The Scope and Legal Implications of Tracking Technologies on Hospital Websites.

This Viewpoint analyzes the scope and legal implications of tracking on hospital websites, including potential HIPAA and state privacy law violations, and suggests that hospitals limit such tracking.

Compliance With Cannabis Act Regulations Regarding Online Promotion Among Canadian Commercial Cannabis-Licensed Firms.

Importance: As global jurisdictions shift toward cannabis legalization, 2 areas of public health importance relate to exposure to youth and to truthful promotion. Although Canada's Cannabis Act specifies many prohibitions related to cannabis promotion, no systematic monitoring or enforcement among licensed firms exists. Compliance with marketing regulations has effects beyond Canadian citizens because of the global outreach of websites and social media. Objectives: To evaluate compliance among licensed firms with the Cannabis Act and analyze trends among violations regarding promotional material. Design, Setting, and Participants: This cross-sectional study evaluated cannabis-licensed firms after cannabis legalization. Data were extracted from online public platforms, including company websites, Facebook, Instagram, and Twitter, from October 1, 2019, to March 31, 2020. Descriptive statistics, Poisson regression, and logistic regression were used to analyze the associations of covariates with promotion violations. Main Outcomes and Measures: The primary outcome was characterization of type and prevalence of promotion violations. Secondary outcomes were the role of various covariates (namely, licensed firm characteristics and online platforms) in the frequency and probability of violations. Hypotheses were formulated before data collection. Results: Among 261 licensed firms, 211 (80.8%) had an online platform, including 204 (96.7%) with websites, 128 (60.7%) with Facebook, 123 (58.3%) with Instagram, and 123 (58.3%) with Twitter. Of all licensed firms with an online platform, 182 (86.3%) had at least 1 violation. Compared with websites, the risk of violations was significantly higher on Facebook (rate ratio [RR], 1.24; 95% CI, 1.11-1.39) and Instagram (RR, 1.19; 95% CI, 1.05-1.34). The most common violations included lack of age restrictions, brand glamorization, and omission of risk information. With websites as the reference group, lack of age restrictions was approximately 15 times more likely to occur on Facebook (odds ratio [OR], 14.76; 95% CI, 8.06-27.05); the odds of an age restriction violation were also higher on Instagram (OR, 2.48; 95% CI, 1.43-4.32) and Twitter (OR, 4.03; 95% CI, 2.29-7.09). For unsubstantiated claims, the odds of violations were significantly decreased on Facebook (OR, 0.23; 95% CI, 0.11-0.48) and Instagram (OR, 0.28; 95% CI, 0.14-0.57). The odds of glamorization were associated with an increase on Instagram (OR, 2.90; 95% CI, 1.72-4.88). Conclusions and Relevance: In this cross-sectional study, widespread violations were observed in online Canadian cannabis promotion. To protect public health and safety amid legalization, decision-makers should make explicit federal regulation and enforcement regarding promotional activities of cannabis retailers. These results suggest that policy and enforcement of cannabis promotion in Canada would have an international impact, from ease of access to online media and downstream consequences of unregulated promotion.

Truth-in-Advertising Laws: Are They Working? A Cross-Sectional Analysis of a "Plastic Surgeon" Patient Search Simulation.

BACKGROUND: Non-board-certified plastic surgeons performing cosmetic procedures and advertising as plastic surgeons may have an adverse effect on a patient's understanding of their practitioner's medical training and patient safety. The authors aim to assess (1) the impact of city size and locations and (2) the impact of health care transparency acts on the ratio of board-certified and non-American Board of Plastic Surgeons physicians. METHODS: The authors performed a systematic Google search for the term "plastic surgeon [city name]" to simulate a patient search of online providers. Comparisons of board certification status between the top hits for each city were made. Data gathered included city population, regional location, practice setting, and states with the passage of truth-in-advertising laws. RESULTS: One thousand six hundred seventy-seven unique practitioners were extracted. Of these, 1289 practitioners (76.9 percent) were American Board of Plastic Surgery-certified plastic surgeons. When comparing states with truth-in-advertising laws and states without such laws, the authors found no significant differences in board-certification rates among "plastic surgery" practitioners (88.9 percent versus 92.0 percent; p = 0.170). There was a significant difference between board-certified "plastic surgeons" versus out-of-scope practitioners on Google search between large, medium, and small cities (100 percent versus 92.9 percent versus 86.5; p < 0.001). CONCLUSIONS: Non-board-certified providers tend to localize to smaller cities. Truth-in-advertising laws have not yet had an impact on the way a number of non-American Board of Plastic Surgery-certified practitioners market themselves. There may be room to expand the scope of truth-in-advertising laws to the online world and to smaller cities.

How Internet Contracts Impact Research: Content Analysis of Terms of Service on Consumer Product Websites.

