A Randomized Trial of Nicotine versus No-nicotine E-cigarettes Among African American Smokers: Changes in Smoking and Tobacco Biomarkers.

INTRODUCTION: The objective of this clinical trial was to compare the effects of e-cigarettes with and without nicotine on patterns of combustible cigarette use and biomarkers of exposure to tobacco toxicants among African American smokers. METHODS: African American smokers (n = 234) were enrolled in a 12-week, single blind, randomized controlled trial and assigned to ad lib use of nicotine e-cigarettes with or without menthol (2.4% nicotine [equivalent to combustible cigarettes], n = 118), or no-nicotine e-cigarettes (n = 116) for 6 weeks. Surveys were administered at baseline, 2, 6, and 12 weeks, and urinary biomarkers 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and total nicotine equivalents (TNE) were assessed at baseline and 6 weeks. RESULTS: Participants smoked an average of 11.4 cigarettes per day (CPD) and 88% used menthol cigarettes at baseline. At Week 6, the nicotine group reported using e-cigarettes 9.1 times per day compared to 11.4 times in the no-nicotine group (p = 0.42). Combustible cigarette smoking decreased 3.0 CPD in the nicotine group compared to 2.7 CPD in the no-nicotine group (p = 0.74). Neither TNE nor NNAL changed significantly between baseline and Week 6. There were no differences in nicotine withdrawal symptoms between treatment groups. Smoking reduction persisted in both groups at Week 12. CONCLUSIONS: Contrary to our hypotheses, nicotine e-cigarettes did not significantly reduce the use of combustible cigarettes compared to no-nicotine e-cigarettes in this cohort of African American smokers. Findings suggest e-cigarettes are modestly associated with the decreased use of combustible cigarettes among non-treatment seeking smokers, regardless of nicotine content, but without a reduction in tobacco toxicants. IMPLICATIONS: Although e-cigarettes have the potential to reduce harm if substituted for combusted cigarettes (or if they promoted cessation) because of lower levels of tobacco toxicants, this study suggests ad lib use of e-cigarettes among African American smokers, with or without nicotine, results in modest smoking reduction but does not change toxicant exposure in a cohort where smoking cessation or reduction is not the goal. These data suggest that testing future harm reduction interventions using e-cigarettes should include more specific behavioral change coaching, including substituting for or completely stopping combusted cigarettes. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov - NCT03084315.

Influence of Flavors and Nicotine Concentration on Nicotine Dependence in Adolescent and Young Adult E-Cigarette Users.

Objective: The objective of this study is to examine the relationships between e-cigarette flavors, nicotine concentration, and their interaction on measures of nicotine dependence.Methods: Survey data are drawn from a cross-sectional convenience sample of past 30-day e-cigarette users aged 15 to 24 years (N = 2037) collected between October 2020 and November 2020. Participants were asked to provide information about the e-cigarette products they used most regularly. Only those with available information on flavors (fruit, mint, menthol/ice, and tobacco), nicotine concentration (0-2.9%, 3-4.9%, and 5% or greater), and time to first vape after waking (within 30 minutes, greater than 30 minutes) were included in analyses (N = 1430). Generalized linear regression models were used with log link and binary distribution to assess the relationship between flavors, nicotine concentration, and nicotine dependence. Effect modification by nicotine concentration was assessed using an interaction term for flavors by nicotine concentration. Models were adjusted for age, race/ethnicity, gender, and financial situation.Findings: Fruit, mint, and menthol flavor user groups had a very similar dose-response relationship between nicotine concentration and prevalence of vaping within 30 minutes. These groups showed that the prevalence of vaping within 30 minutes gradually increased as nicotine concentration increased. Meanwhile, tobacco flavor user groups demonstrated a decrease in prevalence of vaping within 30 minutes, as nicotine concentration increased.Conclusion: Results highlight the need for understanding how e-cigarette product characteristics like flavors and nicotine concentration can facilitate nicotine dependence to e-cigarettes. Findings suggest that comprehensive e-cigarette product regulation of all flavors and reducing nicotine concentration will help to reduce the risk for nicotine dependence among young people.

