Associations between tobacco 21 and state flavour restrictions with young adult tobacco use.

BACKGROUND: States have recently enacted tobacco-related age and flavour restrictions in addition to federal T21 laws. Little is known about the independent effects of these policies on young adult tobacco use. METHODS: Linking 2011-2022 Behavioural Risk Factor Surveillance System data on 2 696 870, 18-59 years from 50 states and DC with policy data, we conducted probit regression models to evaluate the associations between state and federal T21 laws and state flavour restrictions with cigarettes, electronic nicotine delivery system (ENDS) and smokeless tobacco use. Models were adjusted for sociodemographics, additional tobacco policies, COVID-19-related factors, year and state. We tested two-way and three-way interactions between age, state T21 and federal T21 laws. RESULTS: Although we did not find evidence that state T21 laws were associated with cigarette, smokeless tobacco or ENDS use overall, the federal T21 law was associated with lower use of all three tobacco products by 0.39-0.92 percentage points. State flavour restrictions were associated with lower use of cigarettes by 0.68 (-1.27 to -0.09) and ENDS by 0.56 (-1.11 to -0.00) percentage points, but not with smokeless tobacco. A three-way interaction revealed that state and federal T21 laws together were associated with a lower prevalence of ENDS use among 18-20 years, but there were no differences in cigarette use from both policies combined versus either alone. CONCLUSION: State and federal T21 laws are broadly effective at reducing adult tobacco use, while state flavour restrictions specifically lower use of cigarettes and ENDS.

Impact of School Shootings on Adolescent School Safety, 2009-2019.

Objectives. To examine the impact of school shootings on indicators of adolescent school safety in the United States. Methods. We linked 2009-2019 Youth Risk Behavior Survey data on 211 236 adolescents aged 14 to 18 years from 24 school districts with data on high school shootings from the Center for Homeland Defense and Security. We conducted 2-way fixed-effects logistic regression models to assess the impact of shootings on self-report of 3 indicators of school safety: avoiding school because of feeling unsafe, carrying a weapon at school, and being threatened or injured with a weapon at school. Results. High school shootings were associated with adolescents having 20% greater odds of avoiding school because of feeling unsafe (adjusted odd ratio [AOR] = 1.20; 95% confidence interval [CI] = 1.11, 1.29) than those who had not. Findings were slightly attenuated in sensitivity analyses that tested exposure to shootings at any school in the district or state. High school shootings were associated with a statistically nonsignificant (P = .08) elevated risk of carrying a weapon at school (AOR = 1.11; 95% CI = 0.99, 1.25). Conclusions. The negative ramifications of school shootings extend far beyond the event itself to adolescents' concerns about school safety. (Am J Public Health. 2023;113(4):438-441. https://doi.org/10.2105/AJPH.2022.307206).

Impact of contraceptive coverage policies on contraceptive use and risky sexual behavior among adolescent girls in the USA.

OBJECTIVE: This study used representative data to examine the impact of changes in contraceptive coverage policies (contraceptive insurance mandates and pharmacy access to emergency contraception) on contraceptive use and risky sexual behavior among adolescent girls. STUDY DESIGN: Using 2003-17 Youth Risk Behavior Survey data on 116 180 adolescent girls from 34 states, we conducted difference-in-differences models to examine changes in contraceptive use and unprotected sexual intercourse with the implementation of contraceptive coverage policies. We also tested interactions between age and pharmacy access to emergency contraception. RESULTS: Findings indicate that contraceptive insurance mandates and pharmacy access to emergency contraception were not associated with changes in contraceptive use or unprotected sexual intercourse among adolescent girls, although some changes were observed in specific age groups. Despite this, our results show an overall increase in reported use of birth control pills and longer-acting methods from 2003 through 2017. CONCLUSIONS: Using representative data, this study lends support to existing evidence that increased access to emergency contraception does not impact contraceptive method used or unprotected sexual intercourse among adolescent girls. The results underscore the need for expanding access to a wide range of contraceptive options for adolescents, with a focus on safer and more effective longer-acting methods.

Impact of Medicaid Eligibility Changes on Long-acting Reversible Contraception Use in Massachusetts and Maine.

