Recreational cannabis legalization and immigration enforcement: a state-level analysis of arrests and deportations in the United States, 2009-2020.

BACKGROUND: Recreational cannabis laws (RCL) in the United States (US) can have important implications for people who are non-citizens, including those with and without formal documentation, and those who are refugees or seeking asylum. For these groups, committing a cannabis-related infraction, even a misdemeanor, can constitute grounds for status ineligibility, including arrest and deportation under federal immigration policy-regardless of state law. Despite interconnections between immigration and drug policy, the potential impacts of increasing state cannabis legalization on immigration enforcement are unexplored. METHODS: In this repeated cross-sectional analysis, we tested the association between state-level RCL adoption and monthly, state-level prevalence of immigration arrests and deportations related to cannabis possession. Data were from the Transactional Records Access Clearinghouse. Immigration arrest information was available from Oct-2014 to May-2018 and immigration deportation information were available from Jan-2009 to Jun-2020 for. To test associations with RCLs, we fit Poisson fixed effects models that controlled for pre-existing differences between states, secular trends, and potential sociodemographic, sociopolitical, and setting-related confounders. Sensitivity analyses explored potential violations to assumptions and sensitivity to modeling specifications. RESULTS: Over the observation period, there were 7,739 immigration arrests and 48,015 deportations referencing cannabis possession. By 2020, 12 stated adopted recreational legalization and on average immigration enforcement was lower among RCL compared to non-RCL states. In primary adjusted models, we found no meaningful changes in arrest prevalence, either immediately following RCL adoption (Prevalence Ratio [PR]: 0.84; [95% Confidence Interval [CI]: 0.57, 1.11]), or 1-year after the law was effective (PR: 0.88 [CI: 0.56, 1.20]). For the deportation outcome, however, RCL adoption was associated with a moderate relative decrease in deportation prevalence in RCL versus non-RCL states (PR: 0.68 [CI: 0.56, 0.80]; PR 1-year lag: 0.68 [CI: 0.54, 0.82]). Additional analyses were mostly consistent by suggested some sensitivities to modeling specification. CONCLUSIONS: Our findings suggest that decreasing penalties for cannabis possession through state RCLs may reduce some aspects of immigration enforcement related to cannabis possession. Greater attention to the immigration-related consequences of current drug control policies is warranted, particularly as more states weigh the public health benefits and drawbacks of legalizing cannabis.

Punitive legal responses to prenatal drug use in the United States: A survey of state policies and systematic review of their public health impacts.

BACKGROUND: Punitive legal responses to prenatal drug use may be associated with unintended adverse health consequences. However, in a rapidly shifting policy climate, current information has not been summarized. We conducted a survey of U.S. state policies that utilize criminal or civil legal system penalties to address prenatal drug use. We then systematically identified empirical studies evaluating these policies and summarized their potential public health impacts. METHODS: Using existing databases and original statutory research, we surveyed current U.S. state-level prenatal drug use policies authorizing explicit criminalization, involuntary commitment, civil child abuse substantiation, and parental rights termination. Next, we systematically identified quantitative associations between these policies and health outcomes, restricting to U.S.-based peer-reviewed research, published January 2000-December 2022. Results described study characteristics and synthesized the evidence on health-related harms and benefits associated with punitive policies. Validity threats were described narratively. RESULTS: By 2022, two states had adopted policies explicitly authorizing criminal prosecution, and five states allowed pregnancy-specific and drug use-related involuntary civil commitment. Prenatal drug use was grounds for substantiating civil child abuse and terminating parental rights in 22 and five states, respectively. Of the 16 review-identified articles, most evaluated associations between punitive policies generally (k = 12), or civil child abuse policies specifically (k = 2), and multiple outcomes, including drug treatment utilization (k = 6), maltreatment reporting and foster care entry (k = 5), neonatal drug withdrawal syndrome (NDWS, k = 4) and other pregnancy and birth-related outcomes (k = 3). Most included studies reported null associations or suggested increases in adverse outcome following punitive policy adoption. CONCLUSIONS: Nearly half of U.S. states have adopted policies that respond to prenatal drug use with legal system penalties. While additional research is needed to clarify whether such approaches engender overt health harms, current evidence indicates that punitive policies are not associated with public health benefits, and therefore constitute ineffective policy.

