Effects of residential socioeconomic polarization on high blood pressure among nursing home residents.

OBJECTIVE: Neighborhood concentration of racial, income, education, and housing deprivation is known to be associated with higher rates of hypertension. The objective of this study is to examine the association between tract-level spatial social polarization and hypertension in a cohort with relatively equal access to health care, a Veterans Affairs nursing home. METHODS: 41,973 long-term care residents aged ≥65 years were matched with tract-level Indices of Concentration at the Extremes across four socioeconomic domains. We modeled high blood pressure against these indices controlling for individual-level cardiovascular confounders. RESULTS: We found participants who had resided in the most disadvantaged quintile had a 1.10 (95% 1.01, 1.19) relative risk of high blood pressure compared to those in the other quintiles for the joint measuring race/ethnicity and income domain. CONCLUSIONS: We achieved our objective by demonstrating that concentrated deprivation is associated with worse cardiovascular outcomes even in a population with equal access to care. Measures that jointly consider economic and racial/ethnic polarization elucidate larger disparities than single domain measures.

Neighborhood factors and survival to old age: The Jackson Heart Study.

Few studies have evaluated environmental factors that predict survival to old age. Our study included 913 African American participants in the Jackson Heart Study (JHS) who resided in the tri-county area of the Jackson, MS metropolitan area and were 65-80 years at baseline. Participants were followed from 2000 through 2019 for the outcome of survival to 85 years old. We evaluated each of the following census tract-level measures of the social/physical environment as exposures: socioeconomic status, cohesion, violence, disorder, healthy food stores, residential land use, and walkability. We assessed mediation by physical activity and chronic conditions. As a complementary ecologic analysis, we used census-tract data to examine factors associated with a greater life expectancy. A total of 501 (55%) JHS participants survived to age 85 years or older. Higher social cohesion and greater residential land use were modestly associated with survival to old age (risk difference = 25%, 95% CI: 0-49%; and 4%, 95% CI: 1-7%, respectively). These neighborhood effects were modestly mediated through leisure time physical activity; additionally, social cohesion was mediated through home and yard activity. In our ecologic analysis, a greater percentage of homeowners and a greater proportion of people living in partnered families were associated with higher census-tract level life expectancy. African American older adults living in residential neighborhoods or neighborhoods with high social cohesion were more likely to survive to old age.

Adolescent individual, school, and neighborhood influences on young adult diabetes risk.

Using data from the National Longitudinal Study of Adolescent to Adult Health (Add Health), this study examines the association between adolescent school and neighborhood contexts and the likelihood of diabetes in young adulthood. We apply cross-classified multi-level modeling (CCMM) techniques to examine the simultaneous influence of non-nested school and neighborhood contexts as well as individual, school, and neighborhood-level factors (N = 14,041 participants from 128 schools, 1933 neighborhoods). Our findings suggest that individual-level factors are most associated with young adult diabetes, with small contributions from school and neighborhood factors and a small proportion of the variation explained by school and neighborhood contexts.

Telemedicine Utilization Among Patients With Multiple Sclerosis in the US Veterans Health Administration, 2010-2020.

Background and Objectives: Telemedicine may help to bridge the specialty care access gap for patients with MS (PwMS) restricted by distance or disability. The objective of this study is to assess the frequency and longitudinal patterns of telemedicine utilization among PwMS and controls. Methods: We conducted a population-based nested case-control study within the Veterans Health Administration (VHA) from January 1, 2010, to December 31, 2020. MS cases and controls were individually matched on sex, age, and Veterans Affair (VA) service region (Veterans Integrated Service Network). MS case and control participants sample sizes by year included 2010: 19,387/86,379; 2016: 19,752/88,535; and 2020: 16,451/78,315. Telemedicine encounter codes were used to identify telemedicine utilization among MS cases and controls in the VHA for 2010, 2016, and 2020. Telemedicine encounters were categorized according to mode (video, phone, and supplementary remote) and type of care provided. Results: Patients in the VHA have had increasing utilization of telemedicine over the past decade. Among PwMS, mean telemedicine encounters increased steadily from 2010 to 2020 (5.6-10.5 encounters/patient, respectively). Across all years, MS cases were significantly more likely than controls to use telemedicine. The odds ratios (ORs) (95% confidence interval [CI]) of any telemedicine utilization comparing MS cases with controls in 2010, 2016, and 2020, respectively, were 1.5 (CI: 1.3-1.5), 1.9 (CI: 1.8-2.0), and 1.7 (CI: 1.6-1.8). Compared with non-Hispanic White veterans, non-Hispanic Black veterans were more likely to use telemedicine (adjusted OR = 1.5; [CI: 1.40-1.60]). The most common and least common modes of telemedicine among cases and controls were telephone and supplementary remote, respectively. Comparing 2010 with 2020, the largest increases in telemedicine utilization exhibited among MS cases were among primary care, specialty care, specialty neurology care, and other types of health care. States with the highest increases in telemedicine utilization were AL, CA, CO, FL, GA, KS, IL, NY, and SC. PwMS tended to live in counties with more adverse social determinants of health compared with controls. Discussion: PwMS were significantly more likely to use telemedicine than their matched controls. There were significant increases in telemedicine utilization between 2010 and 2020. The VHA has a robust telemedicine system of care that has grown to supplement in person care more so than other US health care systems. Future work is needed to assess the determinants of telemedicine utilization.

