Cannabis use among adolescents and emerging adults who use e-cigarettes: Findings from an online, national U.S. Sample.

Concurrent use of e-cigarettes and cannabis among adolescents and emerging adults is a growing public health concern. More research is needed describing cannabis use among adolescents and emerging adults who vape. The objective of this study was to characterize cannabis use among adolescents and emerging adults (age 14-20) who reported e-cigarette ever-use, particularly their use of blunts and liquid cannabis vape (LCV) products. Using cross-sectional data from a national online survey, we describe their patterns of cannabis use, detail their use of flavored cannabis and tobacco products, and estimate associations of demographic factors and other current substance use behaviors with levels of blunt and LCV use. Of the 2253 respondents in the sample, 1379 (61 %) reported some form of cannabis use in the past 30 days, among whom 80 % used flavored cannabis (including edibles). Significant associations with current cannabis use were observed on several demographic measures, with current cannabis blunt use more frequent among participants not in school, non-Hispanic Blacks, multiracial respondents, and those whose incomes do not meet their expenses. Other than income, demographic characteristics were generally not associated with LCV use frequency. Use of other substances was associated with more frequent use of both blunts and LCV in the past 30 days, and enrollment in college or the military seems somewhat protective for emerging adults. These findings suggest a need for tailored prevention efforts among high-risk adolescents and emerging adults, potential regulation of added flavors in commercialized cannabis products, and stronger enforcement of retail restrictions for individuals under age 21 more broadly.

Use of Emerging and Conventional Oral Tobacco Among Adolescent and Young Adult E-Cigarette Users.

Background: National surveillance assessing use of novel oral tobacco products (OTPs; nicotine pouches, lozenges, and gums not approved for tobacco cessation) among adolescents and young adults is limited. Objectives: To assess OTP behaviors in a sample of adolescent and young adult e-cigarette users, including use prevalence, dual/poly use with other products, and associated demographics. Methods: A national (United States) cross-sectional survey was conducted from March to April 2021 among 2253 participants (ages 14-20; 65% female) who ever used e-cigarettes ≥3 times. Demographics, lifetime use, and past 30-day use of 10 tobacco and cannabis products, including novel and conventional (chew, moist snuff, or snus) OTPs was assessed. Analysis was descriptive, examining use prevalence (lifetime and past 30-day) of each product, including by demographics and other product use. Results: Nearly 44% reported ever using any OTP, with nicotine pouches being the most commonly ever used (29%) and used in the past month (11%). Novel OTP use was more common among older participants (18-20 years), male participants, and past 30-day users of e-cigarettes, combustible tobacco, and conventional oral tobacco. However, female participants and combustible tobacco non-users were over twice and 4-times as likely, respectively, to use novel OTPs than conventional OTPs. Nearly 73% of past 30-day conventional OTP users were past 30-day novel OTP users. Conclusion: Novel OTP use was prevalent among adolescent and young adult e-cigarette users. Compared to conventional OTPs, novel OTPs likely have greater appeal to females and combustible tobacco non-users. Action to restrict access and reduce interest in OTPs is needed to prevent use among this population.

Practice patterns of postgraduate trained dentists in the United States.

OBJECTIVE: Postgraduate dental (PGD) primary care training has grown significantly. This study examines the individual, educational, community, and policy factors that predict practice patterns of PGD-trained dentists. STUDY DESIGN: Individual dentist records from the 2017 American Dental Association Masterfile, with indicators of Medicaid participation and practice in a Federally Qualified Health Center (FQHC), were linked to postdoctoral training, community/practice location, and state policy factors. Generalized logistic models, adjusted for these factors, were used to predict PGD-trained dentists: (1a) serving Medicaid children, (1b) accepting new Medicaid patients, and (2) working in an FQHC. RESULTS: Individual attributes that predicted serving Medicaid children included all race/gender combinations (vs. White females), and foreign-trained dentists and contractors/employees/associates (vs. practice owners). Black women are most likely to work in an FQHC. Residency attributes that predicted serving Medicaid children and working in an FQHC were Health Resources and Services Administration postdoctoral funding and being community based. Dentists practicing in rural or high-poverty communities were more likely to serve Medicaid children and work at FQHCs. States with higher levels of graduate medical education investment, higher Medicaid rates, and more generous adult dental Medicaid benefits increased the likelihood of serving Medicaid children, while states with more expansive adult dental Medicaid benefits increased the likelihood of working in an FQHC. CONCLUSION: Federal training investment in PGD education combined with Medicaid payment and coverage policies can strongly impact access to dental care for vulnerable populations. Yet, oral health equity cannot be achieved without increasing dentist workforce diversity.

