia, and 8.0% (6.8-9.1) in the Western Pacific. The highest prevalence of sexual intercourse before age 14 and practicing sexual intercourse without condom use were 36.5% (34.5-38.5) and 32.2% (30.1-34.3) in Africa, respectively. Findings suggest that current interventions are inadequate in promoting the uptake of safe sexual behaviors and an urgent intervention is needed.

A systematic review of second-hand smoking mass media campaigns (2002-2022).

BACKGROUND: Second-hand smoking (SHS) increases the risk of chronic disease in adults and poses a serious health threat to children. Mass media campaigns are instrumental in raising awareness and reducing SHS exposure. There is a need to identify recent SHS mass media campaigns and assess their sustainability in terms of knowledge, attitudes, and behavioural changes. This systematic review summarises the characteristics and outcomes of mass media campaigns on SHS prevention. METHODS: PubMed, Embase, Web of Science, and grey literature were searched in November 2022 for SHS campaigns implemented between 2016 and 2022. The eligibility criteria included campaigns on the dangers or effects of SHS with any target group, dissemination medium, study design, or language. The database search identified 1,413 peer-reviewed titles, of which 82 full-texts were screened, with 14 meeting the eligibility criteria. The grey literature search identified 9,807 sources, of which 61 were included. We extracted data on the campaign characteristics, metrics, and smoking-related outcomes. The JBI critical appraisal tool was used to assess the risk of bias of the included studies. RESULTS: We found 73 SHS campaigns conducted between 2002 and 2022, across 50 countries. The campaigns reached 378 million people. The reported recall rates range from 8 to 76%. Of the 11 studies that reported smoking-related outcomes, 10 reported increased knowledge in understanding SHS risks (73-85%), five reported an increased prevalence of smoke-free homes, and two reported an increase in number of participants persuading others to quit smoking. Two studies reported a decrease in overall smoking, whereas three studies observed a reduction in smoking in the presence of children. CONCLUSION: The available data provide some support for the effectiveness of SHS campaigns in reducing smoking behaviours in homes and around children. However, the certainty of evidence was low due to the lack of a control group and the substantial heterogeneity in the outcomes assessed. Future campaigns need comprehensive evaluation and reporting to reduce publication bias.

The underbelly of E-cigarette advertising: regulating online markets on social media platforms.

Australia prohibits the sale of nicotine-vaping products unless prescribed by medical practitioners. Significant policy reforms were announced on the 28th of November 2023 including a ban on single-use disposable vapes with and without nicotine, and the removal of the personal importation scheme. Despite stringent regulations, loopholes exist such that e-cigarette vendors are getting around it, and online markets provide a route to do so. We discuss strategies used by vendors to covertly market e-cigarettes online through social media. In this perspective, we highlight three proposed policies to strengthen social media regulations that may be feasible to implement. Our proposed strategies to regulate e-cigarette product listings on social media involve implementing robust age verification measures, enhancing the system for flagging and reporting prohibited content, and developing a more effective system to identify and flag content related to e-cigarettes.

Randomized effectiveness-implementation trial of dialectical behavior therapy interventions for young people with borderline personality disorder symptoms.

OBJECTIVES: Dialectical behavior therapy (DBT) is an evidence-based treatment for people with emerging borderline personality disorder (BPD). In "real world" clinical settings, standard DBT is resource intensive. Emerging evidence suggests that group-based DBT skills training alone can lead to promising outcomes. This hybrid type 1 effectiveness-implementation trial directly compared the effectiveness of an 8-week group DBT-skills training program and a 16-week DBT-informed program including individual treatment and group-based skills training. METHODS: This pragmatic trial employed a staggered, parallel-groups design. We recruited 104 participants, aged 16-25 years, with emotion dysregulation or emerging BPD symptoms. Participants were randomized to receive either program at a youth mental health service located in the Gold Coast, Australia. Data was collected via online surveys at baseline, 8-week, 16-week, and 24-week follow-up. Mixed effect linear models compared groups on the primary outcomes of emotion dysregulation and BPD symptoms, and secondary outcomes of suicidal ideation, coping skills, depression, anxiety, and stress. RESULTS: Across groups there were significant and sustained improvements relating to emotion dysregulation, BPD symptoms, stress, depression, and emotion-focused coping; but not suicide risk, anxiety, or task-focused coping. There was no significant time by group differences between the 8-week and 16-week interventions on any primary or secondary outcome. CONCLUSION: The more intensive mode of delivering DBT was not more effective than the brief group-based skills training. Both interventions resulted in significant improvements across both primary and most secondary outcomes. These results have implications for clinical practice regarding length and intensity of DBT treatment in young people.