BACKGROUND: Availability of long-acting reversible contraception (LARC) is an important indicator of high-quality women's health care. There are limited data on the impact of state-level Medicaid eligibility changes on LARC use. STUDY DESIGN: We used All-Payers Claims Databases to examine LARC insertions among women enrolled in Medicaid in Massachusetts, which expanded Medicaid in 2014, and Maine, which restricted Medicaid eligibility in 2013. We used interrupted time series (ITS) analyses to determine the impact of Medicaid eligibility changes on level and trends in LARC insertions in these states. RESULTS: In Massachusetts, graphical evidence demonstrates that after Medicaid expansion, there was an immediate increase in mean monthly LARC insertions and insertions per 1000 enrollees. In ITS regression adjusting for age, LARC insertions per enrollee increased immediately after Medicaid expansion by 32% (P<0.001). After expansion, as the number of enrollees continued to rise, mean monthly LARC insertions rose, but there was a slightly decreasing trend in insertions per enrollee by 1% per month (P<0.001). In Maine, graphical evidence shows that initial reductions in Medicaid eligibility were associated with an immediate drop in LARC insertion numbers and rates per 1000, with ITS regression demonstrating an immediate 17% drop in insertions per enrollee (P<0.001). As Maine's Medicaid enrollment declined from 2013 to 2015, the number of LARC insertions remained flat, leading to an increasing trend in insertions per enrollee, similar to pre-2013 trends (P=0.17). CONCLUSIONS: Medicaid eligibility changes were associated with immediate changes in LARC uptake. Medicaid expansion may help ensure access to this effective contraceptive method.

Contested racial identity and the health of women and their infants.

Contested racial identity- self-identified race not matching socially-assigned race-may be an indication of experiences with racism. We aimed to understand the relationship between contested racial identity and women's health behaviors, health outcomes, and infant health outcomes. We used 2012-2015 Massachusetts Pregnancy Risk Assessment Monitoring System data on 5735 women linked with infants' birth certificates. We conducted regression analyses to examine associations between contested racial identity with pregnancy and infant health outcomes and further sub-analyses among women who had experienced a contested racial identity. A total of 901 (15.7%) women reported a contested racial identity. When compared to those who did not, women who had a contested racial identity had lower odds of initiating prenatal care in the first trimester (AOR: 0.76, 95% CI: 0.62, 0.95) and higher odds of smoking (AOR: 1.70, 95% CI: 1.32, 2.19). Among women who had experienced a contested racial identity, those who were socially-assigned as White had decreased odds of having a low birth weight baby (AOR: 0.52, 95% CI: 0.28, 0.99) when compared to those socially-assigned as non-White. Contested racial identity is common; it affects the behaviors that women engage in and the outcomes they experience postpartum. Further, we found that there is a potential benefit to a White social ascription. This work adds to growing evidence of the impact of racism on maternal and infant health in the United States.

Flavoured tobacco product restrictions in Massachusetts associated with reductions in adolescent cigarette and e-cigarette use.

BACKGROUND: In the USA, many states do not pre-empt municipalities from enacting stricter tobacco-control policies than state or federal laws. Several municipalities in Massachusetts have passed progressive local laws aimed at reducing adolescent tobacco use. We exploited this variability to examine the associations between county-level flavoured tobacco product restrictions, tobacco 21 policies and smoke-free laws prohibiting e-cigarettes with adolescent cigarette and e-cigarette use in Massachusetts, and to assess whether policy effects varied by age. METHODS: We conducted difference-in-differences models to link changes in county-level tobacco-control policies to changes in adolescents' use of cigarettes and e-cigarettes using 2011-2017 biennial Massachusetts Youth Health Surveys. RESULTS: Counties with greater implementation of flavoured tobacco product restrictions were associated with a decrease in the level of cigarette use among users (Coefficient -1.56; 95% CI -2.54 to -0.58). A significant interaction (p=0.03) revealed the largest reductions among 14 and 18 year olds. Increasing flavoured tobacco product restrictions were also associated with reductions in the likelihood of e-cigarette use (Coefficient -0.87; 95% CI -1.68 to -0.06). Increasing tobacco 21 restrictions were associated with decreases in cigarette use only among 18 year olds, while there was no evidence of associations between smoke-free laws with use of either tobacco product. CONCLUSIONS: Adolescents in Massachusetts decreased their use of cigarettes and e-cigarettes in response to local restrictions that limited the sale of flavoured tobacco products to adult-only retail tobacco stores. Local legislation can reduce adolescent tobacco use and municipalities should enact stricter tobacco-control policies when not pre-empted by state law.