Cardiovascular Diseases, Medications, and ALS: A Population-Based Case-Control Study.

INTRODUCTION: We investigated the associations between antecedent all-cause CVD diagnoses, cause-specific CVD diagnosis, and CVD medication prescriptions with the risk of developing amyotrophic lateral sclerosis (ALS). MATERIALS AND METHODS: We conducted a population-based case-control study of U.S. Medicare enrollees from 2006 to 2013. The final sample included 3,714 incident ALS cases and 18,570 controls (matched on age, sex, enrollment length, and county). Information was collected from Medicare Parts A, B, and D administrative claims data on hypertension, ischemic heart disease, heart failure, acute myocardial infarction, atrial fibrillation, prescriptions of angiotensin-converting enzyme inhibitors, angiotensin II receptors blockers, calcium channel blockers, beta blockers, and antiarrhythmics. Associations were evaluated using conditional logistic regression adjusting for age, sex, race/ethnicity, geographical location, alcohol and tobacco use, and socioeconomic status. RESULTS: The odds ratio (OR) for having one or more ICD-9 codes for any cardiovascular disease diagnosis at least 24 months prior to the date of ALS diagnosis was 0.85 (95% confidence interval [CI]: 0.78-0.92). Cardiovascular conditions that were inversely associated with ALS included heart failure (OR = 0.79; 95% CI 0.70-0.89), atrial fibrillation (OR = 0.81; 95% CI 0.77-0.92), and hypertension (OR = 0.91; 95% CI 0.84-0.98). Exposures to several classes of cardiovascular medications were inversely associated with ALS risk even after adjusting for confounding by indication, including ACE inhibitors (OR = 0.84, 95% CI 0.77-0.91), calcium channel blockers (OR = 0.64, 95% CI 0.59-0.70), and beta blockers (OR = 0.76, 95% CI 0.71-0.83). DISCUSSION/CONCLUSION: These findings merit additional research, including animal studies and pilot clinical trials, to further evaluate and evidence the effects of ACEIs, CCBs, and BBs on the risk of developing and clinical expression of ALS.

Increasing Representation of Epidemiologists From Around the World in the Society for Epidemiologic Research: The Case of Mexico.

Mexico has a population of 129 million and is considered one of the most unequal countries in the world, suffering from widespread health disparities. There is a pressing need to strengthen epidemiologic capacity in Mexico, to help solve the complex health problems the country faces and to reduce health inequities. However, the representation of Mexican epidemiologists in the largest epidemiologic society in North America is low, despite the short distance to the United States. In this commentary, we discuss the barriers to higher representation of Mexican epidemiologists within the Society for Epidemiologic Research (SER), including language barriers, costs, and regional necessities. We also discuss opportunities to expand Mexican SER representation and collaboration. Overall, we hope that this is a call towards expanding SER global participation and starting a conversation on a common agenda for epidemiologic research.

Adolescent individual, school, and neighborhood influences on young adult hypertension risk.