Vaping on TikTok: a systematic thematic analysis.

INTRODUCTION: The rising popularity of TikTok among adolescents may influence their awareness and perceptions of e-cigarette use via user-generated content. This study aimed to examine how e-cigarette/vaping-related videos are portrayed on TikTok. METHODS: The nine most viewed hashtag based keywords were used to identify popular e-cigarette/vaping-related videos on TikTok (n=1000) from its inception (earliest upload date: January 2019) to November 2020. Five researchers independently coded the number of views, likes, user category and theme. RESULTS: A final sample of 808 e-cigarette/vaping-related videos that met study criteria were included. Collectively, these videos were viewed over 1.5 billion times, with a median view count of 1 000 000 (range 112 900-78 600 000) and a median 'likes' count of 143 000 (range 10 000-1 000 000). A majority of the videos portrayed e-cigarette use positively (63%; collectively viewed over 1.1 billion times). Neutral depictions of e-cigarette use were viewed a total of 290 million times (24%) and negative depictions of e-cigarettes were viewed a total of 193 million times (13%). The video themes included (not mutually exclusively): 'comedy and joke' (52%; total of 618 million views), 'lifestyle and acceptability' (35%; 459 million), 'marketing' (29%; 392 million), 'vaping tricks' (20%; 487 million), 'nicotine and addiction' (20%; 194 million), 'creativity' (16%; 322 million) and 'warning' (11%; 131 million). CONCLUSION: Our findings illustrated that positively framed e-cigarette and vaping-related postings available without age restrictions on TikTok-a rising video-sharing platform that is popular among adolescents-have been viewed many times. Effective age restrictions are needed to reduce adolescents' potential exposure to videos that portray vaping positively.

Efficacy of smokeless tobacco for smoking cessation: a systematic review and meta-analysis.

OBJECTIVE: Smoking remains prevalent in many countries despite rigorous tobacco control strategies. The use of Swedish snus, a type of low-nitrosamine smokeless tobacco, has been promoted as a tobacco harm reduction strategy. DATA SOURCES AND STUDY SELECTION: Three databases were searched for studies that assessed the effectiveness of snus in promoting smoking abstinence. A total of 28 studies were reviewed (5 randomised controlled trials (RCTs), 7 longitudinal and 16 cross-sectional studies). DATA EXTRACTION: Separate meta-analyses were conducted by study type, pooling effect estimates where outcome measures and design were sufficiently comparable. Study details and quality assessment (Risk of Bias 2 for RCTs, Newcastle-Ottawa Scale for observational studies) are provided for each study. DATA SYNTHESIS: While the meta-analysis of RCTs did not show a significant association between snus use and smoking cessation (risk ratio (RR)=1.33, 95% CI 0.71 to 2.47 and RR=0.62, 95% CI 0.27 to 1.41), the results of the meta-analysis of longitudinal cohort studies (RR=1.38, 95% CI 1.05 to 1.82, p=0.022) and cross-sectional studies (OR=1.87, 95% CI 1.29 to 2.72, p=0.001) indicated that use of snus was associated with an increased likelihood of quitting or having quit smoking. There was significant heterogeneity in the cross-sectional studies, and leave-one-out analysis indicated that the longitudinal cohort results were driven by one study. Most studies examined were subject to an elevated risk of bias. CONCLUSION: There is weak evidence for the use of snus for smoking cessation. Better RCTs and longitudinal studies are needed; meanwhile, existing cessation aids may be better placed than snus to promote abstinence.

Predicting the long-term effects of electronic cigarette use on population health: a systematic review of modelling studies.