An integrative literature review of birth cohort and time period trends in adolescent depression in the United States.

PURPOSE: The aim of this literature review is to examine evidence of time trends and birth cohort effects in depressive disorders and symptoms among US adolescents in peer-reviewed articles from January 2004 to April 2022. METHODS: We conducted an integrative systematic literature review. Three reviewers participated at different stages of article review. Of the 2234 articles identified in three databases (Pubmed, ProQuest Central, Ebscohost), 10 met inclusion criteria (i.e., adolescent aged United States populations, included information about birth cohort and survey year, focused on depressive symptoms/disorders). RESULTS: All 10 articles observed increases in depressive symptoms and disorders in adolescents across recent survey years with increases observed between 1991 and 2020. Of the 3 articles that assessed birth cohort trends, birth cohort trends were less prominent than time period trends. Proposed explanations for increases included social media, economic-related reasons, changes in mental health screening and diagnosis, declining mental health stigma, increased treatment, and, in more recent years, the COVID-19 pandemic. CONCLUSIONS: Multiple cross-sectional surveys and cohort studies documented rising prevalence of depressive symptoms and disorder among adolescents from 1991 to 2020. Mechanisms driving this increase are still unknown. Research to identify these mechanisms is needed to inform depression screening and intervention efforts for adolescents.

Recreational cannabis legislation and binge drinking in U.S. adolescents and adults.

BACKGROUND: Recreational cannabis laws (RCLs) may have spillover effects on binge drinking. Our aims were to investigate binge drinking time trends and the association between RCLs and changes in binge drinking in the United States (U.S.). METHODS: We used restricted National Survey on Drug Use and Health data (2008-2019). We examined trends in the prevalence of past-month binge drinking by age groups (12-20, 21-30, 31-40, 41-50, 51+). Then, we compared model-based prevalences of past-month binge drinking before and after RCL by age group, using multi-level logistic regression with state random intercepts, an RCL by age group interaction term, and controlling for state alcohol policies. RESULTS: Binge drinking declined overall from 2008 to 2019 among people aged 12-20 (17.54% to 11.08%), and those aged 21-30 (43.66% to 40.22%). However, binge drinking increased among people aged 31+ (ages 31-40: 28.11% to 33.34%, ages 41-50: 25.48% to 28.32%, ages 51+: 13.28% to 16.75%). When investigating model-based prevalences after versus before RCL, binge drinking decreased among people aged 12-20 (prevalence difference=-4.8%; adjusted odds ratio (aOR)=0.77, [95% confidence interval (CI) 0.70-0.85]), and increased among participants aged 31-40 (+1.7%; 1.09[1.01-1.26]), 41-50 (+2.5; 1.15[1.05-1.26]) and 51+ (+1.8%; 1.17[1.06-1.30]). No RCL-related changes were noted in respondents ages 21-30. CONCLUSIONS: Implementation of RCLs was associated with increased past-month binge drinking in adults aged 31+ and decreased past-month binge drinking in those aged < 21. As the cannabis legislative landscape continues to change in the U.S., efforts to minimize harms related to binge drinking are critical.

Naloxone expansion is not associated with increases in adolescent heroin use and injection drug use: Evidence from 44 US states.

