Spatiotemporal link between El Niño Southern Oscillation (ENSO), extreme heat, and thermal stress in the Asia-Pacific region.

Climate change is closely monitored and numerous studies reports increasing air temperature and weather extremes across the globe. As a direct consequence of the increase of global temperature, the increased heat stress is becoming a global threat to public health. While most climate change and epidemiological studies focus on air temperature to explain the increasing risks, heat strain can be predicted using comprehensive indices such as Universal Thermal Climate Index (UTCI). The Asia-Pacific region is prone to thermal stress and the high population densities in the region impose high health risk. This study evaluated the air temperature and UTCI trends between 1990 and 2019 and found significant increasing trends for air temperature for the whole region while the increases of UTCI are not as pronounced and mainly found in the northern part of the region. These results indicate that even though air temperature is increasing, the risks of heat stress when assessed using UTCI may be alleviated by other factors. The associations between El Niño Southern Oscillation (ENSO) and heat stress was evaluated on a seasonal level and the strongest regional responses were found during December-January (DJF) and March-May (MAM).

Incidence of opioid misuse by cigarette smoking status in the United States.

BACKGROUND: The combination of opioid misuse and cigarette smoking contributes to increased morbidity and mortality compared to each substance use alone. We estimated the incidence of opioid misuse for persons who currently or formerly smoked versus never smoked. METHODS: Data came from the 2015-2020 National Surveys on Drug Use and Health cross-sectional surveys of US civilians aged 12+ (n = 315,661). Weighted opioid misuse incidence and average time between cigarette use initiation and opioid misuse initiation were calculated annually by smoking status. Logistic regression models tested time trends in incidence by smoking status. RESULTS: Overall, 0.75% of persons initiated opioid misuse per year; opioid misuse incidence was 1.35% for those who currently smoked cigarettes, 0.54% for those who formerly smoked, and 0.67% for those who never smoked. For persons who currently smoked and misused opioids (1.50%), 95.08% smoked prior to opioid use. The average time between smoking followed by opioid misuse was 12.93 years and for opioid misuse followed by smoking was 4.36 years. Persons who currently smoked were more likely to initiate opioid misuse than those who had never smoked (AOR = 1.81, 95% CI: 1.60, 2.06). There was a decrease in the opioid misuse incidence over time (AOR = 0.90; 95% CI: 0.85, 0.92), which did not differ by smoking status. CONCLUSIONS: Persons who currently smoked cigarettes, relative to those who never smoked, were more likely to initiate opioid misuse. As most individuals smoked before opioid misuse, it may be useful for primary prevention efforts to decrease opioid misuse initiation by focusing on smoking status.

Longitudinal associations between receiving E-cigarette price promotions and subsequent E-cigarette use among U.S. Young adult cigarette smokers.

INTRODUCTION: E-cigarette price promotions (EPPs; i.e., marketed reductions in cost) may influence young adult cigarette smokers to try, dual use with, or completely transition to e-cigarettes. We assessed whether receiving EPPs was associated with subsequent e-cigarette use among this group. METHODS: Data were from Waves 4 (2016-2018) and 5 (2018-2019) of the nationally representative Population Assessment of Tobacco and Health (PATH) Study survey. Analysis was restricted to participants who were young adult (18-34 years) established, current cigarette smokers who did not use e-cigarettes at Wave 4 (baseline; n = 2,664; Sample 1), and a subsample of those who tried to quit smoking completely in the past year at Wave 5 (follow-up; n = 948; Sample 2). Multivariable logistic regressions were used to examine associations between receiving EPPs at baseline and past year use of e-cigarettes in general (Sample 1) and to help quit smoking (Sample 2) at follow-up, controlling for covariates. RESULTS: Overall, 4.1% and 4.9% of Sample 1 and 2 participants received EPPs, respectively; At follow-up, 33.4% of Sample 1 participants used e-cigarettes, and 12.0% of Sample 2 participants used e-cigarettes to quit smoking. Receiving EPPs was associated with subsequent past-year e-cigarette use in general (AOR = 2.07; 95% CI = 1.31 to 3.27), and past-year e-cigarette use to help with quitting smoking (AOR = 3.20; 95% CI = 1.48 to 6.90). DISCUSSION: EPPs may increase e-cigarette use among established, current smokers and may be used to quit smoking. Research is needed to understand how EPPs may be differentially associated with complete product transition versus dual/poly use among young adult smokers.