BACKGROUND: Companies use brand websites as a promotional tool to engage consumers on the web, which can increase product use. Given that some products are harmful to the health of consumers, it is important for marketing associated with these products to be subject to public health surveillance. However, terms of service (TOS) governing the use of brand website content may impede such important research. OBJECTIVE: The aim of this study is to explore the TOS for brand websites with public health significance to assess possible legal and ethical challenges for conducting research on consumer product websites. METHODS: Using Statista, we purposefully constructed a sample of 15 leading American tobacco, alcohol, psychiatric pharmaceutical, fast-food, and gun brands that have associated websites. We developed and implemented a structured coding system for the TOS on these websites and coded for the presence versus absence of different types of restriction that might impact the ability to conduct research. RESULTS: All TOS stated that by accessing the website, users agreed to abide by the TOS (15/15, 100%). A total of 11 out of 15 (73%) websites had age restrictions in their TOS. All alcohol brand websites (5/15, 33%) required users to enter their age or date of birth before viewing website content. Both websites for tobacco brands (2/15, 13%) further required that users register and verify their age and identity to access any website content and agree that they use tobacco products. Only one website (1/15, 7%) allowed users to display, download, copy, distribute, and translate the website content as long as it was for personal and not commercial use. A total of 33% (5/15) of TOS unconditionally prohibited or put substantial restrictions on all of these activities and/or failed to specify if they were allowed or prohibited. Moreover, 87% (13/15) of TOS indicated that website access could be restricted at any time. A total of 73% (11/15) of websites specified that violating TOS could result in deleting user content from the website, revoking access by having the user's Internet Protocol address blocked, terminating log-in credentials, or enforcing legal action resulting in civil or criminal penalties. CONCLUSIONS: TOS create complications for public health surveillance related to e-marketing on brand websites. Recent court opinions have reduced the risk of federal criminal charges for violating TOS on public websites, but this risk remains unclear for private websites. The public health community needs to establish standards to guide and protect researchers from the possibility of legal repercussions related to such efforts.

Thousands of reptile species threatened by under-regulated global trade.

Wildlife trade is a key driver of the biodiversity crisis. Unregulated, or under-regulated wildlife trade can lead to unsustainable exploitation of wild populations. International efforts to regulate wildlife mostly miss 'lower-value' species, such as those imported as pets, resulting in limited knowledge of trade in groups like reptiles. Here we generate a dataset on web-based private commercial trade of reptiles to highlight the scope of the global reptile trade. We find that over 35% of reptile species are traded online. Three quarters of this trade is in species that are not covered by international trade regulation. These species include numerous endangered or range-restricted species, especially hotspots within Asia. Approximately 90% of traded reptile species and half of traded individuals are captured from the wild. Exploitation can occur immediately after scientific description, leaving new endemic species especially vulnerable. Pronounced gaps in regulation imply trade is having unknown impacts on numerous threatened species. Gaps in monitoring demand a reconsideration of international reptile trade regulations. We suggest reversing the status-quo, requiring proof of sustainability before trade is permitted.

Managing Illicit Online Pharmacies: Web Analytics and Predictive Models Study.

BACKGROUND: Online pharmacies have grown significantly in recent years, from US $29.35 billion in 2014 to an expected US $128 billion in 2023 worldwide. Although legitimate online pharmacies (LOPs) provide a channel of convenience and potentially lower costs for patients, illicit online pharmacies (IOPs) open the doors to unfettered access to prescription drugs, controlled substances (eg, opioids), and potentially counterfeits, posing a dramatic risk to the drug supply chain and the health of the patient. Unfortunately, we know little about IOPs, and even identifying and monitoring IOPs is challenging because of the large number of online pharmacies (at least 30,000-35,000) and the dynamic nature of the online channel (online pharmacies open and shut down easily). OBJECTIVE: This study aims to increase our understanding of IOPs through web data traffic analysis and propose a novel framework using referral links to predict and identify IOPs, the first step in fighting IOPs. METHODS: We first collected web traffic and engagement data to study and compare how consumers access and engage with LOPs and IOPs. We then proposed a simple but novel framework for predicting the status of online pharmacies (legitimate or illicit) through the referral links between websites. Under this framework, we developed 2 prediction models, the reference rating prediction method (RRPM) and the reference-based K-nearest neighbor. RESULTS: We found that direct (typing URL), search, and referral are the 3 major traffic sources, representing more than 95% traffic to both LOPs and IOPs. It is alarming to see that direct represents the second-highest traffic source (34.32%) to IOPs. When tested on a data set with 763 online pharmacies, both RRPM and R2NN performed well, achieving an accuracy above 95% in their predictions of the status for the online pharmacies. R2NN outperformed RRPM in full performance metrics (accuracy, kappa, specificity, and sensitivity). On implementing the 2 models on Google search results for popular drugs (Xanax [alprazolam], OxyContin, and opioids), they produced an error rate of only 7.96% (R2NN) and 6.20% (RRPM). CONCLUSIONS: Our prediction models use what we know (referral links) to tackle the many unknown aspects of IOPs. They have many potential applications for patients, search engines, social media, payment companies, policy makers or government agencies, and drug manufacturers to help fight IOPs. With scarce work in this area, we hope to help address the current opioid crisis from this perspective and inspire future research in the critical area of drug safety.