OBJECTIVE: To systematically review and synthesise the findings of modelling studies on the population impacts of e-cigarette use and to identify potential gaps requiring future investigation. DATA SOURCE AND STUDY SELECTION: Four databases were searched for modelling studies of e-cigarette use on population health published between 2010 and 2023. A total of 32 studies were included. DATA EXTRACTION: Data on study characteristics, model attributes and estimates of population impacts including health outcomes and smoking prevalence were extracted from each article. The findings were synthesised narratively. DATA SYNTHESIS: The introduction of e-cigarettes was predicted to lead to decreased smoking-related mortality, increased quality-adjusted life-years and reduced health system costs in 29 studies. Seventeen studies predicted a lower prevalence of cigarette smoking. Models that predicted negative population impacts assumed very high e-cigarette initiation rates among non-smokers and that e-cigarette use would discourage smoking cessation by a large margin. The majority of the studies were based on US population data and few studies included factors other than smoking status, such as jurisdictional tobacco control policies or social influence. CONCLUSIONS: A population increase in e-cigarette use may result in lower smoking prevalence and reduced burden of disease in the long run, especially if their use can be restricted to assisting smoking cessation. Given the assumption-dependent nature of modelling outcomes, future modelling studies should consider incorporating different policy options in their projection exercises, using shorter time horizons and expanding their modelling to low-income and middle-income countries where smoking rates remain relatively high.

Study protocol of the Our Futures Vaping Trial: a cluster randomised controlled trial of a school-based eHealth intervention to prevent e-cigarette use among adolescents.

BACKGROUND: Effective and scalable prevention approaches are urgently needed to address the rapidly increasing rates of e-cigarette use among adolescents. School-based eHealth interventions can be an efficient, effective, and economical approach, yet there are none targeting e-cigarettes within Australia. This paper describes the protocol of the OurFutures Vaping Trial which aims to evaluate the efficacy and cost-effectiveness of the first school-based eHealth intervention targeting e-cigarettes in Australia. METHODS: A two-arm cluster randomised controlled trial will be conducted among Year 7 and 8 students (aged 12-14 years) in 42 secondary schools across New South Wales, Western Australia and Queensland, Australia. Using stratified block randomisation, schools will be assigned to either the OurFutures Vaping Program intervention group or an active control group (health education as usual). The intervention consists of four web-based cartoon lessons and accompanying activities delivered during health education over a four-week period. Whilst primarily focused on e-cigarette use, the program simultaneously addresses tobacco cigarette use. Students will complete online self-report surveys at baseline, post-intervention, 6-, 12-, 24-, and 36-months after baseline. The primary outcome is the uptake of e-cigarette use at 12-month follow-up. Secondary outcomes include the uptake of tobacco smoking, frequency/quantity of e-cigarettes use and tobacco smoking, intentions to use e-cigarettes/tobacco cigarettes, knowledge about e-cigarettes/tobacco cigarettes, motives and attitudes relating to e-cigarettes, self-efficacy to resist peer pressure and refuse e-cigarettes, mental health, quality of life, and resource utilisation. Generalized mixed effects regression will investigate whether receiving the intervention reduces the likelihood of primary and secondary outcomes. Cost-effectiveness and the effect on primary and secondary outcomes will also be examined over the longer-term. DISCUSSION: If effective, the intervention will be readily accessible to schools via the OurFutures platform and has the potential to make substantial health and economic impact. Without such intervention, young Australians will be the first generation to use nicotine at higher rates than previous generations, thereby undoing decades of effective tobacco control. TRIAL REGISTRATION: The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12623000022662; date registered: 10/01/2023).

Promotions of vaping products near schools and central business district: A descriptive cross-sectional study.