Associations between living in localities with e-cigarette sales restrictions and e-cigarette use change among young adults in Los Angeles County.

INTRODUCTION: Local e-cigarette sales restrictions (ESRs) may impact e-cigarette use. This study examined the associations between living in localities with various ESR policies and changes in e-cigarette use among young adults in Los Angeles (LA) County, California, USA. METHODS: Data were from a cohort of LA County young adults (18-21 years; n=2100) who completed two waves of surveys (Fall 2018-Summer 2019 and Summer-Fall 2020). Local flavoured (n=9) and comprehensive (n=2) ESRs in LA County implemented between June 2019 and May 2020 were identified, coded and merged with the baseline data. Multivariable logistic regressions were used to examine the associations between living in ESR localities and e-cigarette use at follow-up, controlling for covariates and stratified by cigarette smoking at baseline. RESULTS: Overall, 20.9% and 14.3% of participants lived in localities with flavoured and comprehensive ESRs, respectively. Participants who were non-Hispanic, had higher socioeconomic statuses and were currently using e-cigarettes were generally more likely to live in ESR localities than their counterparts. The associations between living in ESR localities and e-cigarette use at follow-up were not found among baseline non-e-cigarette users regardless of their cigarette smoking status; a positive relationship was found among baseline e-cigarette users who also smoked cigarettes but not among non-smokers. DISCUSSION: Participants who lived in localities with various ESR policies were different in their baseline e-cigarette use and socioeconomic backgrounds. Future research examining the potential impact of ESRs on e-cigarette use change should consider the localities' overall sociodemographic and tobacco-using characteristics and individuals' cigarette smoking histories.

Longitudinal associations between U.S. youth exposure to E-cigarette marketing and E-cigarette use harm perception and behavior change.

E-cigarette marketing tactics to reach and appeal to youth are rapidly changing. This study examined to what extent youth e-cigarette marketing exposure was associated with e-cigarette use behavior change one year later, during a time when youth e-cigarette use was starting to surge in the U.S. Using nationally representative longitudinal public-use data from the Population Assessment of Tobacco and Health (PATH) Study, we examined associations between recalled e-cigarette marketing exposure (2016-2018) at Wave (W) 4 and e-cigarette use harm perception and behavior change (ever, current, and regular use) one year later (W4.5; 2017-2018) among W4 never tobacco users (n = 9405). Recall of exposure to e-cigarette marketing through different channels was also examined in multivariable models controlling for socio-demographic factors and established e-cigarette use risk factors. Results show that the most frequently recalled channels of e-cigarette marketing exposure were retail stores (50.3%), television (22.2%), and websites/social media (20.2%). Over one year, 21.2%, 7.8%, 3.4%, and 1.2% of respondents reported reduced harm perceptions, and ever, current, and regular use of e-cigarettes, respectively, at follow-up. Recalled exposure to e-cigarette marketing was associated with reduced e-cigarette harm perception (AOR = 1.20; 95% CI = 1.05-1.37) and ever (AOR = 1.26; 95% CI = 1.01-1.56) and current use (AOR = 1.40; 95% CI = 1.02-1.92) at follow-up. E-cigarette marketing exposure through websites/social media was associated with reduced harm perceptions and all stages of e-cigarette use change, including regular use. Identifying marketing techniques and channels that change youth e-cigarette harm perceptions and influence e-cigarette use progression is essential to inform e-cigarette regulatory policies and prevention campaigns.

Visual Attention to Health Warning Labels on Waterpipe Venue Menus in Immersive Virtual Reality.