Associations between ACA-related policies and a clinical recommendation with HPV vaccine initiation.

PURPOSE: We examined associations between the 2010 Affordable Care Act (ACA) provisions, 2011 Advisory Committee on Immunization Practices (ACIP) recommendation, and 2014 ACA-related health insurance reforms with HPV vaccine initiation rates by sex and health insurance type. METHODS: Using 2009-2015 public and private health insurance claims for 551,764 males and females aged 9-26 years (referred to as youth) from Maine, New Hampshire, and Massachusetts, we conducted linear regression models to examine the associations between three policy changes and HPV vaccine initiation rates by sex and health insurance type. RESULTS: In 2009, HPV vaccine initiation rates for males and females were 0.003 and 0.604 per 100 enrollees, respectively. Among males, the 2010 ACA provisions and ACIP recommendation were associated with significant increases in HPV vaccine uptake among those with private plans (0.207 [0.137, 0.278] and 0.419 [0.353, 0.486], respectively) and Medicaid (0.157 [0.083, 0.230] and 0.322 [0.257, 0.386], respectively). Among females, the 2010 ACA provisions were associated with significant increases in HPV vaccine uptake among Medicaid enrollees only (0.123 [0.033, 0.214]). The ACA-related health insurance reforms were associated with significant increases in HPV vaccine uptake for male and female Medicaid enrollees (0.257 [0.137, 0.377] and 0.214 [0.102, 0.327], respectively), but no differences among privately insured youth. By 2015, there were no differences in HPV vaccine initiation rates between males (0.278) and females (0.305). CONCLUSIONS: Both ACA provisions and the ACIP recommendation were associated with significant increases in HPV vaccine initiation rates among privately and publicly insured males in three New England states, closing the gender gap. In contrast, females and youth with private insurance did not exhibit the same changes in HPV vaccine uptake over the study period.

Gender Differences in Reasons for Using Electronic Cigarettes and Product Characteristics: Findings From the 2018 ITC Four Country Smoking and Vaping Survey.

INTRODUCTION: Little is known about why males are more likely to use electronic cigarettes (ECs) compared with females. This study examined gender differences in reasons for vaping and characteristics of EC used (device type, device capacity, e-liquid nicotine strength, and flavor). METHODS: Data were obtained from 3938 current (≥18 years) at-least-weekly EC users who participated in Wave 2 (2018) ITC Four Country Smoking and Vaping Survey in Canada, the United States, England, and Australia. RESULTS: Of the sample, 54% were male. The most commonly cited reasons for vaping in females were "less harmful to others" (85.8%) and in males were "less harmful than cigarettes" (85.5%), with females being more likely to cite "less harmful to others" (adjusted odds ratio [aOR] = 1.64, p = .001) and "help cut down on cigarettes" (aOR = 1.60, p = .001) than males. Significant gender differences were found in EC device type used (χ  2 = 35.05, p = .043). Females were less likely to report using e-liquids containing >20 mg/mL of nicotine, and tank devices with >2 mL capacity (aOR = 0.41, p < .001 and aOR = 0.65, p = .026, respectively) than males. There was no significant gender difference in use of flavored e-liquids, with fruit being the most common flavor for both males (54.5%) and females (50.2%). CONCLUSION: There were some gender differences in reasons for vaping and characteristics of the product used. Monitoring of gender differences in patterns of EC use would be useful to inform outreach activities and interventions for EC use. IMPLICATIONS: Our findings provide some evidence of gender differences in reasons for vaping and characteristics of EC used. The most common reason for vaping reported by females was "less harmful to others," which may reflect greater concern by female vapers about the adverse effects of secondhand smoke compared with male vapers. Gender differences might be considered when designing gender-sensitive smoking cessation policies. Regarding characteristics of EC products used, we found gender differences in preferences for e-liquid nicotine strength and device capacity. Further studies should examine whether the observed gender differences in EC use reasons and product characteristics are predictive of smoking cessation. Furthermore, studies monitoring gender-based marketing of ECs may be considered.

Associations between insurance-related affordable care act policy changes with HPV vaccine completion.