BACKGROUND: Geographic and contextual socioeconomic risk factors in adolescence may be more strongly associated with young adult hypertension than individual-level risk factors. This study examines the association between individual, neighborhood, and school-level influences during adolescence on young adult blood pressure. METHODS: Data were analyzed from the National Longitudinal Study of Adolescent to Adult Health (1994-1995 aged 11-18 and 2007-2008 aged 24-32). We categorized hypertension as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg. Secondary outcomes included continuous systolic and diastolic blood pressure. We fit a series of cross-classified multilevel models to estimate the associations between young adulthood hypertension with individual-level, school-level, and neighborhood-level factors during adolescence (i.e., fixed effects) and variance attributable to each level (i.e., random effects). Models were fit using Bayesian estimation procedures. For linear models, intra-class correlations (ICC) are reported for random effects. RESULTS: The final sample included 13,911 participants in 128 schools and 1,917 neighborhoods. Approximately 51% (7,111) young adults were hypertensive. Individual-level characteristics-particularly older ages, Non-Hispanic Black race, Asian race, male sex, BMI, and current smoking-were associated with increased hypertension. Non-Hispanic Black (OR = 1.21; 95% CI: 1.03-1.42) and Asian (OR = 1.28; 95% CI: 1.02-1.62) students had higher odds of hypertension compared to non-Hispanic White students. At the school level, hypertension was associated with the percentage of non-Hispanic White students (OR for 10% higher = 1.06; 95% CI: 1.01-1.09). Adjusting for individual, school, and neighborhood predictors attenuated the ICC for both the school (from 1.4 null to 0.9 fully-adjusted) and neighborhood (from 0.4 to 0.3). CONCLUSION: We find that adolescents' schools and individual-level factors influence young adult hypertension, more than neighborhoods. Unequal conditions in school environments for adolescents may increase the risk of hypertension later in life. Our findings merit further research to better understand the mechanisms through which adolescents' school environments contribute to adult hypertension and disparities in hypertension outcomes later in life.

Prevalence and Sociodemographic Correlates of Unmet Need for Mental Health Counseling Among Adults During the COVID-19 Pandemic.

OBJECTIVE: This study aimed to determine the prevalence and correlates of unmet need for mental health counseling among U.S. adults during the COVID-19 pandemic. METHODS: Data from the December 9-21, 2020, cross-sectional Household Pulse Survey (N=69,944) were analyzed. RESULTS: Overall, 12.8% of adults reported an unmet need for mental health counseling in the past month, including 25.2% of adults with a positive screen for depression or anxiety. Among adults with a positive screen, risk factors associated with an unmet need for mental health counseling included female sex, younger age, income below the federal poverty line, higher education, and household job loss during the pandemic, while protective factors included Asian and Black race. CONCLUSIONS: Over one-quarter of U.S. adults with a positive screen for depression or anxiety experienced an unmet need for mental health counseling during the pandemic. Policy makers should consider increasing funding for mental health services as part of pandemic relief legislation.

Differences in COVID-19 Risk by Race and County-Level Social Determinants of Health among Veterans.

COVID-19 disparities by area-level social determinants of health (SDH) have been a significant public health concern and may also be impacting U.S. Veterans. This retrospective analysis was designed to inform optimal care and prevention strategies at the U.S. Department of Veterans Affairs (VA) and utilized COVID-19 data from the VAs EHR and geographically linked county-level data from 18 area-based socioeconomic measures. The risk of testing positive with Veterans' county-level SDHs, adjusting for demographics, comorbidities, and facility characteristics, was calculated using generalized linear models. We found an exposure-response relationship whereby individual COVID-19 infection risk increased with each increasing quartile of adverse county-level SDH, such as the percentage of residents in a county without a college degree, eligible for Medicaid, and living in crowded housing.

Creation and validation of a polysocial score for mortality among community-dwelling older adults in the USA: the health and retirement study.

BACKGROUND: the interrelatedness between social determinants of health impedes researchers to identify important social factors for health investment. A new approach is needed to quantify the aggregate effect of social factors and develop person- centred social interventions. METHODS: participants ([n = 7,383], 54.5% female) were aged 65 years or above who complete an additional psychosocial questionnaire in the health and retirement study in 2006 or 2008. Social determinants of health encompassed five social domains: economic stability, neighbourhood and physical environment, education, community and social context, and healthcare system. We used the forward stepwise logistic regression to derive a polysocial score model for 5-year mortality. Indices of goodness-of-fit, discrimination and reclassification were used to assess model performance. We used logistic regression to identify the association between polysocial score and mortality. Subgroup analyses were conducted to examine sex- and race-specific association. RESULTS: polysocial score was created using 14 social determinants of health. In the training cohort, the C-statistic was 0.71 for the reference model (only age, sex and race/ethnicity) and increased to 0.75 for the continuous and categorical polysocial score. Compared with the reference model, the integrated discrimination index for adding the continuous or categorical polysocial score was both 0.03 (P values < 0.001). Participants with an intermediate (odds ratio [OR] = 0.69; 95% confidence interval [CI], 0.51-0.82) or high (OR = 0.48; 95% CI, 0.38-0.60) polysocial score had lower odds of death than those in the low category in the fully adjusted model, respectively. CONCLUSIONS: the polysocial approach may offer possible solutions to monitor social environments and suggestions for older people to improve their social status for specific health outcomes.