BACKGROUND: Naloxone distribution is central to ongoing efforts to address the opioid overdose crisis. Some critics contend that naloxone expansion may inadvertently promote high-risk substance use behaviors among adolescents, but this question has not been directly investigated. METHODS: We examined relationships between naloxone access laws and pharmacy naloxone distribution with lifetime heroin and injection drug use (IDU), 2007-2019. Models generating adjusted odds ratios (aOR) and 95% confidence intervals (CI) included year and state fixed effects, controlled for demographics and sources of variation in opioid environments (e.g., fentanyl penetration), as well as additional policies expected to impact substance use (e.g., prescription drug monitoring). Exploratory and sensitivity analyses further examined naloxone law provisions (e.g., third-party prescribing) and applied e-value testing to assess vulnerability to unmeasured confounding. RESULTS: Adoption of any naloxone law was not associated with changes in adolescent lifetime heroin or IDU. For pharmacy dispensing, we observed a small decrease in heroin use (aOR: 0.95 [CI: 0.92, 0.99]) and a small increase in IDU (aOR: 1.07 [CI: 1.02, 1.11]). Exploratory analyses of law provisions suggested that third-party prescribing (aOR: 0.80, [CI: 0.66, 0.96]) and non-patient-specific dispensing models (aOR: 0.78, [CI: 0.61, 0.99]) were associated with decreased heroin use but not decreased IDU. Small e-values associated with the pharmacy dispensing and provision estimates indicate that unmeasured confounding may explain observed findings. CONCLUSION: Naloxone access laws and pharmacy naloxone distribution were more consistently associated with decreases rather than increases in lifetime heroin and IDU among adolescents. Our findings therefore do not support concerns that naloxone access promotes high-risk adolescent substance use behaviors. As of 2019, all US states have adopted legislation to improve naloxone access and facilitate use. However, further removal of adolescent naloxone access barriers is an important priority given that the opioid epidemic continues to affect people of all ages.

Cannabis Recreational Legalization and Prevalence of Simultaneous Cannabis and Alcohol Use in the United States.

BACKGROUND: Simultaneous cannabis/alcohol use, using both substances within a short time interval so that their effects overlap, has a greater risk of potential negative consequences than single-substance use and is more common in younger age. Relationships between recreational cannabis laws (RCLs) and changes in simultaneous cannabis/alcohol use prevalence remain untested. OBJECTIVE: To examine trends in simultaneous cannabis/alcohol use from 2008 to 2019, and investigate associations between implementation of RCLs (i.e., presence of active legal dispensaries or legal home cultivation) and simultaneous cannabis/alcohol use in the United States (U.S.). DESIGN: Repeated cross-sectional samples from the 2008-2019 U.S. National Survey on Drug Use and Health (NSDUH). PARTICIPANTS: Respondents (51% female) aged 12 and older. INTERVENTIONS: Changes in simultaneous cannabis/alcohol use before and after RCL implementation (controlling for medical cannabis law implementation) were compared in different age groups (12-20, 21-30, 31-40, 41-50, 51+), using adjusted multi-level logistic regression with state random intercepts and an RCL/age group interaction. MEASUREMENTS: Self-reported simultaneous cannabis/alcohol use. RESULTS: From 2008 to 2019, the overall prevalence of simultaneous cannabis/alcohol use declined among those aged 12-20 but increased in adults aged 21+. Model-based simultaneous cannabis/alcohol use prevalence increased after RCL implementation among respondents aged 21-30 years (+1.2%; aOR= 1.15 [95%CI = 1.04-1.27]), 31-40 years (+1.0; 1.15 [1.04-1.27]), and 41-50 years (+1.75; 1.63 [1.34-1.98]), but not in individuals aged <21 or 51+ years. CONCLUSIONS: Implementation of recreational cannabis policies resulted in increased simultaneous use of cannabis and alcohol, supporting the complementarity hypothesis, but only among adults aged 21+. Efforts to minimize harms related to simultaneous cannabis/alcohol use are critical, especially in states with RCLs. Future studies should investigate cultural norms, perceived harm, and motives related to simultaneous use.

US Trends in Drug Overdose Mortality Among Pregnant and Postpartum Persons, 2017-2020.

This study evaluates changes in overall and drug-specific overdose mortality among pregnant and postpartum persons before and during the COVID-19 pandemic.

Policing the pandemic: Estimating spatial and racialized inequities in New York City police enforcement of COVID-19 mandates.