ISSUES ADDRESSED: The increase of youth vaping in Australia has raised concerns, especially with increasing promotions of vaping products. We observed the visibility of vaping products near high-adolescent-traffic areas. METHODS: We examined stores within walking distance of high schools and the central business district (CBD) in Brisbane, Australia, observing the number and proportion of stores selling or displaying vaping products. Using an observational approach, we analysed advertisements and open displays of vaping products at tobacconists, vape stores, and convenience stores. RESULTS: We identified 61 eligible stores located near schools or in the CBD. Overall, 20% of stores displayed vaping products externally, with higher proportions among vape stores (78%) compared to tobacconists (36%). Additionally, 46% of stores had visible interior displays, with vape stores (89%) displaying them more frequently than tobacconists (71%). Among the 28 stores displaying vaping products, 57% included warnings, one store featured only flavoured products, and 25% showcased nicotine-containing products. Youth-appealing features were present in all but one store, with cartoons (61%) as the most common feature. CONCLUSION: Vapes were displayed near high schools and in the city, often featuring youth-appealing features, such as colours and flavours. SO WHAT?: The exposure to such promotions could normalise vaping and contribute to increased youth uptake. Continued monitoring of vaping product promotions is essential, particularly considering recent policy changes.

Mood and Anxiety Symptoms in Persons Taking Prescription Opioids: A Systematic Review with Meta-Analyses of Longitudinal Studies.

OBJECTIVE: To review evidence from longitudinal studies on the association between prescription opioid use and common mood and anxiety symptoms. DESIGN: We conducted a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. METHODS: We searched PubMed, Embase, and PsycINFO for search terms related to opioids AND (depression OR bipolar OR anxiety OR post-traumatic stress disorder [PTSD]). Findings were summarized narratively, and random-effects meta-analyses were used to pool effect sizes. RESULTS: We identified 10,290 records and found 10 articles that met our inclusion criteria. Incidence studies showed that people who used prescription opioids had an elevated risk of any mood outcome (adjusted effect size [aES] = 1.80 [95% confidence interval = 1.40-2.30]) and of an anxiety outcome (aES = 1.40 [1.20-1.80]) compared with those who did not use prescription opioids. Associations with depression were small and not significant after adjustment for potential confounders (aES = 1.18 [0.98-1.41]). However, some studies reported an increased risk of depressive symptoms after increased (aES = 1.58 [1.30-1.93]) or prolonged opioid use (aES = 1.49 [1.19-1.86]). CONCLUSIONS: Mental health should be considered when opioids are prescribed because some patients could be vulnerable to adverse mental health outcomes.

Changes in patterns of youth multiple tobacco and/or e-cigarette product use in the US between 2014 and 2020: a multiple-group latent class analysis.

BACKGROUND: Multiple tobacco and e-cigarette product (MTEP) use, the concurrent use of two or more different types of tobacco and/or e-cigarettes products, is common among young people in the US. Changes in patterns of MTEP use among US youth between 2014 and 2020 were identified and the determinants of MTEP use were examined. METHODS: Four years of repeated cross-sectional data from the US National Youth Tobacco Survey of middle and high school students from grade 6 to 12 (Ntotal=77 402). Multigroup latent class analysis (LCA) was applied to the data series to allow for simultaneous identification of MTEP use patterns between 2014 and 2020. Logistic regression was used to predict class membership on demographic and tobacco-related variables. FINDINGS: Over the 7-year period, LCA identified three patterns: minimal/non-users (MNU: ~89.8%), mostly occasional e-cigarette and cigarette users (MOEC: ~9%) and polytobacco users (POLY: ~1.2%). From 2014 to 2020, MNU increased from 86.4% to 92% (p<0.05), while MOEC and POLY decreased from 11.2% to 7.9% and from 2.4% to 0.1%, respectively. The probability of regular e-cigarette use increased from 0 to 2.3% among MNU, 6% to 31.9% among MOEC and 29.6% to 67.6% among POLY (p<0.05). In binomial logistic regression, being male, in high school, non-heterosexual, living with someone who uses tobacco at home, having cognitive difficulties, having lower perceptions of tobacco's danger and exposure to tobacco marketing were associated with greater odds of MOEC and POLY than MNU. CONCLUSIONS: There was an increase in regular e-cigarette use in all three classes, but a corresponding decrease in the proportion of MTEP use. Public health interventions to discourage uptake of e-cigarettes, such as tighter restrictions on marketing to minors, are warranted and there is a need to consider disparities in the determinants of MTEP use.

A Systematic Review of Trends in US Attitudes toward Cannabis Legalization.