INTRODUCTION: This study examined how health warning labels (HWL) on a waterpipe venue menu captured and held the attention of consumers and influenced waterpipe tobacco smoking (WTS) attitudes, beliefs, and behaviors. AIMS AND METHODS: A randomized experiment (N = 96) of young adult waterpipe smokers was conducted in an immersive virtual reality laboratory. Participants viewed one of two virtual reality scenarios, a menu with an HWL and nicotine concentration or menu without an HWL and nicotine concentration. Eye-tracking metrics were collected, and participants completed posttest questionnaires on demographics, tobacco use history, and WTS attitudes, beliefs, and behaviors. T-tests were used to assess group differences, and a mediation analysis conducted to examine the relationship between the HWL and intention to quit WTS. RESULTS: Participants in the HWL group demonstrated greater visual attention to the warning and nicotine areas and less visual attention to the flavor and ingredients areas of the menu compared to the control group. The HWL group demonstrated greater negative attitudes toward WTS (p = .002), greater perceived risk of decreased lung function (p = .026), and greater intention to quit WTS (p = 0.003). The mediation model indicated the relationship between the HWL on a menu and intention to quit WTS was mediated by an increase in negative attitudes toward WTS. CONCLUSIONS: The HWLs on a menu captured and held the attention of consumers and increased negative attitudes, perceptions of health risk, and intention to quit WTS indicating potential benefit of including a warning label or nicotine concentration on menus to correct misperceptions of WTS. IMPLICATIONS: The study contributes to the broader literature on communicating the harms and risks of WTS. The findings suggest that HWL and nicotine concentration on waterpipe venue menus attract attention from consumers in environments comparable to the real world and the strategy warrants further exploration as a targeted policy intervention to educate the public and reduce the health burden of WTS.

Health Information on Waterpipe Lounge Menus to Educate Young Adults: Pilot Study Findings.

BACKGROUND: For years, tobacco risk communication has largely focused on cigarette smoking. New strategies must be developed to adapt to emerging tobacco products, such as waterpipe tobacco smoking (WTS). AIMS: The purpose of this pilot study was to determine the preliminary effects of health information on waterpipe lounge menus on the perceptions of harm and risk from WTS and inform future efficacy interventions for health communication (i.e., educating populations on the risks, harms, and health consequences of WTS). METHOD: Participants aged 18 to 24 years (n = 213) who smoked waterpipe at least monthly were randomized to one of four waterpipe lounge menu groups using a two-by-two experimental design with "warning message" and "nicotine content" as factors. RESULTS: Those who viewed waterpipe lounge menus that included a warning message had greater perceived relative harm to health and perceived risk of decreased lung function from WTS. Those who viewed waterpipe lounge menus that included nicotine content had greater perceived risk of heart attack from WTS. DISCUSSION: Participants who were exposed to health warnings of WTS and information on the nicotine content of waterpipe tobacco increased on measures of perceived relative harm and risk of health consequences. CONCLUSION: The pilot test results indicate promise for providing health information on waterpipe lounge menus to educate young adults on the harms and risks of WTS.

Forecasting COVID-19 Cases Based on Social Distancing in Maryland, USA: A Time-Series Approach.

OBJECTIVE: Our objective is to forecast the number of coronavirus disease 2019 (COVID-19) cases in the state of Maryland, United States, using transfer function time series (TS) models based on a Social Distancing Index (SDI) and determine how their parameters relate to the pandemic mechanics. METHODS: A moving window of 2 mo was used to train the transfer function TS model that was then tested on the next week data. After accounting for a secular trend and weekly cycle of the SDI, a high correlation was documented between it and the daily caseload 9 days later. Similar patterns were also observed on the daily COVID-19 cases and incorporated in our models. RESULTS: In most cases, the proposed models provide a reasonable performance that was, on average, moderately better than that delivered by TS models based only on previous observations. The model coefficients associated with the SDI were statistically significant for most of the training/test sets. CONCLUSIONS: Our proposed models that incorporate SDI can forecast the number of COVID-19 cases in a region. Their parameters have real-life interpretations and, hence, can help understand the inner workings of the epidemic. The methods detailed here can help local health governments and other agencies adjust their response to the epidemic.