The use of policing to enforce public health guidelines has historically produced harmful consequences, and early evidence from the police enforcement of COVID-19 mandates suggested Black New Yorkers were disproportionately represented in arrests. The over-policing of Black and low-income neighborhoods during a pandemic risks increased transmission, potentially exacerbating existing health inequities. To assess racialized and class-based inequities in the enforcement of COVID-19 mandates at the ZIP-code-level, we conducted a retrospective spatial analysis of demographic factors and public health policing in New York City from March 12-May 24, 2020. Policing outcomes (COVID-19 criminal court summonses and public health and nuisance arrests) were measured using publicly available police administrative data. After controlling for two measures of social distancing compliance, a standard deviation increase in percentage of Black residents was associated with a 73% increase (95% CI: 35%, 123%) in the COVID-19-specific summons rate and a 34% increase (95% CI: 17%, 53%) in the public health and nuisance arrest rate. Percentage of Black residents and historical stop-and-frisk rates had stronger associations with COVID-19 summons rates than multiple measures of social distancing compliance. Findings demonstrate pronounced spatial and racialized inequities in pandemic policing of public health that mimic historical policing practices deemed racially discriminatory. If the field of public health supports criminalization and punishment as public health strategies, it risks reinscribing racialized health inequities.

Prescription Drug Monitoring and Child Maltreatment in the United States, 2004-2018.

OBJECTIVE: To test whether a policy approach aimed at decreasing prescription drug misuse, specifically, state monitoring of controlled substance prescriptions-prescription drug monitoring programs (PDMPs)-were associated with changes in Child Protective Services-reported maltreatment prevalence. STUDY DESIGN: Using a difference-in-differences design and maltreatment data (2004-2018) from 50 states and the District of Columbia, we compared the prevalence of total maltreatment incidents and total victims, in states with and without PDMPs, before and after implementation. Exploratory analyses further examined models disaggregated by maltreatment type (neglect, physical abuse, sexual abuse, psychological abuse) and among different racial/ethnic groups. Quasi-Poisson models included state-level covariates, state- and year-fixed effects, and cluster-robust standard errors. RESULTS: Difference-in-differences models identified greater relative reductions in PDMP states relative to controls (total prevalence ratio, 0.87; 95% CI, 0.80, 0.940; victimization prevalence ratio, 0.92; 95% CI, 0.85-0.98) over the observation period. Decreases seemed to be driven by changes in neglect (prevalence ratio, 0.87; 95% CI, 0.80-0.93) and physical abuse (prevalence ratio, 0.78; 95% CI, 0.71-0.87) incidents, and may have been especially salient for American Indian/Alaskan Native children (prevalence ratio, 0.78; 95% CI, 0.65-0.94). CONCLUSIONS: We found evidence supporting an association between prescription drug monitoring and reduced maltreatment prevalence at the state level. Policies aimed at restricting the prescribing and dispensing of controlled substances may have indirect implications for child welfare.

Spatiotemporal Analysis of the Association Between Pain Management Clinic Laws and Opioid Prescribing and Overdose Deaths.

Pain management clinic (PMC) laws were enacted by 12 states to promote appropriate opioid prescribing, but their impact is inadequately understood. We analyzed county-level opioid overdose deaths (National Vital Statistics System) and patients filling long-duration (≥30 day) or high-dose (≥90 morphine milligram equivalents per day) opioid prescriptions (IQVIA, Inc.) in the United States in 2010-2018. We fitted Besag-York-Mollié spatiotemporal models to estimate annual relative rates (RRs) of overdose and prevalence ratios (PRs) of high-risk prescribing associated with any PMC law and 3 provisions: payment restrictions, site inspections, and criminal penalties. Laws with criminal penalties were significantly associated with reduced PRs of long-duration and high-dose opioid prescriptions (adjusted PR = 0.82, 95% credible interval (CrI): 0.82, 0.82, and adjusted PR = 0.73, 95% CI: 0.73, 0.74 respectively) and reduced RRs of total and natural/semisynthetic opioid overdoses (adjusted RR = 0.86, 95% CrI: 0.80, 0.92, and adjusted RR = 0.84, and 95% CrI: 0.77, 0.92, respectively). Conversely, PMC laws were associated with increased relative rates of synthetic opioid and heroin overdose deaths, especially criminal penalties (adjusted RR = 1.83, 95% CrI: 1.59, 2.11, and adjusted RR = 2.59, 95% CrI: 2.22, 3.02, respectively). Findings suggest that laws with criminal penalties were associated with intended reductions in high-risk opioid prescribing and some opioid overdoses but raise concerns regarding unintended consequences on heroin/synthetic overdoses.