Association Between Income Inequality and County-Level COVID-19 Cases and Deaths in the US.

Importance: Socioeconomically marginalized communities have been disproportionately affected by the COVID-19 pandemic. Income inequality may be a risk factor for SARS-CoV-2 infection and death from COVID-19. Objective: To evaluate the association between county-level income inequality and COVID-19 cases and deaths from March 2020 through February 2021 in bimonthly time epochs. Design, Setting, and Participants: This ecological cohort study used longitudinal data on county-level COVID-19 cases and deaths from March 1, 2020, through February 28, 2021, in 3220 counties from all 50 states, Puerto Rico, and the District of Columbia. Main Outcomes and Measures: County-level daily COVID-19 case and death data from March 1, 2020, through February 28, 2021, were extracted from the COVID-19 Data Repository by the Center for Systems Science and Engineering at Johns Hopkins University in Baltimore, Maryland. Exposure: The Gini coefficient, a measure of unequal income distribution (presented as a value between 0 and 1, where 0 represents a perfectly equal geographical region where all income is equally shared and 1 represents a perfectly unequal society where all income is earned by 1 individual), and other county-level data were obtained primarily from the 2014 to 2018 American Community Survey 5-year estimates. Covariates included median proportions of poverty, age, race/ethnicity, crowding given by occupancy per room, urbanicity and rurality, educational level, number of physicians per 100 000 individuals, state, and mask use at the county level. Results: As of February 28, 2021, on average, each county recorded a median of 8891 cases of COVID-19 per 100 000 individuals (interquartile range, 6935-10 666 cases per 100 000 individuals) and 156 deaths per 100 000 individuals (interquartile range, 94-228 deaths per 100 000 individuals). The median county-level Gini coefficient was 0.44 (interquartile range, 0.42-0.47). There was a positive correlation between Gini coefficients and county-level COVID-19 cases (Spearman ρ = 0.052; P < .001) and deaths (Spearman ρ = 0.134; P < .001) during the study period. This association varied over time; each 0.05-unit increase in Gini coefficient was associated with an adjusted relative risk of COVID-19 deaths: 1.25 (95% CI, 1.17-1.33) in March and April 2020, 1.20 (95% CI, 1.13-1.28) in May and June 2020, 1.46 (95% CI, 1.37-1.55) in July and August 2020, 1.04 (95% CI, 0.98-1.10) in September and October 2020, 0.76 (95% CI, 0.72-0.81) in November and December 2020, and 1.02 (95% CI, 0.96-1.07) in January and February 2021 (P < .001 for interaction). The adjusted association of the Gini coefficient with COVID-19 cases also reached a peak in July and August 2020 (relative risk, 1.28 [95% CI, 1.22-1.33]). Conclusions and Relevance: This study suggests that income inequality within US counties was associated with more cases and deaths due to COVID-19 in the summer months of 2020. The COVID-19 pandemic has highlighted the vast disparities that exist in health outcomes owing to income inequality in the US. Targeted interventions should be focused on areas of income inequality to both flatten the curve and lessen the burden of inequality.

Mental disorder prevalence among populations impacted by coronavirus pandemics: A multilevel meta-analytic study of COVID-19, MERS & SARS.