Teaching Community Health Needs Assessment to First Year Medical Students: Integrating with Longitudinal Clinical Experience in Rural Communities.

Community health education is especially important for physicians who will practice in rural communities. However, the majority of efforts to teach community and population health in medical school appear in later years and focus on non-rural contexts. This article presents data from a formative evaluation of a newly developed curricular component on population health and community health assessment for first year medical students in a rural longitudinal clinical preceptorship. Curricular elements included: a classroom lecture and review of online community health databases, an individual homework assignment and a classroom debriefing session. In a sample of 210 students, pre- and post-course surveys and exam questions assessed gains in awareness and skills over the course period. Analyses of data aggregated over four academic years (2013-2014 to 2016-2017) showed that first year medical students reported significant increases in familiarity with online resources (29.5% pre vs. 94.8% post, p < .001), understanding the importance of community health assessments (67.5% pre vs. 96.7%, p < .001), knowing how to plan a community health assessment (20.0% pre vs. 90.5%, p < .001), and awareness of Affordable Care Act expectations for community health assessments (12.4% pre vs. 82.4% post, p < .001). Further, students performed well on exam questions and reported that this component fit well with the objectives of the rural longitudinal clinical preceptorship course. Later-year education should reinforce early learnings and future studies involving long-term follow-up of physicians could assess the impact of early exposure to community health education on physician behaviors.

The Interprofessional Standardized Patient Experience: An Effective Interprofessional Education Activity for Prelicensure Health Professional Students.

Introduction: For future success in the modern health care environment, health professions students require effective interprofessional education experiences to develop their perceptions of other professionals on the health care team. The Interprofessional Standardized Patient Experience (ISPE) is an interprofessional education activity for prelicensure health professional students in nursing, pharmacy, physical therapy, medicine, social work, and occupational therapy. Methods: The ISPE involved collaboration among students to conduct a subjective interview. Students from six health care professions individually interviewed a simulated patient while being observed by students from other professions. A structured faculty-guided debriefing session followed the comprehensive interview process. Students completed a voluntary pre- and post-ISPE survey with interprofessional questions and feedback on the activity. Descriptive statistics were used to analyze individual responses. Differences in student opinions by student profession and by the number of professions present were examined using chi-square tests. Results: Over 4 consecutive academic years, 1,265 students completed the ISPE, and 1,028 completed the pre- and post-ISPE surveys. Analysis of the survey responses indicated that the ISPE enhanced student awareness of the functions of an interprofessional team and increased student knowledge of the roles of different health care professions. Students rated the ISPE as a valuable experience. Differences were noted in some of the measures by profession and group size. Discussion: A single ISPE had a significant impact on prelicensure students' perceptions. The ISPE is a novel and effective approach to interprofessional education that students appreciate.

The Availability of Culturally Preferred Fruits, Vegetables and Whole Grains in Corner Stores and Non-Traditional Food Stores.

Chronic health inequities for communities of color is partially attributed to a lack of healthy preferred food access. This manuscript explores whether corner stores and non-traditional food stores stock fruits, vegetables and whole grain foods that the area cultural communities may prefer as part of complying with a local ordinance. This exploratory analysis identified corner and non-traditional food stores located in immigrant populations of color and African American neighborhoods as part of a larger study. Culturally preferred foods were identified from a list of food items in the parent (STORE) study and used to assess changes in availability. Stores did not have a great variety of culturally relevant foods pre- or post-ordinance, and overall findings show no significant changes over time and/or between ordinance and control community. Further interventions are needed to address cultural food availability in stores near communities of color.

Obstetrical Care in Rural Minnesota: Family Physician Perspectives on Factors Affecting the Ability to Provide Prenatal, Labor, and Delivery Care.