BACKGROUND: Although all 11- or 12-year-olds in the US were recommended to receive a 3-dose series of the human papillomavirus (HPV) vaccine within a 12-month period prior to 2016, rates of completion of the HPV vaccine series remained suboptimal. The effects of the Affordable Care Act (ACA), including private insurance coverage with no cost-sharing and health insurance expansions, on HPV vaccine completion are largely unknown. The aim of this study was to examine the associations between the ACA's 2010 provisions and 2014 insurance expansions with HPV vaccine completion by sex and health insurance type. METHODS: Using 2009-2015 public and private health insurance claims from Maine, New Hampshire, and Massachusetts, we identified 9-to-26-year-olds who had at least one HPV vaccine dose. We conducted a logistic regression model to examine the associations between the ACA policy changes with HPV vaccine completion (defined as receiving a 3-dose series within 12 months from the date of initiation) as well as interactions by sex and health insurance type. RESULTS: Over the study period, among females and males who initiated the HPV vaccine, 27.6 and 28.0%, respectively, completed the series within 12 months. Among females, the 2010 ACA provision was associated with a 4.3 percentage point increases in HPV vaccine completion for the privately-insured (0.043; 95% CI: 0.036-0.061) and a 5.7 percentage point increase for Medicaid enrollees (0.057; 95% CI: 0.032-0.081). The 2014 health insurance expansions were associated with a 9.4 percentage point increase in vaccine completion for females with private insurance (0.094; 95% CI: 0.082-0.107) and a 8.5 percentage point increase for Medicaid enrollees (0.085; 95% CI: 0.068-0.102). Among males, the 2014 ACA reforms were associated with a 5.1 percentage point increase in HPV vaccine completion for the privately-insured (0.051; 95% CI: 0.039-0.063) and a 3.4 percentage point increase for Medicaid enrollees (0.034; 95% CI: 0.017-0.050). In a sensitivity analysis, findings were similar with HPV vaccine completion within 18 months. CONCLUSIONS: Despite low HPV vaccine completion overall, both sets of ACA provisions were associated with increases in completion among females and males. Our results suggest that expanding Medicaid across the remaining states could increase HPV vaccine completion among publicly-insured youth and prevent HPV-related cancers.

State-Level Changes in Firearm Laws and Workplace Homicide Rates: United States, 2011 to 2017.

Objectives. To test whether year-over-year strengthening of state-level firearm laws is associated with decreases in workplace homicide rates.Methods. In this time-series ecological study of working people in all 50 US states, we used federal data on workplace homicides by state and year from 2011 to 2017, linked to an index of state-year firearm laws, to characterize the regulatory environment (overall and within legislative categories). We used generalized linear regression to model associations between changes in firearm laws and changes in workplace homicide rates the following year.Results. From 2011 to 2017, more than 3000 people died as a result of workplace homicides; over that period, 23 states strengthened firearm regulations and 23 weakened them. We modeled the impact of states strengthening laws within the interquartile range (IQR; equivalent to adding 20.5 firearm laws). This change was associated with a 3.7% reduction in the workplace homicide rate (95% confidence interval [CI] = -3.86, -3.51). Positive IQR changes in specific categories of firearm laws-concealed carry permitting (-5.79%; 95% CI = -6.09, -3.51), domestic violence-related restrictions (-5.31%; 95% CI = -5.57, -5.05), and background checks (-5.07%; 95% CI = -5.32, -4.82)-were also associated with significant reductions.Conclusions. Strengthening state-level firearm laws may reduce the population-level mortality and morbidity burden posed by workplace homicides.

Support for Minimum Legal Sales Age Laws Set to Age 21 Across Australia, Canada, England, and United States: Findings From the 2018 ITC Four Country Smoking and Vaping Survey.

INTRODUCTION: Although the United States has seen a rapid increase in tobacco minimum legal sales age (MLSA) laws set to age 21, there is wide variation across high-income countries and less is known about policy support outside of the United States. We examined the prevalence of support for tobacco MLSA 21 laws as well as associations by sociodemographic, smoking, and household characteristics among current and former adult smokers. METHODS: In this cross-sectional analysis, we used the 2018 International Tobacco Control Four Country Smoking and Vaping Survey to examine support for MLSA 21 laws among 12 904 respondents from Australia, Canada, England, and United States. RESULTS: Support for raising the legal age of purchasing cigarettes/tobacco to 21 ranged from 62.2% in the United States to 70.8% in Canada. Endorsement also varied by age, such that 40.6% of 18-20 years old supported the policy compared with 69.3% of those aged ≥60 years. In the adjusted regression model, there was also higher support among respondents who were female than male, non-white than white, those who did not allow smoking in the household than those that did, and those who had children in the household than those that did not. There were no differences by household income, education, or smoking status. CONCLUSIONS: Most current and former smokers, including a sizable minority of those aged ≤20 years, support raising the legal age of purchasing cigarettes/tobacco to 21. IMPLICATIONS: There was strong support for MLSA 21 laws among smokers and former smokers across Australia, Canada, England, and the United States, providing evidence for the increasing public support of the passage of these laws beyond the United States.