METHODS: A systematic search was conducted for publications in PubMed, EMBASE, and PsycINFO up to October 2019. Six studies with a regionally or nationally representative adult US-based populations were included. A secondary analysis was conducted using data from the National Survey of Drug Use and Health. Hierarchical age-period-cohort analysis assessed the trends in perceived harmfulness and availability of cannabis between 1996 and 2018. Ecological comparisons were made between these perceptions and support for cannabis legalization over time. RESULTS: A steep growth in support for cannabis legalization began in the 1990s and continued to grow in a relatively linear manner. Most people developed more liberal views, with no evidence that changes within any one sociodemographic group was disproportionately responsible for the overall attitudinal change. Increases in the proportion of people who use cannabis, non-religious population and political liberalism may partially explain the increased support for legalization. The decline in perceived harmfulness of cannabis, as reflected in the media, may have contributed to the increased support for legalization. However, perceptions of the availability of cannabis remained stable despite significant relaxations in cannabis regulations. CONCLUSIONS: The US population has become more accepting of cannabis legalization. The attitudinal change is related to changes in the perceived risks and benefits of cannabis use, influenced by broader political and cultural changes over the study period.

A longitudinal cohort study observed increasing perfectionism and declining resilience, ambiguity tolerance and calling during medical school which is not explained by student personality.

BACKGROUND: The medical degree is a long and challenging program, not just academically, but regarding the expectations engrained in the culture of medical education. The recent proliferation of literature on the poor mental well-being among students suggests a dilemma that often lays the onus on students to improve their health. The link between personality and vulnerability to psychological distress is acknowledged. This longitudinal study looked at personality in 1st-year and changes in levels of certain psychological traits, as proxy indicators of well-being, in 4th-year. We aimed to determine to what extent changes in psychological traits over time may be attributed to personality. METHODS: Medical students completed surveys at the start (1st-year: baseline) and finish (4th-year: follow-up) of their medical degree (N = 154). Temperament and character personality, Perfectionism-Concern over mistakes (CoM), Ambiguity Tolerance, Resilience, Calling to medicine, and demographic variables were measured. Paired t-tests compared changes in psychological traits from baseline to follow-up. Linear regression examined whether personality at baseline would predict levels of psychological traits at follow-up. RESULTS: The temperament and character profile of the sample was as expected, and congruent with previous studies, which describe a mature personality. Over four years, levels of Perfectionism-CoM significantly increased, while Resilience, Ambiguity Tolerance and Calling to medicine decreased. Harm Avoidance, Persistence, Self-Directedness and Cooperativeness at baseline significantly predicted levels of these traits at follow-up, but effect sizes were weak. Correlations were in the expected direction and weak. CONCLUSIONS: Most commencing medical students, including this cohort, have mature personalities with an industrious temperament and an adaptable character. Yet over four years of medicine, Ambiguity Tolerance, Resilience and Calling declined while Perfectionism-CoM, already elevated at baseline, continued to increase to the final year. Of concern is the increased perfectionism that is strongly associated with poor mental health and psychological distress. The findings suggest a closer look at the entirety of the education environment and how its culture, including secondary school and the medical school admissions processes may influence these trends in students. As medical educators we should question why the pathway to medicine places such unhealthy pressure on students who aspire to be doctors.

Depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies.