Regulatory, Legal, and Ethical Considerations of Telemedicine.

Sleep telemedicine practitioners must ensure their practice complies with all applicable institutional, state, and federal regulations. Providers must be licensed in any state in which they provide care, have undergone credentialing and privileging procedures at outside facilities, and avoid real or perceived conflicts of interest while providing that care. Internet-based prescribing remains limited to certain circumstances. Whether or not a malpractice insurance policy covers telemedicine depends on the insurer, especially if interstate care is provided. All telemedicine programs must protect patient health information. Similarly, bioethical principles of autonomy, beneficence, nonmaleficence, and justice apply to both in-person and telemedicine-based care.

How behavioural sciences can promote truth, autonomy and democratic discourse online.

Public opinion is shaped in significant part by online content, spread via social media and curated algorithmically. The current online ecosystem has been designed predominantly to capture user attention rather than to promote deliberate cognition and autonomous choice; information overload, finely tuned personalization and distorted social cues, in turn, pave the way for manipulation and the spread of false information. How can transparency and autonomy be promoted instead, thus fostering the positive potential of the web? Effective web governance informed by behavioural research is critically needed to empower individuals online. We identify technologically available yet largely untapped cues that can be harnessed to indicate the epistemic quality of online content, the factors underlying algorithmic decisions and the degree of consensus in online debates. We then map out two classes of behavioural interventions-nudging and boosting- that enlist these cues to redesign online environments for informed and autonomous choice.

[Problematic Online Gambling: Review of the Situation in Switzerland]. / Glücksspielsucht über das Internet ­ eine Übersicht der Situation in der Schweiz.

Problem gambling is a DSM-5-recognized behavioural addiction of growing concern through the emergence of the Internet with better availability and accessibility of gambling and a wider range of game offers. Thus, a new target group is approached through Online Gambling, which is leading to new issues in the prevention on problem gambling. In this study we discuss the differences in characteristics between Online and Offline Gamblers, the risk factors to develop a gambling problem as well as prevention methods and therapies. This review focuses on the situation in Switzerland with regard to the actual political occurrences and the new law on Online Gambling.

Non-consensual sharing of personal sexually explicit imagery among young people in Australia: results from an online survey.

Consensual sharing of personal sexually explicit imagery (SEI) is part of young people's sexual practise; however, harms arise if content is shared without consent. Australians aged 15-29 years were recruited for an online survey. Participants indicated if they had ever sent SEI of themselves to someone else, received SEI directly from the person in the imagery and whether they thought it was illegal to forward SEI without consent. Participants reported whether anyone shared their SEI without permission, if they told people, made official reports or if there were consequences for perpetrator(s). Logistic regression was used to identify associations between victimisation, gender, age group, sexual identity and knowledge of SEI-related law. In total, 1007 participants (65% female, mean age 23 years, 67% heterosexual) were recruited; 63% sent personal SEI to another person, 71% received SEI from the person pictured and 77% correctly identified it is illegal to forward SEI without consent. Thirteen percent (n = 126) indicated another person forwarded personal SEI without consent. In univariate analysis, victimisation was associated with identifying as non-heterosexual (odds ratio = 1.51, confidence interval = 1.03-2.22), but was independent from age group, gender and knowledge. In multivariate analysis, sexual identity, age group, gender and knowledge were not significantly associated with victimisation. Among participants who experienced non-consensual sharing of personal SEI, 63% told friends, 10% told family, 93% made no official report and 94% reported no consequences for perpetrator(s). Initiatives are needed to promote legal rights and enable young people to seek support.

Alcohol Sponsorship and Esports: Reinforcing the Need for Legislative Restrictions on Alcohol Sponsorship.

Alcohol sponsorship in esports is on the rise. Many esports athletes and viewers are children and young people. Alcohol sponsorship of esports places millions of children and young people at risk of alcohol-related harm. Action on alcohol sponsorship in esports may provide policy makers an opportunity for greater restrictions on all alcohol sports sponsorship.

An Internet for Some threatens health for All: What effects could the repeal of net neutrality in the USA have on individual and population health?

In the United States of America, the Federal Communications Commission's repeal of the popular Open Internet Order (a.k.a 'net neutrality') has yielded pointed criticism from many different sectors, but it has yet to be examined for its potential effect on the public's health. In this commentary, we focus on the health implications of this policy change, considering expert opinion on the subject, past history, and global perspectives. We argue that the repeal of net neutrality has the potential to compromise health education and promotion efforts by widening the 'digital divide', thereby impairing health literacy and exacerbating health inequities. By negatively affecting people's ability to access, understand, and use unbiased, evidence-based health information to improve and maintain their health, the repeal of net neutrality may hinder the World Health Organization's vision of 'Health for All' by dismantling public protections in the name of corporate profit.