Associations Between Gun Laws and Suicides.

We examined the impact of a state gun law environment on suicides overall and within demographic subgroups. We linked 211,766 firearm suicides and 204,625 nonfirearm suicides in the 50 states of the United States for 2005-2015 to the population in each state, year, race/ethnicity, sex, and age, as well as to an index of state-level gun control. Difference-in-differences, zero-inflated, negative-binomial models were used to evaluate the impact of strengthening gun control on firearm and nonfirearm suicides. We subsequently stratified by sex and tested for interactions with race/ethnicity and age. We found 25 states strengthened gun control by an average of 6 points. Such an increase may result in a 3.3% (incidence rate ratio = 0.967; 95% confidence interval: 0.938, 0.996) decrease in firearm suicides. Although no impact on nonfirearm suicides was found overall, interaction models showed an increase in nonfirearm suicides among black men, white women, black women, and older individuals. Strengthening gun control may reduce firearm suicides overall but may increase nonfirearm suicides in some populations. The results indicate stricter gun laws should be advocated for and that additional policies are needed for populations who shifted to nonfirearm suicides.

Impact of state tobacco control policies on birth defects.

While research has demonstrated the effects of tobacco control policies on birth outcomes, there is little known about their impact on birth defects. Using 2005-2015 natality data on 26,334,854 singletons from 47 US states and District of Columbia linked to state-level cigarette taxes and smoke-free restaurant legislation, we examined the impact of tobacco control policies on birth defects by maternal race/ethnicity and education. We found that among white women with less than a high school degree, every $1.00 increase in cigarette taxes reduced prenatal smoking by 3.48 percentage points and reduced the risk of their infant having any birth defect by 0.0023 percentage points. Tax increases also reduced the risk of cyanotic heart defects, cleft palate, gastroschisis, and limb reduction. We found no evidence for associations between the enactment of smoke-free legislation, prenatal smoking and birth defects. Our findings suggest that state cigarette taxes are a population-level intervention that can help reduce prenatal smoking and the risk of birth defects.

Rural-urban disparities in colonoscopies after the elimination of patient cost-sharing by the Affordable Care Act.

INTRODUCTION: Improving the prevention and early detection of colorectal cancer is a priority for reducing rural-urban disparities in colorectal cancer mortality. By eliminating out-of-pocket (OOP) costs for preventive colonoscopies, the Affordable Care Act (ACA) could have reduced rural-urban disparities in screening. METHODS: We used the Maine Health Data Organization All-Payer Claims Database including all commercially-insured and Medicare beneficiaries aged 50-75 between 2009 and 2012. Rural-urban commuting areas were used to classify rural/urban residence. ICD-9 and CPT codes identified colonoscopies. We summed all OOP payments per patient-day. An interrupted time series model estimated the impact of the ACA on trends in rural-urban disparities in colonoscopy rates and OOP costs. RESULTS: Before the ACA, colonoscopy rates were 16% lower in rural than urban areas (5.1% vs. 6.1% of enrollees annually) and median OOP costs were nearly double ($195 vs. $98). The ACA reduced median OOP payments by $94 (p = .001) initially and $4 monthly (p = .038) in rural areas, and $63 (p < .001) in urban areas. The rural-urban gap in OOP payments dropped by $4 monthly (p = .007). The ACA also reduced rural-urban disparities in colonoscopy rates (disparity decrease of 0.005 (6%) monthly, p < .001). The rural-urban gap in colonoscopy rates declined 40% relative to the pre-ACA period by December 2012. CONCLUSIONS: The ACA was associated with significant reductions in rural-urban disparities in colonoscopies in Maine, suggesting that OOP costs are an important barrier for rural residents. Further research is needed to determine whether increased uptake, particularly in rural areas, translated into better patient outcomes for colorectal cancer.

A quasi-experimental evaluation of marijuana policies and youth marijuana use.