PURPOSE: With decreasing access to rural obstetrical care, this study aimed to identify factors that contribute to the ability of Minnesota's rural communities to continue to offer obstetrical services locally. The study also sought to characterize attributes that differentiate rural communities that continue to offer obstetrical care from those that do not. METHODS: Family medicine physicians practicing in communities of fewer than 20,000 people were interviewed through a phone survey that included multiple choice and open-ended questions. Quantitative and qualitative analyses were performed on data collected from the responses. FINDINGS: Within the Minnesota communities represented (N = 25), prenatal care was provided broadly, regardless of whether labor and delivery services were available. For the communities providing local labor and delivery (N = 17), several factors seemed to be key to sustaining these services: having a sufficient cohort of delivering providers, having surgical backup, having accessible confident nurses and nurse anesthetists, sustaining a sufficient annual birth volume at the hospital, and having organizational and administrative support. In addition, supporting anesthesia and analgesic services, access to specialist consultation, having resources for managing and referring both newborn and maternal complications, and sustaining proper equipment were also requisite. CONCLUSIONS: Rural Minnesota family medicine physicians practicing in communities providing local labor and delivery care emphasized several essential components for sustainable provision of these services. With awareness of these essential components, rural health care providers, administrators, and policy makers can focus resources and initiatives on efforts that are most likely to support a sustainable and coordinated rural labor and delivery program.

First year allopathic medical student attitudes about vaccination and vaccine hesitancy.

First year medical students at an allopathic medical school regional campus were asked to complete a 10-question survey at both the beginning and the conclusion of a required course on immunology, hematology and oncology. The survey was designed to solicit student attitudes about vaccination and the students' level of comfort with and exposure to vaccine hesitant patients. Surveys were administered to five consecutive classes from 2013 to 2017. Total response rate for completion of both surveys was 58.0% (178/307). Pre- and post-course surveys were administered to assess whether curricular experiences altered the students' perceptions about vaccinations and their ability to counsel vaccine hesitant patients. Curricular elements were presented in several different formats aimed at increasing student knowledge about vaccinations and student capacity to work with vaccine hesitant patients and families (problem-based learning, didactic lecture and interactive panel discussion). In the pre-survey, the majority of students reported having already encountered people who decline vaccinations (78.8%). Additionally, in the pre-survey the majority of medical students expressed strong support for vaccination (99.6% agreed with the statement that Vaccinations are a great public health accomplishment) and strong disagreement with both of the assertions that childhood vaccines cause autism and vaccine preservatives cause adverse health effects. In response to questions about comfort level while talking with patients about vaccine choices, baseline responses demonstrated a moderately high level of comfort. Post-course surveys revealed a statistically significant increase in student-rated comfort level in talking with patients about vaccine choices (pre-survey 79.2% report comfort versus post 97.8%; p < 0.001). Though this study is limited to student self-reporting, survey responses suggest that targeted curricular elements can improve medical student confidence in counseling patients about vaccinations. Future curricular elements designed to directly observe student performance could provide verification of counseling skill acquisition.

Location and duration of secondhand smoke exposure among Minnesota Nonsmokers, 2018.

In 2007 Minnesota passed into law a comprehensive ban on indoor smoking of tobacco products in public places including bars, restaurants, and workplaces. Despite reductions in smoking prevalence in the past 12 years, people are still exposed to secondhand smoke (SHS). It remains important to understand where and how long nonsmokers face exposure to SHS. The 2018 Minnesota Adult Tobacco Survey was analyzed to examine self-reported SHS exposure among nonsmoking adults. We report prevalence and 95 percent confidence intervals of SHS exposure overall, by specific locations, and by demographics. Length of exposure to SHS was summarized in median minutes. Overall, 30 percent of nonsmokers reported exposure in the past seven days. A total of 1382 participants indicated a location of exposure. The most common locations other than one's own home or car included building entrances (18.7 [16.2-21.1] percent), somewhere else outdoors (17.7 [15.1-20.3] percent), and restaurant/bar patios (12.8 [10.5-15.0] percent). Exposure was more likely to be reported by young adults (44.6 percent) and males (33.7 percent). The locations with the longest duration of SHS exposure in the prior seven days were a gambling venue (117.2 [72.2-162.2] minutes), another person's home (26.1 [15.4-36.8] minutes), and a bus stop (10.8 [4.7-16.9] minutes). Monitoring nonsmokers' self-reported exposure to SHS remains important as a way to measure the impact and compliance with smoke-free policies. Additional information on the location and duration of exposure can be used programmatically to address high levels of exposure and consider additional policies or strategies.