OBJECTIVE: Through a systematic review and meta-analysis of research on COVID-19, severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS) pandemics, we investigated whether mental disorder prevalence: (a) was elevated among populations impacted by coronavirus pandemics (relative to unselected populations reported in the literature), and (b) varied by disorder (undifferentiated psychiatric morbidity, anxiety, depressive, posttraumatic stress disorders [PTSD]) and impacted population (community, infected/recovered, healthcare provider, quarantined). METHOD: From 68 publications (N = 87,586 participants), 808 estimates were included in a series of multilevel meta-analyses/regressions including random effects to account for estimates nested within studies. RESULTS: Median summary point prevalence estimates varied by disorder and population. Psychiatric morbidity (20-56%), PTSD (10-26%) and depression (9-27%) were most prevalent in most populations. The highest prevalence of each disorder was found among infected/recovered adults (18-56%), followed by healthcare providers (11-28%) and community adults (11-20%). Prevalence estimates were often notably higher than reported for unselected samples. Sensitivity analyses demonstrated that overall prevalence estimates moderately varied by pandemic, study location, and mental disorder measure type. CONCLUSION: Coronavirus pandemics are associated with multiple mental disorders in several impacted populations. Needed are investigations of causal links between specific pandemic-related stressors, threats, and traumas and mental disorders.

Differences in COVID-19 Testing and Test Positivity Among Veterans, United States, 2020.

OBJECTIVE: COVID-19 disproportionately affects racial/ethnic minority groups in the United States. We evaluated characteristics associated with obtaining a COVID-19 test from the Veterans Health Administration (VHA) and receiving a positive test result for COVID-19. METHODS: We conducted a retrospective cohort analysis of 6 292 800 veterans in VHA care at 130 VHA medical facilities. We assessed the number of tests for SARS-CoV-2 administered by the VHA (n = 822 934) and the number of positive test results (n = 82 094) from February 8 through December 28, 2020. We evaluated associations of COVID-19 testing and test positivity with demographic characteristics of veterans, adjusting for facility characteristics, comorbidities, and county-level area-based socioeconomic measures using nested generalized linear models. RESULTS: In fully adjusted models, veterans who were female, Black/African American, Hispanic/Latino, urban, and low income and had a disability had an increased likelihood of obtaining a COVID-19 test, and veterans who were Asian had a decreased likelihood of obtaining a COVID-19 test. Compared with veterans who were White, veterans who were Black/African American (risk ratio [RR] = 1.23; 95% CI, 1.19-1.27) and Native Hawaiian/Other Pacific Islander (RR = 1.13; 95% CI, 1.05-1.21) had an increased likelihood of receiving a positive test result. Hispanic/Latino veterans had a 43% higher likelihood of receiving a positive test result than non-Hispanic/Latino veterans did. CONCLUSIONS: Although veterans have access to subsidized health care at the VHA, the increased risk of receiving a positive test result for COVID-19 among Black and Hispanic/Latino veterans, despite receiving more tests than White and non-Hispanic/Latino veterans, suggests that other factors (eg, social inequities) are driving disparities in COVID-19 prevalence.

Addressing the mental health impact of COVID-19 through population health.

The COVID-19 pandemic has and will continue to result in negative mental health outcomes such as depression, anxiety and traumatic stress in people and populations throughout the world. A population mental health perspective informed by clinical psychology, psychiatry and dissemination and implementation science is ideally suited to address the broad, multi-faceted and long-lasting mental health impact of the pandemic. Informed by a systematic review of the burgeoning empirical research on the COVID-19 pandemic and research on prior coronavirus pandemics, we link pandemic risk factors, negative mental health outcomes and appropriate intervention strategies. We describe how social risk factors and pandemic stressors will contribute to negative mental health outcomes, especially among vulnerable populations. We evaluate the scalability of primary, secondary and tertiary interventions according to mental health target, population, modality, intensity and provider type to provide a unified strategy for meeting population mental health needs. Traditional models, in which evidence-based therapies delivered are delivered in-person, by a trained expert, at a specialty care location have proved difficult to scale. The use of non-traditional models, tailoring preventive interventions to populations based on their needs, and ongoing coordinated evaluation of intervention implementation and effectiveness will be critical to refining our efforts to increase reach.

Disentangling individual, school, and neighborhood effects on screen time among adolescents and young adults in the United States.

OBJECTIVES: To examine the association between individual, neighborhood, and school-level influences on individual screen time among adolescents and young adults (AYAs) in the National Longitudinal Study of Adolescent to Adult Health. METHODS: We classified screen time continuously as self-reported total hours per week of television, videos, and video/computer games at baseline and categorical as extended screen time (≥14 h per week). We fit cross-classified multilevel models (CCMM) to examine to examine the individual-, school- and neighborhood-level demographic and socioeconomic factors associated with screen time. Models were fit using MLwiN with Bayesian estimation procedures. RESULTS: AYAs reported an average of 22.8 (SD = 19.4) and 21.9 (SD = 20.3) hours of screen time, respectively. At the individual level, younger age, male sex, Black/multiracial race, receipt of public assistance, and lower parental education were associated with higher screen time. At the school level, being out of session (i.e., school and national holidays including summer), having a higher proportion of non-White students, and having a lower proportion of parents with a college education were associated with higher individual screen time. CONCLUSIONS: We found that individual-level factors most influence youth screen time, with smaller contributions from school factors.