Trends in postgraduate dental training in the United States.

OBJECTIVE: This study examines the individual, educational, and policy factors that predict dentists pursuing postgraduate dental (PGD) training. METHODS: Individual dentist records from the 2017 American Dental Association Masterfile were linked with pre-doctoral training attributes and state-level dental policy factors. Generalized logistic models, adjusted for individual, educational, and policy factors, were used to predict: (1) attending any PGD program, and (2) primary (i.e., advanced general practice, pediatrics, or dental public health, per the Health Resources and Services Administration [HRSA]) versus specialty care. RESULTS: The majority of new PGD residency slots (77%) were in primary care. Women held 56% of primary care slots; men held 62% of specialty slots. Individual characteristics that predicted PGD primary care training included being Black, Hispanic, Asian, or other race; being male or older age reduced the odds. Pre-doctoral school characteristics that predicted PGD primary care training included having a pre-doctoral HRSA grant, affiliation with an academic medical center, and being a historically Black college/university; being a private school or in a small metro area lowered the odds. At the policy level, the strongest predictors of attending PGD primary care training are a residency requirement in the state you currently practice in and federal graduate medical education (GME) investment per residency slot. CONCLUSION: Pursuing PGD training is variable based on the race/ethnicity/gender of the dentist. Federal investments in pre-doctoral dental education and GME can drive equity, as they significantly increase the odds that dentists will go on to PGD training, as do state licensure requirements.

Preferences, use, and perceived access to flavored e-cigarettes among United States adolescents and young adults.

Background: Citing concern over youth use, the Food and Drug Administration announced a prioritized enforcement policy against cartridge-based (reusable pod) e-cigarettes in non-menthol, non-tobacco flavors, effective February 2020. Data are needed regarding youth e-cigarette access and use behaviors following this policy. Methods: This cross-sectional national (USA) online panel survey, conducted March/April 2021, included 2253 participants ages 14-20 who ever used e-cigarettes ≥3 times (73% past 30-day users). Participants reported their flavor preferences, use reasons, and perceived ease of access. Latent class analysis categorized participants according to their preferred e-cigarette flavors, and multinominal logistic regression identified sociodemographic and behavioral correlates of class membership. Results: Most past 30-day e-cigarette users used reusable pod (77%) or modern disposable (68%) devices, ≥1 non-tobacco (92%), sweet (76%), and/or menthol flavors including fruit-ice (70%) (flavor and device categories not mutually exclusive). Most past 30-day users (70%) and non-users (63%) perceived it would be somewhat or very easy to acquire e-cigarettes in flavors they like. Latent class analysis identified four e-cigarette flavor preference classes: mint (34% of sample), no preference (29%), fruit/sweet (28%), and dislikes ≥1 flavor (10%). Relative to no preference, membership in fruit/sweet (RRR: 1.87; 95% CI: 1.37, 2.57) and mint (RRR: 3.85; 95% CI: 2.77, 5.36) classes was associated with using e-cigarettes ≥50 times. Fruit/sweet membership was inversely associated with combustible tobacco use (RRR: 0.50; 95% CI: 0.38, 0.66). Conclusion: Young e-cigarette users maintained ample access to flavored and cartridge-based products. Stronger access restrictions and enforcement are required to reduce youth e-cigarette use.

A longitudinal cohort study of opioid prescriptions associated with nonsurgical dental visits among Oregon and New York state Medicaid beneficiaries, 2014-2016.