Impact of irrigation water type and sampling frequency on Microbial Water Quality Profiles required for compliance with U.S. Food Safety Modernization Act Produce Safety Rule standards.

The U.S. Food Safety Modernization Act (FSMA) Produce Safety Rule (PSR) requires that farmers generate a Microbial Water Quality Profile (MWQP) from 20 samples per agricultural water source, taken over 2-4 years and five annual samples thereafter. Farmers must use the MWQP to ascertain a geometric mean (GM) of ≤126 CFU/100 mL and statistical threshold value (STV) of ≤410 CFU/100 mL of generic Escherichia coli. Farmers are responsible for collecting samples and paying for testing, incurring a financial and time burden. To determine if testing frequency can be reduced without compromising accuracy, water samples (n = 279) were collected from twelve sites in the U.S. Mid-Atlantic region from 2016 to 2018 comprising tidal brackish river, non-tidal fresh river, pond, vegetable processing, and reclaimed water. The GM and STV were calculated for all sites and water types using all samples, and for multiple sub-samples of <20 from each site and water type. A Monte Carlo simulation was used to determine the proportion of sub-sample sizes that yielded the same determination as the entire sample size of PSR standard compliance. Four sites, two pond and two reclaimed water sites, complied with PSR GM and STV requirements when using the entire sample set. When a water source's calculated GM and STV using the entire sample set hovered close to the PSR thresholds, sub-sample sizes approached the recommended 20 samples to reach a congruent compliance determination. However, 99% agreement was obtained with a sub-sample of five when the absolute difference between the GM and STV from total samples and the PSR thresholds was ≥2.6 and 4.5 log CFU/100 mL E. coli, respectively. These findings suggest that under certain conditions the MWQP may be generated with well below 20 samples, reducing the economic burden on farmers while still maintaining a representative MWQP.

El Niño Southern Oscillation, monsoon anomaly, and childhood diarrheal disease morbidity in Nepal.

Climate change is adversely impacting the burden of diarrheal diseases. Despite significant reduction in global prevalence, diarrheal disease remains a leading cause of morbidity and mortality among young children in low- and middle-income countries. Previous studies have shown that diarrheal disease is associated with meteorological conditions but the role of large-scale climate phenomena such as El Niño-Southern Oscillation (ENSO) and monsoon anomaly is less understood. We obtained 13 years (2002-2014) of diarrheal disease data from Nepal and investigated how the disease rate is associated with phases of ENSO (El Niño, La Niña, vs. ENSO neutral) monsoon rainfall anomaly (below normal, above normal, vs. normal), and changes in timing of monsoon onset, and withdrawal (early, late, vs. normal). Monsoon season was associated with a 21% increase in diarrheal disease rates (Incident Rate Ratios [IRR]: 1.21; 95% CI: 1.16-1.27). El Niño was associated with an 8% reduction in risk while the La Niña was associated with a 32% increase in under-5 diarrheal disease rates. Likewise, higher-than-normal monsoon rainfall was associated with increased rates of diarrheal disease, with considerably higher rates observed in the mountain region (IRR 1.51, 95% CI: 1.19-1.92). Our findings suggest that under-5 diarrheal disease burden in Nepal is significantly influenced by ENSO and changes in seasonal monsoon dynamics. Since both ENSO phases and monsoon can be predicted with considerably longer lead time compared to weather, our findings will pave the way for the development of more effective early warning systems for climate sensitive infectious diseases.

Manual Palpation vs. Femoral Arterial Doppler Ultrasound for Comparison of Pulse Check Time During Cardiopulmonary Resuscitation in the Emergency Department: A Pilot Study.