Prescription Opioid Laws and Opioid Dispensing in US Counties: Identifying Salient Law Provisions With Machine Learning.

BACKGROUND: Hundreds of laws aimed at reducing inappropriate prescription opioid dispensing have been implemented in the United States, yet heterogeneity in provisions and their simultaneous implementation have complicated evaluation of impacts. We apply a hypothesis-generating, multistage, machine-learning approach to identify salient law provisions and combinations associated with dispensing rates to test in future research. METHODS: Using 162 prescription opioid law provisions capturing prescription drug monitoring program (PDMP) access, reporting and administration features, pain management clinic provisions, and prescription opioid limits, we used regularization approaches and random forest models to identify laws most predictive of county-level and high-dose dispensing. We stratified analyses by overdose epidemic phases-the prescription opioid phase (2006-2009), heroin phase (2010-2012), and fentanyl phase (2013-2016)-to further explore pattern shifts over time. RESULTS: PDMP patient data access provisions most consistently predicted high-dispensing and high-dose dispensing counties. Pain management clinic-related provisions did not generally predict dispensing measures in the prescription opioid phase but became more discriminant of high dispensing and high-dose dispensing counties over time, especially in the fentanyl period. Predictive performance across models was poor, suggesting prescription opioid laws alone do not strongly predict dispensing. CONCLUSIONS: Our systematic analysis of 162 law provisions identified patient data access and several pain management clinic provisions as predictive of county prescription opioid dispensing patterns. Future research employing other types of study designs is needed to test these provisions' causal relationships with inappropriate dispensing and to examine potential interactions between PDMP access and pain management clinic provisions. See video abstract at, http://links.lww.com/EDE/B861.

Analysis of unused prescription opioids and benzodiazepines remaining after death among Medicare decedents.

BACKGROUND: Millions of opioid and benzodiazepine prescriptions are dispensed near end-of-life. After death, patients' unused prescription pills belong to family members, who often save rather than dispose of them. We sought to quantify this exposure in Medicare beneficiaries. METHODS: We estimated the share of decedent Medicare beneficiaries who potentially left behind opioid or benzodiazepine pills at the time of death using Part D claims of a 20 % national sample of Medicare beneficiaries between 2006-2015 linked to the National Death Index. RESULTS: We estimated that 1 in 6 Medicare beneficiaries who died between 2006-2015 potentially left behind opioid pills, and 1 in 10 who died between 2013-2015 potentially left benzodiazepines as well. Leftover pills were more common among younger, dually enrolled, and lower-income beneficiaries, as well as beneficiaries living in non-urban areas and those with a history of mental illness, drug use disorders, and chronic pain. North American Natives and Non-Hispanic Whites had higher proportions than Black, Hispanic, and Asian decedents. CONCLUSIONS: Opioids and benzodiazepines are commonly left behind at death. Policies and interventions that encourage comprehensive and safe medication disposal after death may reduce risk for intra-household diversion and misuse of prescription opioids and benzodiazepines.

Estimating the long-run relationship between state cigarette taxes and county life expectancy.