BACKGROUND: Studies estimate that approximately one-third of all opioid prescriptions (Rxs) from dentists are associated with nonsurgical dental procedures, which suggests unwarranted opioid use. METHODS: The authors conducted a retrospective longitudinal cohort study of adult Medicaid beneficiaries using administrative claims data from New York (NY) and Oregon (OR) (2014-2016) to examine opioid Rxs associated with nonsurgical dental visits. The primary outcomes were the number of all opioid Rxs from dentists compared with nondentists, number of opioid Rxs associated with surgical and nonsurgical dental visits, time to subsequent dental visits and visit type, and total dental morphine milligram equivalents (MMEs) received during the 90 days after an opioid-related, nonsurgical dental visit. RESULTS: Dentists prescribed 6.9% (NY) and 11.9% (OR) of all opioid Rxs during the 3-year study period. One-third of all opioid-related dental visits were nonsurgical and one-half of the subsequent dental visits were either nonsurgical or did not occur within 90 days. Mean time to a subsequent dental visit was 3 weeks. Beneficiaries with a surgical dental follow-up visit received significantly higher total MMEs (NY: 1.19 MMEs; OR: 1.21 MMEs; P < .001) for each additional day before the follow-up visit compared with nonsurgical dental follow-up visits. CONCLUSIONS: Medicaid beneficiaries might be exposed to unnecessary opioid Rxs in situations in which they may not be indicated or effective and without a plan for more definitive treatment. PRACTICAL IMPLICATIONS: Dentists need to avoid delays in scheduling definitive treatment and take appropriate steps to monitor prescribed opioid use to reduce the well-known risks associated with undue or prolonged opioid exposure.

Dental Therapists in the United States: Health Equity, Advancing.

BACKGROUND: Dental therapists (DTs) are primary care dental providers, used globally, and were introduced in the United States (US) in 2005. DTs have now been adopted in 13 states and several Tribal nations. OBJECTIVES: The objective of this study is to qualitatively examine the drivers and outcomes of the US dental therapy movement through a health equity lens, including community engagement, implementation and dissemination, and access to oral health care. METHODS: The study compiled a comprehensive document library on the dental therapy movement including literature, grant documents, media and press, and gray literature. Key stakeholder interviews were conducted across the spectrum of engagement in the movement. Dedoose software was used for qualitative coding. Themes were assessed within a holistic model of oral health equity. FINDINGS: Health equity is a driving force for dental therapy adoption. Community engagement has been evident in diverse statewide coalitions. National accreditation standards for education programs that can be deployed in 3 years without an advanced degree reduces educational barriers for improving workforce diversity. Safe, high-quality care, improvements in access, and patient acceptability have been well documented for DTs in practice. CONCLUSION: Having firmly taken root politically, the impact of the dental therapy movement in the US, and the long-term health impacts, will depend on the path of implementation and a sustained commitment to the health equity principle.

Flavored Cannabis Product Use Among Adolescents in California.

Given the well-documented role of flavors in encouraging tobacco use among adolescents and diversity of the cannabis market, we describe flavored cannabis product use, both smoked and aerosolized ("vaped"), among a sample of adolescents. We surveyed 1,423 students in 8 Northern and Central California public high schools (2019-2020) to record flavored tobacco and cannabis use. Among past 30-day cannabis users, use of flavored cannabis, most often fruit-flavored, was common for smoked (48.1%) and vaped (58.0%) products. Given that youth-appealing flavors may contribute to underage cannabis use, emerging cannabis control policies should consider lessons from tobacco control to prevent youth cannabis use.

Beverage Advertisement Receptivity Associated With Sugary Drink Intake and Harm Perceptions Among California Adolescents.

PURPOSE: Evaluate associations of adolescents' beverage marketing receptivity with sugar-sweetened beverage (SSB) perceived harm and intake. DESIGN: School-based cross-sectional health behavior survey. SETTING: Seven rural schools in California, 2019-2020. SUBJECTS: 815 student participants in grades 9 or 10. MEASURES: Participants viewed 6 beverage advertisement images with brand obscured, randomly selected from a larger pool. Ads for telecommunications products were an internal control. Receptivity was a composite of recognizing, liking, and identifying the displayed brand (later categorized: low, moderate, high). Weekly SSB servings were measured with a quantitative food frequency questionnaire and perceived SSB harm as 4 levels ("no harm" to "a lot"). ANALYSIS: Outcomes SSB intake (binomial regression) and perceived harm (ordered logistic regression) were modeled according to advertisement receptivity (independent variable), with multiple imputation, school-level clustering, and adjustment for presumed confounders (gender, age, screen time, etc.). RESULTS: In covariable-adjusted models, greater beverage advertisement receptivity independently predicted higher SSB intake (ratio of SSB servings, high vs. low receptivity: 1.48 [95% CI: 1.15, 1.89]) and lower perceived SSB harm (odds ratio, high vs. low receptivity: 0.59 [0.40, 0.88]). Perceived SSB harm was inversely associated with SSB intake. CONCLUSION: Beverage advertisement receptivity was associated with less perceived SSB harm and greater SSB consumption in this population. Policy strategies, including marketing restrictions or counter-marketing campaigns could potentially reduce SSB consumption and improve health.