BACKGROUND: Marijuana use carries risks for adolescents' well-being, making it essential to evaluate effects of recent marijuana policies. OBJECTIVES: This study sought to delineate associations between state-level shifts in decriminalization and medical marijuana laws (MML) and adolescent marijuana use. METHODS: Using data on 861,082 adolescents (14 to 18+ years; 51% female) drawn from 1999 to 2015 state Youth Risk Behavior Surveys (YRBS), difference-in-differences models assessed how decriminalization and MML policy enactment were associated with adolescent marijuana use, controlling for tobacco and alcohol policy shifts, adolescent characteristics, and state and year trends. RESULTS: MML enactment was associated with small significant reductions (OR = 0.911, 95% CI [0.850, 0.975]) of 1.1 percentage points in current marijuana use, with larger significant declines for male, Black, and Hispanic (2.7-3.9 percentage points) adolescents. Effects of MML increased significantly with each year of exposure (OR = 0.980, 95% CI [0.968, 0.992]). In contrast, decriminalization was not associated with significant shifts in use for the sample as a whole, but predicted significant declines in marijuana use among 14-year olds and those of Hispanic and other ancestry (1.7-4.4 percentage points), and significant increases among white adolescents (1.6 percentage points). Neither policy was significantly associated with heavy marijuana use or the frequency of use, suggesting that heavy users may be impervious to such policy signals. CONCLUSION: As the first study to concurrently assess unique effects of multiple marijuana policies, results assuage concerns over potential detrimental effects of more liberal marijuana policies on youth use.

Associations Between State Tobacco Control Policies and Adolescent ENDS Use.

BACKGROUND: Despite an increase in adolescent use of electronic nicotine delivery systems (ENDS), little is known about the role of tobacco control policies on ENDS use. OBJECTIVE: For aim 1, we examined how trends in adolescent use of cigarettes were affected by the introduction of ENDS; for aim 2, we examined the associations between ENDS age restrictions, cigarette taxes, and smoke-free legislation and adolescent use of ENDS and cigarettes. DESIGN AND SETTING: Repeated cross-sections of the 1999-2015 Youth Risk Behavior Surveys linked to state-level tobacco control policies. PARTICIPANTS: 938 486 adolescents aged 14 to 18 years from 45 states. MAIN OUTCOME MEASURES: For aim 1, we examined adolescent use of cigarettes. For aim 2, we examined adolescent use of ENDS, only ENDS, and cigarettes. RESULTS: We found there was an overall decreasing trend in adolescent use of cigarettes, but the actual decline was greater than the predicted decline for 17- and 18-year-olds. While we found no associations between ENDS use and ENDS age restrictions or cigarette taxes, ENDS use was 3.8 percentage points higher in those states with smoke-free legislation for combustible tobacco products. CONCLUSIONS: Our findings highlight that ENDS age restrictions may not be adequate to curb ENDS use and additional local- and state-level policies governing ENDS are needed.

Impact of tobacco control policies on adolescent smokeless tobacco and cigar use: a difference-in-differences approach.

BACKGROUND: While increasing cigarette taxes has been a major policy driver to decrease smoking, taxes on other tobacco products have received less attention. Our aims were to evaluate the impact of chewing tobacco/cigar taxes, cigarette taxes, and smoke-free legislation on adolescent male and female use of smokeless tobacco and cigars. METHODS: We analyzed data on 499,381 adolescents age 14-18 years from 36 US states in the Youth Risk Behavior Surveys (1999-2013) linked to state-level tobacco control policies. We conducted difference-in-differences regression models to assess whether changes in taxes and the enactment of smoke-free legislation were associated with smokeless tobacco use and, separately, cigar use. Models were stratified by adolescent sex. RESULTS: We found that chewing tobacco taxes had no effect on smokeless tobacco use and cigar taxes had no effect on cigar use. In contrast, among males a 10% increase in cigarette taxes was associated with a 1.0 percentage point increase (0.0010, 95% CI 0.0003-0.0017) in smokeless tobacco use. A 10% increase in cigarette taxes was also associated with a 1.5 percentage point increase (0.0015, 95% CI 0.0006-0.0024) in cigar use among males and a 0.7 percentage point increase (0.0007, 95% CI 0.0001-0.0013) in cigar use among females. There was some evidence that smoke-free legislation was associated with an 1.1 percentage point increase (0.0105, 95% CI 0.0015-0.0194) in smokeless tobacco use among males only, but no effect of smoke-free legislation on cigar use for males or females. CONCLUSIONS: Higher state cigarette taxes are associated with adolescents' use of cheaper, alternative tobacco products such as smokeless tobacco and cigars. Reducing tobacco use will require comprehensive tobacco control policies that are applied equally to and inclusive of all tobacco products.