BACKGROUND: Manual palpation (MP) is frequently employed for pulse checks, but studies have shown that trained medical personnel have difficulty accurately identifying pulselessness or return of spontaneous circulation (ROSC) using MP. Any delays in identifying pulselessness can lead to significant delays in starting or resuming high-quality chest compressions. OBJECTIVES: This study explored whether femoral arterial Doppler ultrasound (FADU) decreases pulse check duration during cardiopulmonary resuscitation (CPR) compared with MP among patients in the emergency department (ED) receiving CPR directed by emergency medicine physicians who had received minimal additional didactic ultrasound training. METHODS: We performed a prospective observational cohort study from October 2018 to May 2019 at an urban community ED. Using convenience sampling, we enrolled patients arriving at our ED or who decompensated during their ED stay and received CPR. For continuous data, median (interquartile range [IQR]) were calculated, and medians were compared using Kruskal-Wallis test. RESULTS: Fifty-two eligible patients were enrolled and 135 pulse checks via MP and 35 via FADU were recorded. MP observations had a median (IQR) of 11.00 (7.36-15.48) s, whereas FADU had a median (IQR) of 8.98 (5.45-13.85) s. There was a difference between the two medians of 2.02 s (p = 0.05). CONCLUSIONS: In this study, the use of FADU was superior to MP in achieving shorter pulse check times. Further research is needed to confirm the accuracy of FADU for identifying ROSC as well as to determine whether FADU can improve clinical outcomes.

Racial and Sex Differences between Urinary Phthalates and Metabolic Syndrome among U.S. Adults: NHANES 2005-2014.

Phthalates, plasticizers ubiquitous in household and personal care products, have been associated with metabolic disturbances. Despite the noted racial differences in phthalate exposure and the prevalence of metabolic syndrome (MetS), it remains unclear whether associations between phthalate metabolites and MetS vary by race and sex. A cross-sectional analysis was conducted among 10,017 adults from the National Health and Nutritional Examination Survey (2005-2014). Prevalence odds ratios (POR) and 95% confidence intervals (CIs) were estimated for the association between 11 urinary phthalate metabolites and MetS using weighted sex and race stratified multivariable logistic regression. Higher MCOP levels were significantly associated with increased odds of MetS among women but not men, and only remained significant among White women (POR Q4 vs. Q1 = 1.68, 95% CI: 1.24, 2.29; p-trend = 0.001). Similarly, the inverse association observed with MEHP among women, persisted among White women only (POR Q4 vs. Q1 = 0.53, 95% CI: 0.35, 0.80; p-trend = 0.003). However, ΣDEHP metabolites were associated with increased odds of MetS only among men, and this finding was limited to White men (POR Q4 vs. Q1 = 1.54, 95% CI: 1.01, 2.35; p-trend = 0.06). Among Black men, an inverse association was observed with higher MEP levels (POR Q4 vs. Q1 = 0.43, 95% CI: 0.24, 0.77; p-trend = 0.01). The findings suggest differential associations between phthalate metabolites and MetS by sex and race/ethnicity.

Biomarker Categorization in Transcriptomic Meta-Analysis by Concordant Patterns With Application to Pan-Cancer Studies.

With the increasing availability and dropping cost of high-throughput technology in recent years, many-omics datasets have accumulated in the public domain. Combining multiple transcriptomic studies on related hypothesis via meta-analysis can improve statistical power and reproducibility over single studies. For differential expression (DE) analysis, biomarker categorization by DE pattern across studies is a natural but critical task following biomarker detection to help explain between study heterogeneity and classify biomarkers into categories with potentially related functionality. In this paper, we propose a novel meta-analysis method to categorize biomarkers by simultaneously considering the concordant pattern and the biological and statistical significance across studies. Biomarkers with the same DE pattern can be analyzed together in downstream pathway enrichment analysis. In the presence of different types of transcripts (e.g., mRNA, miRNA, and lncRNA, etc.), integrative analysis including miRNA/lncRNA target enrichment analysis and miRNA-mRNA and lncRNA-mRNA causal regulatory network analysis can be conducted jointly on all the transcripts of the same category. We applied our method to two Pan-cancer transcriptomic study examples with single or multiple types of transcripts available. Targeted downstream analysis identified categories of biomarkers with unique functionality and regulatory relationships that motivate new hypothesis in Pan-cancer analysis.