Electronic cigarette and moist snuff product characteristics independently associated with youth tobacco product perceptions.

INTRODUCTION: Tobacco product characteristics convey product attributes to potential users. This study aimed to assess independent contributions of specific e-cigarette and smokeless tobacco product characteristics to adolescents' perceptions about these products. METHODS: In 2019-2020, students (N=1003) attending a convenience sample of 7 high schools in California (USA) were individually randomized to one of two discrete choice experiments, featuring either electronic cigarettes (e-cigarettes) or moist snuff. Participants were presented like-product pairs of randomlygenerated hypothetical tobacco products differing in device type, flavor, vapor cloud, and nicotine amount (for e-cigarettes) or differing in brand, flavor, cut, and price (for moist snuff). Within pairs, participants were asked about which product they were more curious, was more dangerous, would give a greater 'buzz,' and would be easier to use. Conditional logistic regression was used to quantify independent associations of product characteristics to participants' choices. RESULTS: Each e-cigarette and moist snuff characteristic was independently associated with multiple product perceptions. All non-tobacco flavors were associated with more curiosity and perceived ease-of-use but lower perceived danger. Tank and pod-type e-cigarettes were viewed as easier to use and garnered more curiosity than 'cigalike' or 'drip-mod' devices. Smaller vapor cloud e-cigarettes and lower-price moist snuff were viewed as less dangerous, less buzz-inducing, and easier to use. Product ever users held stronger perceptions than never users about device type (e-cigarettes) and brands (moist snuff), while product naïve participants more strongly associated flavor with danger and buzz. CONCLUSIONS: Tobacco product characteristics convey product attributes to adolescents that may increase appeal. Restricting specific characteristics, including flavors, could reduce positive perceptions of these products among youth.

A bimodular PKS platform that expands the biological design space.

Traditionally engineered to produce novel bioactive molecules, Type I modular polyketide synthases (PKSs) could be engineered as a new biosynthetic platform for the production of de novo fuels, commodity chemicals, and specialty chemicals. Previously, our investigations manipulated the first module of the lipomycin PKS to produce short chain ketones, 3-hydroxy acids, and saturated, branched carboxylic acids. Building upon this work, we have expanded to multi-modular systems by engineering the first two modules of lipomycin to generate unnatural polyketides as potential biofuels and specialty chemicals in Streptomyces albus. First, we produce 20.6 mg/L of the ethyl ketone, 4,6 dimethylheptanone through a reductive loop exchange in LipPKS1 and a ketoreductase knockouts in LipPKS2. We then show that an AT swap in LipPKS1 and a reductive loop exchange in LipPKS2 can produce the potential fragrance 3-isopropyl-6-methyltetrahydropyranone. Highlighting the challenge of maintaining product fidelity, in both bimodular systems we observed side products from premature hydrolysis in the engineered first module and stalled dehydration in reductive loop exchanges. Collectively, our work expands the biological design space and moves the field closer to the production of "designer" biomolecules.

Chemoinformatic-Guided Engineering of Polyketide Synthases.

Polyketide synthase (PKS) engineering is an attractive method to generate new molecules such as commodity, fine and specialty chemicals. A significant challenge is re-engineering a partially reductive PKS module to produce a saturated ß-carbon through a reductive loop (RL) exchange. In this work, we sought to establish that chemoinformatics, a field traditionally used in drug discovery, offers a viable strategy for RL exchanges. We first introduced a set of donor RLs of diverse genetic origin and chemical substrates  into the first extension module of the lipomycin PKS (LipPKS1). Product titers of these engineered unimodular PKSs correlated with chemical structure similarity between the substrate of the donor RLs and recipient LipPKS1, reaching a titer of 165 mg/L of short-chain fatty acids produced by the host Streptomyces albus J1074. Expanding this method to larger intermediates that require bimodular communication, we introduced RLs of divergent chemosimilarity into LipPKS2 and determined triketide lactone production. Collectively, we observed a statistically significant correlation between atom pair chemosimilarity and production, establishing a new chemoinformatic method that may aid in the engineering of PKSs to produce desired, unnatural products.