The link between depression and anxiety status and cancer outcomes has been well-documented but remains unclear. We comprehensively quantified the association between depression and anxiety defined by symptom scales or clinical diagnosis and the risk of cancer incidence, cancer-specific mortality, and all-cause mortality in cancer patients. Pooled estimates of the relative risks (RRs) for cancer incidence and mortality were performed in a meta-analysis by random effects or fixed effects models as appropriate. Associations were tested in subgroups stratified by different study and participant characteristics. Fifty-one eligible cohort studies involving 2,611,907 participants with a mean follow-up period of 10.3 years were identified. Overall, depression and anxiety were associated with a significantly increased risk of cancer incidence (adjusted RR: 1.13, 95% CI: 1.06-1.19), cancer-specific mortality (1.21, 1.16-1.26), and all-cause mortality in cancer patients (1.24, 1.13-1.35). The estimated absolute risk increases (ARIs) associated with depression and anxiety were 34.3 events/100,000 person years (15.8-50.2) for cancer incidence and 28.2 events/100,000 person years (21.5-34.9) for cancer-specific mortality. Subgroup analyses demonstrated that clinically diagnosed depression and anxiety were related to higher cancer incidence, poorer cancer survival, and higher cancer-specific mortality. Psychological distress (symptoms of depression and anxiety) was related to higher cancer-specific mortality and poorer cancer survival but not to increased cancer incidence. Site-specific analyses indicated that overall, depression and anxiety were associated with an increased incidence risks for cancers of the lung, oral cavity, prostate and skin, a higher cancer-specific mortality risk for cancers of the lung, bladder, breast, colorectum, hematopoietic system, kidney and prostate, and an increased all-cause mortality risk in lung cancer patients. These analyses suggest that depression and anxiety may have an etiologic role and prognostic impact on cancer, although there is potential reverse causality; Furthermore, there was substantial heterogeneity among the included studies, and the results should be interpreted with caution. Early detection and effective intervention of depression and anxiety in cancer patients and the general population have public health and clinical importance.

Clinical correlates and outcomes associated with pregabalin use among people prescribed opioids for chronic non-cancer pain: A five-year prospective cohort study.

AIMS: Pregabalin has become widely used as an alternative to opioids in treating certain types of chronic non-cancer pain, but few studies have examined its clinical efficacy outside trials. We address this gap by examining the utilization, correlates and clinical outcomes of pregabalin use among an Australian community-based cohort of people prescribed opioids for chronic non-cancer pain. METHODS: Through a five-year prospective cohort study (n = 1514) we examined associations between pregabalin use and pain severity and interference, mental health, opioid dose and past month use of ambulance and emergency department services. We used fixed-effects regression models to examine within-participant differences, and random-effects regression models to examine within- and between-participant differences in clinical outcomes. RESULTS: In an analysis of cases with complete data over five-years (n = 896), the prevalence of pregabalin use ranged from 16% at cohort entry to 29% at 36- and 48-months, and 46% reported pregabalin use at any time during the five years. Pregabalin use was associated with greater pain severity and interference and greater use of high-risk opioid doses (>90 oral morphine equivalents/day). Pregabalin use was not associated with changes in mental health symptoms, ambulance or emergency department attendance in the fixed or random effects models. CONCLUSIONS: Pregabalin use was common, but for most people use was not associated with clinically meaningful improvements in pain or functioning.

Effect of income inequality, community infrastructure and individual stressors on adult depression.

This paper considers the impact of variables at three different levels-city, community and individual-on the depression of adults aged 45 years and above in China. Evidence shows that community factors, such as infrastructure and elderly centres, are critical to reduce depression but the effect of city-level factors such as lowering income inequality and improving public health investment is different for the segments of poor and non-poor as well as the rural and urban residents. This highlights the need to consider targeted policy mix options to avoid resource misallocation. Lastly, Chinese females' depression has worsened over time with ageing, particularly those who drink alcohol or are less educated are prone to depression prompting the need for specialist women health centres.

Mental health, quality of life, wellbeing, loneliness and use of social media in a time of social distancing during the COVID-19 outbreak. A cross-country comparative study.

BACKGROUND: The COVID-19 outbreak raised questions about how people experience their mental health, quality of life (QoL), wellbeing and loneliness in the context of social distancing, and the use of social media during this time. AIMS: To examine the experience of mental health, QoL, wellbeing and loneliness and use of social media among people living in Norway, USA, UK and Australia. METHODS: A cross-country comparative survey of people living in Norway, USA, UK and Australia. Relevant statistical analyses were used to examine differences between the countries and to explore associations between demographic, mental health and psychosocial variables and use of social media. RESULTS: There were 3810 respondents from four countries, of which 50 - 74% showed a high level of emotional distress. The Norwegian population reported significantly better mental health, QoL and wellbeing and lower levels of loneliness compared to the other countries. High-frequent use of social media after the COVID-19 outbreak was associated with poorer mental- and psychosocial health. CONCLUSIONS: The results suggest that the COVID-19 outbreak took a toll on people's experience of mental health, QoL, wellbeing and experienced loneliness, and high-frequent use of social media was associated with these factors.