Effect of the Affordable Care Act on Disparities in Breastfeeding: The Case of Maine.

OBJECTIVES: To evaluate the Affordable Care Act (ACA) breastfeeding provision and test whether changes in coverage affected women differently according to health insurance status. METHODS: We used the All-Payer Claims Database from Maine (2012-2014) to compare health insurance claims for lactation classes and breast pumps between women with private insurance and women with Medicaid (1) before the ACA breastfeeding provision, (2) after the provision came into effect, and (3) after health insurance expansion through the Marketplace. RESULTS: We found limited change in claims for lactation classes over the study period. By contrast, the number of claims for breast pumps among women with private insurance increased from 70 claims in the third quarter of 2012 to 629 claims 1 year later and 803 claims in the third quarter of 2014. Women with Medicaid had only 11 claims for breast pumps over the entire study period. CONCLUSIONS: This 11-fold rise in claims for breast pumps by women with private insurance suggests that these women will likely increase breastfeeding initiation or duration; however, without additional support for women with Medicaid, disparities in breastfeeding may increase.

The impact of the 2008 recession on the health of older workers: data from 13 European countries.

Background: Fluctuations in the national economy shape labour market opportunities and outcomes, which in turn influence the health conditions of older workers. This study examined whether overall economic shifts during the 2008 recession was associated with four health indicators among older workers. Method: Data came from 4917 respondents (16 090 contacts) aged 50-70 in 13 European countries (Austria, Belgium, Czech Republic, Denmark, France, Germany, Israel, Italy, Netherlands, Poland, Spain, Sweden, Switzerland) participating in the Survey of Health, Ageing and Retirement in Europe. Health and employment assessments from 2004-13 were linked to annual data on fluctuations in Gross Domestic Product (GDP) per capita, life expectancy and unemployment rates for each country. Using fixed effects models, we assessed the recession's implications on four individual health outcomes: body mass index (BMI), drinking alcohol, depression and general health, while isolating cyclical variation within countries and individual changes over time. Results: Overall economic shifts had an effect on older workers: decreases in GDP were associated with a decline in average BMI, consumption of alcohol and deterioration in self-rated health; country-level unemployment rate had no effect on health outcomes, while life expectancy at birth was significant but not consistently across models. Being employed or retired were associated with fewer depressive symptoms and better self-rated health. Conclusions: Overall economic shifts during recessions affect certain health outcomes of older workers, and better health conditions together with being employed or retired may limit the negative health consequences of a recession.

The Impact of Sex of Child on Breastfeeding in the United States.

Background Sex of child has been shown to impact breastfeeding duration in India, Australia, Scandinavia, Latin America, and, within the US, in a sample in Eastern Connecticut and in a separate sample of Indian and Chinese immigrants. Objectives The objective of this study is to examine differences in breastfeeding initiation and duration by sex of child across racial/ethnic groups in the US. Methods We used the Pregnancy Risk Assessment Monitoring System 2009-2010 and logistic regression to examine whether sex of child impacts breastfeeding initiation and duration for at least 8 weeks by women's racial/ethnic group. Results Among the 66,107 women in our sample representing 12 different race/ethnic groups, Hispanic women (n = 9049) had lower odds of breastfeeding initiation (adjusted odds ratio [AOR] = 0.81, 95% CI 0.71-0.93) and breastfeeding duration (AOR = .87, 95% CI 0.80-0.96) if they have sons compared to Hispanic women who have daughters. Sex of child did not impact the odds of breastfeeding initiation or duration among any other race/ethnic group. Conclusion We have shown that, for Hispanics in the US, sex of child may have an impact on breastfeeding, a health behavior that has a variety of positive impacts on infants throughout their lives. Boys, relative to girls, were at a disadvantage in breastfeeding initiation and duration. Future work is necessary to unpack the mechanisms behind these findings. In particular, how sex of child impacts how mothers and fathers view the nutritional needs of their children and breastfeeding more broadly.