Public Compliance With Social Distancing Measures and SARS-CoV-2 Spread : A Quantitative Analysis of 5 States.

OBJECTIVE: We quantified the association between public compliance with social distancing measures and the spread of SARS-CoV-2 during the first wave of the epidemic (March-May 2020) in 5 states that accounted for half of the total number of COVID-19 cases in the United States. METHODS: We used data on mobility and number of COVID-19 cases to longitudinally estimate associations between public compliance, as measured by human mobility, and the daily reproduction number and daily growth rate during the first wave of the COVID-19 epidemic in California, Illinois, Massachusetts, New Jersey, and New York. RESULTS: The 5 states mandated social distancing directives during March 19-24, 2020, and public compliance with mandates started to decrease in mid-April 2020. As of May 31, 2020, the daily reproduction number decreased from 2.41-5.21 to 0.72-1.19, and the daily growth rate decreased from 0.22-0.77 to -0.04 to 0.05 in the 5 states. The level of public compliance, as measured by the social distancing index (SDI) and daily encounter-density change, was high at the early stage of implementation but decreased in the 5 states. The SDI was negatively associated with the daily reproduction number (regression coefficients range, -0.04 to -0.01) and the daily growth rate (from -0.009 to -0.01). The daily encounter-density change was positively associated with the daily reproduction number (regression coefficients range, 0.24 to 1.02) and the daily growth rate (from 0.05 to 0.26). CONCLUSIONS: Social distancing is an effective strategy to reduce the incidence of COVID-19 and illustrates the role of public compliance with social distancing measures to achieve public health benefits.

Social media use and human papillomavirus awareness and knowledge among adults with children in the household: examining the role of race, ethnicity, and gender.

BACKGROUND: Though human papillomavirus (HPV) vaccination is a safe and effective method of protecting against associated cancers, uptake rates remain low among adolescents. Few studies have examined how social media use contributes to HPV-related knowledge gaps among parents and caregivers. OBJECTIVE: To investigate the association between social media use and HPV-related awareness and knowledge with a focus on differences by gender and race/ethnicity among a nationally representative sample of adults with children in the household. METHODS: We used data from the Health Information National Trends (HINTS) Survey (2017-2019) (N = 2,720). Multivariate logistic regressions were used to examine the association of social media use on HPV awareness and knowledge outcomes. RESULTS: Compared to non-users, engaging in one, two, three, or four social media behaviors were associated with greater HPV awareness (aOR: 2.09; 95%CI: 1.18-3.70, aOR: 2.49; 95%CI: 1.40-4.42, aOR: 2.64; 95%CI: 1.15-6.05, and aOR: 2.44; 95%CI: 1.11-5.36, respectively). Increased social media use was associated with increased HPV vaccine awareness. Men, African American, Hispanic, and Asian American respondents were less likely to be aware of HPV or HPV vaccine. Social media use was not associated with cancer knowledge. CONCLUSIONS: Increased social media use is associated with an increased awareness of HPV and HPV vaccine for adults with children in the household. Social media-based efforts can be utilized to increase knowledge of the benefits of HPV vaccination as cancer prevention, which may be a precursor to reducing HPV vaccine hesitancy and encouraging uptake to decrease cancer incidence rates among vulnerable populations.

Association between private drinking water wells and the incidence of Campylobacteriosis in Maryland: An ecological analysis using Foodborne Diseases Active Surveillance Network (FoodNet) data (2007-2016).