Tobacco Retail Density and Initiation of Alternative Tobacco Product Use Among Teens.

PURPOSE: The rise of noncigarette, alternative tobacco product (ATP) use among adolescents may be due in part to an increase in retail availability of ATPs. We examined whether proximity and density of tobacco retailers near students' homes are associated with a higher likelihood of initiating ATP use over time. METHODS: Using data from 728 adolescents (aged 13-19 years at baseline) residing in 191 different neighborhoods and attending 10 different California high schools, longitudinal multilevel and cross-classified random effect models evaluated individual-level, neighborhood-level, and school-level risk factors for ATP initiation after 1 year. Covariates were obtained from the American Community Survey and the California Department of Education. RESULTS: The sample was predominantly female (63.5%) and was racially and ethnically diverse. Approximately one third of participants (32.5%) reported ever ATP use at baseline, with 106 (14.5%) initiating ATP use within 1 year. The mean number of tobacco retailers per square mile within a tract was 5.66 (standard deviation = 6.3), and the average distance from each participant's residence to the nearest tobacco retailer was .61 miles (standard deviation = .4). Living in neighborhoods with greater tobacco retailer density at baseline was associated with higher odds of ATP initiation (odds ratio = 1.22, 95% confidence interval = 1.07-2.12), controlling for individual and school factors. CONCLUSIONS: Tobacco retailers clustered in students' home neighborhood may be an environmental influence on adolescents' ATP use. Policy efforts to reduce adolescent ATP use should aim to reduce the density of tobacco retailers and limit the proximity of tobacco retailers near adolescents' homes and schools.

Association of Alternative Tobacco Product Initiation With Ownership of Tobacco Promotional Materials Among Adolescents and Young Adults.

Importance: Use of alternative tobacco products (ATPs) such as electronic cigarettes, chewing tobacco, pipes, cigars, cigarillos, little cigars, and hookah is rapidly increasing. Although marketing restrictions exist for cigarettes, marketing of ATPs is not yet fully regulated, and studies have not assessed the association between ownership of ATP promotional materials and subsequent ATP or cigarette initiation among adolescents and young adults. Objective: To estimate the association between marketing receptivity measured at baseline and ATP and any tobacco initiation 1 year later, including cigarettes, among adolescents and young adults. Design, Setting, and Participants: Longitudinal cohort study of adolescents and young adults aged 13 to 19 years recruited at high schools in California from July 2014 to October 2015, with follow-up 1 year later. Data were analyzed from January to March 2018. Exposures: Ownership of ATP-specific promotional material and ownership of any tobacco promotional materials (eg, samples, coupons, branded caps, t-shirts, or posters) assessed in wave 1. Main Outcomes and Measures: Outcomes were (1) ATP initiation and (2) either ATP or cigarette initiation in wave 2. Results: Of 757 participants (mean [SD] age at wave 1, 16.1 [1.1] years; 481 [63.5%] female; 166 [21.9%] Asian or Pacific Islander, 202 [26.7%] white, and 276 [36.4%] Latino), 129 (17.0%) initiated ATP use and 141 (18.6%) initiated ATP or cigarette use 1 year later. In unadjusted models, wave 2 ATP initiation was found to be significantly associated with wave 1 ownership of ATP promotional materials (odds ratio, 2.23; 95% CI, 1.26-3.97). After adjustment for wave 1 demographic covariates, the association between ownership of ATP promotional material and ATP initiation 1 year later yielded similar results (odds ratio, 2.13; 95% CI, 1.16-3.91). Results of models assessing a combined outcome variable of either ATP or cigarette ever use were not statistically significant. Conclusions and Relevance: Ownership of ATP promotional materials was associated with subsequent initiation of ATPs. The results of this study are consistent with the suggestion that current marketing restrictions for cigarettes, including restrictions of the distribution of samples, coupons, and other promotional material, should extend to ATPs.