INTRODUCTION: While a large body of literature suggests that tobacco control legislation-including fiscal measures such as excise taxes-effectively reduces tobacco smoking, the long-run (10+ years) relationship between cigarettes excise taxes and life expectancy has not been directly evaluated. Here, we test the hypothesis that increases in state cigarette excise taxes are positively associated with long-run increases in population-level life expectancy. METHODS: We studied age-standardised life expectancy among all US counties from 1996 to 2012 by sex, in relation to state cigarette excise tax rates by year, controlling for other demographic, socioeconomic and county-specific features. We used an error-correction model to assess the long-run relationship between taxes and life expectancy. We additionally examine whether the relationship between cigarette taxes and life expectancy was mediated by changes to county smoking prevalence and varied by the sex, income and rural/urban composition of a county. RESULTS: For every one-dollar increase in cigarette tax per pack (in 2016 dollars), county life expectancy increased by 1 year (95% CI 0.60 to 1.40 years) over the long run, with the first 6-month increase in life expectancy taking 10 years to materialise. The association was mediated by changes in smoking prevalence and the magnitude of the association steadily increased as county income decreased. CONCLUSIONS: Results suggest that increasing cigarette excise tax rates translates to consequential population-level improvements in life expectancy, with larger effects in low-income counties.

The Mental Health of Hispanic/Latino Americans Following National Immigration Policy Changes: United States, 2014-2018.

Objectives. To examine the relationship between aggressive enforcement of anti-immigration policies and mental health among Hispanics/Latinos in the United States before and after major national immigration policy changes.Methods. Data were drawn from Behavioral Risk Factor Surveillance System surveys administered from 2014 to 2018. The exposure was the rate of immigration arrests in the 2 months before the survey date within the respondent's state of residence. Outcomes included past-month reporting of (1) number of days of poor mental health, (2) at least 1 day of poor mental health, and (3) frequent mental distress.Results. There was no relationship between arrest rates and mental health among Hispanic/Latino respondents across the overall period. After consideration of policy changes, however, a 1-percentage-point increase in a state's immigration arrest rate in the postpolicy period was significantly associated with each mental health morbidity outcome.Conclusions. We found evidence supporting an association between worsening mental health among Hispanics/Latinos and increased arrest rates following the announcement of several restrictive immigration policies. The potential public health effects of aggressive immigration enforcement must be better acknowledged and addressed in immigration debates.

Satellite images and machine learning can identify remote communities to facilitate access to health services.

OBJECTIVE: Community health systems operating in remote areas require accurate information about where people live to efficiently provide services across large regions. We sought to determine whether a machine learning analyses of satellite imagery can be used to map remote communities to facilitate service delivery and planning. MATERIALS AND METHODS: We developed a method for mapping communities using a deep learning approach that excels at detecting objects within images. We trained an algorithm to detect individual buildings, then examined building clusters to identify groupings suggestive of communities. The approach was validated in southeastern Liberia, by comparing algorithmically generated results with community location data collected manually by enumerators and community health workers. RESULTS: The deep learning approach achieved 86.47% positive predictive value and 79.49% sensitivity with respect to individual building detection. The approach identified 75.67% (n = 451) of communities registered through the community enumeration process, and identified an additional 167 potential communities not previously registered. Several instances of false positives and false negatives were identified. DISCUSSION: Analysis of satellite images is a promising solution for mapping remote communities rapidly, and with relatively low costs. Further research is needed to determine whether the communities identified algorithmically, but not registered in the manual enumeration process, are currently inhabited. CONCLUSIONS: To our knowledge, this study represents the first effort to apply image recognition algorithms to rural healthcare delivery. Results suggest that these methods have the potential to enhance community health worker scale-up efforts in underserved remote communities.

Huntington's disease in the United States: Variation by demographic and socioeconomic factors.