Campylobacter is a leading cause of bacterial foodborne illness in the United States. Campylobacter infections have most often been associated with food-related risk factors, such as the consumption of poultry and raw milk. Socioeconomic, agricultural and environmental factors, including drinking water source, can also influence the risk of campylobacteriosis. Approximately 19% of Maryland residents rely on private wells as their sole source of water. Given that the federal Safe Drinking Water Act does not regulate the water quality of private wells, these could be important non-foodborne transmission pathways for Campylobacter. To address this issue, data on the number of culture-confirmed cases of Campylobacter infection in Maryland between 2007 and 2016 were obtained from the Foodborne Diseases Active Surveillance Network. Cases were linked by zip code with data from the Maryland well permits registry, the 2010 U.S. Census, the 2016 American Community Survey, and the USDA Agricultural Census. Campylobacteriosis incidence rates and well prevalence were calculated by zip code. Negative binomial regression models were then constructed to evaluate the association between the prevalence of private wells, presence/absence of animal feeding operations and the incidence of campylobacteriosis across the physiographic provinces in Maryland. From 2007 to 2016, a total of 5746 cases of campylobacteriosis were reported in Maryland, and annual incidence rates ranged from 6.65 to 11.59 per 100,000 people. In our statewide analysis, a significant positive association was observed between well prevalence and increased campylobacteriosis incidence at the zip code level (Incidence Rate Ratio (IRR) = 1.35, 95% Confidence Interval (CI) = 1.11, 1.63). A significant positive association was also observed between well prevalence and increased campylobacteriosis incidence in the Appalachian and Coastal provinces of Maryland (IRR = 2.94, 95% CI = 1.11, 7.76 and IRR = 1.70, 95% CI = 1.25, 2.31, respectively). The presence of broiler chicken operations, increasing median age and percentage of residents living in poverty were also significantly associated with campylobacteriosis incidence at the zip code level in some physiographic provinces in Maryland. To our knowledge, these are the first US data to demonstrate an association between prevalence of private wells and campylobacteriosis incidence at the zip code level.

Tobacco Point-of-Sale Influence on U.S. Adult Smokers.

INTRODUCTION: Prior research has shown that tobacco companies target point-of-sale (POS) marketing to low-income communities. This research assessed the association between demographic characteristics and venue type with purchasing tobacco products in response to marketing. METHODS: Using Population Assessment of Tobacco and Health (PATH) Study Wave 1 Adult data, this analysis compared promotion awareness and purchase influence among current smokers. RESULTS: Tobacco promotions were more likely to be noticed at convenience stores, gas stations, or tobacco stores than at other outlets. Smokers who bought their cigarettes at these outlets were more likely to purchase a brand other than their usual brand because of marketing. Smokers below the poverty level had greater odds than others to have noticed tobacco ads and to indicate purchase influence. CONCLUSIONS: Point-of-sale marketing is effective in garnering the attention of low-income populations and influencing their tobacco purchases. Enforcing retailers' adherence to regulations is vital.

Causes of Excess Deaths in Puerto Rico After Hurricane Maria: A Time-Series Estimation.

Objectives. To determine the number and causes of excess deaths in Puerto Rico after Hurricane Maria made landfall on September 20, 2017. Methods. We obtained monthly vital statistics data on all deaths from January 2008 through October 2017. We conducted a time-series analysis to estimate excess mortality in September and October 2017 overall and by age, sex, and cause of death. Results. We estimated a total of 1205 excess deaths (95% confidence interval [CI] = 707, 1702). Excess deaths were slightly higher among men than women (632 and 579 deaths, respectively) and found only among people aged 60 years or older (1038 deaths). Most excess deaths occurred from heart disease (253 deaths), "other" causes (204 deaths), diabetes (195 deaths), Alzheimer's disease (122 deaths), and septicemia (81 deaths). Conclusions. The number of excess deaths was similar to recent government estimates. However, this study is the first to identify the causes of death that were exacerbated by the disaster. Public Health Implications. An accurate estimation of the top causes of excess mortality can help authorities plan resource allocation for the island's recovery and for the prevention of deaths in future disasters.