Sleep quality in cigarette smokers: Associations with smoking-related outcomes and exercise.

INTRODUCTION: Compared to the general population, cigarette smokers report poorer sleep quality. Poor sleep quality in cigarette smokers is associated with greater nicotine dependence. While exercise is known to improve sleep quality in the general population, less is known about how exercise effects sleep in those who smoke. The goal of this study was to explore the relationships between exercise, sleep, and smoking in cigarette smokers. METHODS: Data on sleep quality (Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI)), smoking-related outcomes (e.g., cigarettes/day, Fagerstrom Test for Nicotine Dependence, Minnesota Nicotine and Withdrawal Scale, and Questionnaire of Smoking Urges) and exercise (Fitbit activity measures) were collected for 32 participants (63% female, mean age 30.3 ±â€¯1.0 years) participating in a 12-week clinical research study. Analyses included simple linear regression models. RESULTS: Overall, participants reported poor sleep quality at baseline (PSQI > 5). Poorer sleep quality at baseline was associated with increased withdrawal (ß = 1.63 ±â€¯0.53, p = 0.0043), craving (ß = 0.51 ±â€¯0.43, p = 0.2471), and total smoking urges (ß = 1.10 ±â€¯0.41, p = 0.0118). During follow-up (i.e., from baseline to week 12), a daily increase in exercise was associated with improved sleep quality over the same time period (PSQI: ß = -0.82 ±â€¯0.35, p = 0.0379). CONCLUSION: Our data suggest that better sleep quality may be associated with lower levels of withdrawal, craving, and smoking urges. Further, exercise may be associated with better sleep quality in cigarette smokers. Future work should explore how increasing exercise and improving sleep quality could inform future smoking cessation interventions.

Subjective response to intranasal nicotine administration in oral contraceptive users and naturally-cycling women.

INTRODUCTION: Approximately half of premenopausal women who smoke cigarettes also use hormonal contraceptives, with most using oral contraceptives (OCs). While research on the effects of endogenous hormones on smoking-related outcomes continues to expand, little is known about the influence of OCs on similar outcomes. We sought to explore differences in the subjective response to nicotine by OC use after stratifying by testing condition (e.g., smoking status). METHODS: Participants were regular (≥5 cigarettes/day) smokers, classified into OC and naturally cycling (NC) groups. All participants completed four total lab sessions by smoking status (ad libitum smoking, acute smoking abstinence) and anticipated progesterone level (low progesterone week (LPW), high progesterone week (HPW)). Each lab session included self-administration of intranasal nicotine (Time 0 min), assessment of subjective response via the Subjective State Scale (-30 and + 5 min). RESULTS: Compared to the NC group (n = 28), the OC group (n = 14) was younger (26.2 ±â€¯1.1 versus 24.2 ±â€¯1.1; p < 0.001) and had a lower Fagerström Test for Nicotine Dependence score (3.4 ±â€¯0.5 versus 2.6 ±â€¯0.5; p = 0.011). Progesterone-to-estradiol ratios varied significantly by group at three of the four time points (p < 0.05). During ad libitum smoking, the OC group had significantly lower craving after nicotine administration than the NC group (1.93 ±â€¯0.33 versus 2.89 ±â€¯0.23; p = 0.024). No other significant differences in subjective response were identified. CONCLUSIONS: Despite significantly different hormone levels, group differences in subjective response to nicotine were relatively few. Additional research is needed to elucidate the mechanisms involved in these observations, as well as explore how they may influence cessation in women.