BACKGROUND: Despite extensive research regarding the etiology of Huntington's disease, relatively little is known about the epidemiology of this rare disorder, particularly in the United States where there are no national-scale estimates of the disease. OBJECTIVES: To provide national-scale estimates of Huntington's disease in a U.S. population and to test whether disease rates are increasing, and whether frequency varies by race, ethnicity, or other factors. METHODS: Using an insurance database of over 67 million enrollees, we retrospectively identified a cohort of 3,707 individuals diagnosed with Huntington's disease between 2003 and 2016. We estimated annual incidence, annual diagnostic frequency, and tested for trends over time and differences in diagnostic frequency by sociodemographic characteristics. RESULTS: During the observation period, the age-adjusted cumulative incidence rate was1.22 per 100,000 persons (95% confidence interval: 1.53, 1.65), and age-adjusted diagnostic frequency was 6.52 per 100,000 persons (95% confidence interval: 5.31, 5.66); both rates remained relatively stable over the 14-year period. We identified several previously unreported differences in Huntington's disease frequency by self-reported sex, income, and race/ethnicity. However, racial/ethnic differences were of lower magnitude than have previously been reported in other country-level studies. CONCLUSIONS: In these large-scale estimates of U.S. Huntington's disease epidemiology, we found stable disease frequency rates that varied by several sociodemographic factors. These findings suggest that disease patterns may be more driven by social or environmental factors than has previously been appreciated. Results further demonstrate the potential utility of administrative Big Data in rare disease epidemiology when other data sources are unavailable. © 2019 International Parkinson and Movement Disorder Society.

Assessment of Risk of Harm Associated With Intensive Blood Pressure Management Among Patients With Hypertension Who Smoke: A Secondary Analysis of the Systolic Blood Pressure Intervention Trial.

Importance: The randomized Systolic Blood Pressure Intervention Trial (SPRINT) showed that lowering systolic blood pressure targets for adults with hypertension reduces cardiovascular morbidity and mortality in general. However, whether the overall benefit from intensive blood pressure control masks important heterogeneity in risk is unknown. Objective: To test the hypothesis that the overall benefit observed in SPRINT masked important heterogeneity in risk from intensive blood pressure control. Design, Setting, and Participants: In this exploratory, hypothesis-generating, ad hoc, secondary analysis of data obtained from 9361 participants in SPRINT, a random forest-based analysis was used to identify potential heterogeneous treatment effects using half of the trial data. Cox proportional hazards regression models were applied to test potential heterogeneous treatment effects on the remaining data. The original trial was conducted at 102 sites in the United States between November 2010 and March 2013. This analysis was conducted between November 2016 and August 2017. Interventions: Participants were assigned a systolic blood pressure target of less than 120 mm Hg (intervention treatment) or of less than 140 mm Hg (standard treatment). Main Outcomes and Measures: The primary composite cardiovascular outcome was myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from cardiovascular causes. Results: Of 9361 participants in SPRINT, 466 participants (5.0%) were current smokers with systolic blood pressure greater than 144 mm Hg at baseline, with 230 participants (49.4%) randomized to the training data set and 236 participants (50.6%) randomized to the testing data set; 286 participants (61.4%) were male, and the mean (SD) age was 60.7 (7.2) years. Combinations of 2 covariates (ie, baseline smoking status and systolic blood pressure) distinguished participants who were differentially affected by the intervention. In the testing data, Cox proportional hazards models for the primary outcome revealed a number needed to harm of 43.7 to cause 1 event across 3.3 years among participants who, at baseline, were current smokers with systolic blood pressure greater than 144 mm Hg (10.9% [12 of 110] of primary outcome events for intervention treatment vs 4.8% [6 of 126] for standard treatment; hazard ratio, 10.6; 95% CI, 1.3-86.1; P = .03). This subgroup was also associated with a higher likelihood to experience acute kidney injury under intensive blood pressure control (with a frequency of 10.0% [11 of 110] of acute kidney injury events for intervention treatment vs 3.2% [4 of 126] for standard treatment; hazard ratio, 9.4; 95% CI, 1.2-77.3; P = .04). Conclusions and Relevance: In this secondary analysis of SPRINT data, current smokers with a baseline systolic blood pressure greater than 144 mm Hg had a higher rate of cardiovascular events in the intensive treatment group vs the standard treatment group. Further research is needed to evaluate the potential tradeoffs of intensive blood pressure control in hypertensive smokers.