Public health implications of legalising the production and sale of cannabis for medicinal and recreational use.

We assess the current and describe possible future public health impacts of the legalisation of cannabis production, sale, and use in the Americas. First, we describe global patterns of cannabis use and their most probable adverse health effects. Second, we summarise evidence regarding the effectiveness of cannabinoids for medicinal use and describe approaches that have been used to regulate the use of medicinal cannabis and how these approaches might have affected medicinal and recreational use and harms (eg, road crashes). Third, we describe how jurisdictions that have legalised recreational use have regulated production and sale of cannabis. Fourth, we evaluate the effects of cannabis legalisation on cannabis use and harms and on the use of alcohol, tobacco, and other drugs. Fifth, we use alcohol and tobacco policy examples to identify possible long-term public health effects of cannabis legalisation. Finally, we outline policy approaches that could minimise harms to public health arising from the legalisation of a commercial cannabis industry.

Perfectionism as a mediator of psychological distress: Implications for addressing underlying vulnerabilities to the mental health of medical students.

OBJECTIVE: Medical students have personalities that are often shown to be perfectionistic. Perfectionism can manifest as maladaptive and lead to psychological distress. This study examined the mediating role of perfectionism on the association between personality trait profiles and levels of psychological distress. METHODS: First-year medical students completed a questionnaire containing measures of personality, perfectionism (Concern over Mistakes: CoM), stress, anxiety and depression. Latent profile analysis classified students based on their personality traits and identified a profile vulnerable to psychological distress. Structural equation models examined the mediation effects of perfectionism on the relationship between the vulnerable personality profile and distress. RESULTS: The sample totalled 376 (84% response). The vulnerable personality profile was highest in Harm Avoidance, lowest in Self-Directedness, and significantly correlated with the highest Perfectionism-CoM. High Perfectionism-CoM was associated with the highest levels of stress, anxiety and depression. Perfectionism-CoM was a significant mediator for the relationship between personality and higher levels of psychological distress. CONCLUSION: Certain personality profiles are predisposed to psychological distress such as anxiety, stress and depression. Perfectionism, as a mediator between personality and psychological distress, may be a target strategy to help increase students' self-acceptance, and self-awareness of their perfectionistic tendencies and lower their vulnerability to poor mental health.

A Global Meta-analysis of the Prevalence of HIV, Hepatitis C Virus, and Hepatitis B Virus Among People Who Inject Drugs-Do Gender-Based Differences Vary by Country-Level Indicators?

BACKGROUND: Women-specific factors exist that increases vulnerability to drug-related harms from injection drug use, including blood-borne viruses (BBVs), but gender-based differences in BBV prevalence have not been systematically examined. METHODS: We conducted meta-analyses to estimate country, regional, and global prevalence of serologically confirmed human immunodeficiency virus (HIV), hepatitis C virus (HCV; based on detection of anti-HCV antibody), and hepatitis B virus (HBV; based on detection of HBV surface antigen) in people who inject drugs (PWID), by gender. Gender-based differences in the BBV prevalence (calculated as the risk among women relative to the risk among men) were regressed on country-level prevalence and inequality measures (Gender inequality index, Human development index, Gini coefficient, and high, low or middle income of the country). RESULTS: Gender-based differences varied by countries and regions. HIV prevalence was higher among women than men in sub-Saharan Africa (relative risk [RR], 2.8; 95% confidence interval [CI], 1.8-4.4) and South Asia (RR, 1.7; 95% CI, 1.1-2.7); anti-HCV was lower among women in the Middle East and North Africa (RR, 0.6; 95% CI, .5-.7) and East and Southeast Asia (RR, 0.8; 95% CI, .7-.9). Gender-based differences varied with country-levels of the BBV prevalence in the general population, human development, and income distribution. CONCLUSION: HIV was more prevalent in women who inject drugs as compared to their male counterparts in some countries, but there is variation between and within regions. In countries where women are at higher risks, there is a need to develop gender-sensitive harm-reduction services for the particularly marginalized population of women who inject drugs.