Tobacco 21 Laws and Youth Tobacco Use: The Role of Policy Attributes.

Objectives. To estimate Tobacco-21 policies' relationships to 18- to 20 year-old youth cigarette, cigar, and electronic nicotine delivery system (ENDS) use, and to test for effect modification by policy attributes. Methods. In fall 2022, we used Tobacco 21 Population Coverage Database data to calculate the percentage of state residents covered by state or local Tobacco 21 (T21) laws monthly through June 2020. Matching T21 coverage to Population Assessment of Tobacco and Health and Behavioral Risk Factor Surveillance System data, we used 2-way fixed effect analyses to assess the relationship between T21 laws and 18- to 20-year-old youth cigarette, cigar, and ENDS use, and tested for differences by policy attributes: possession, use, or purchase (PUP) penalties, retailer noncompliance penalties, and compliance check requirements. Results. Increased T21 exposure yielded significant reductions in cigarette and cigar use, as well as in ENDS use, when accounting for policy attributes. These effects were dampened in T21 laws with PUP penalties relative to those without. Conclusions. Tobacco-21 laws yield reductions in 18- to 20-year-old youth cigarette, cigar, and ENDS use, with dampened effects when policies include PUP penalties. Public Health Implications. State policymakers should consider implementing T21 laws without PUP penalties to reduce underage nicotine and tobacco use. (Am J Public Health. 2024;114(1):90-97. https://doi.org/10.2105/AJPH.2023.307447).

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021.

INTRODUCTION: The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the lung injuries outbreak, flavour bans, Tobacco 21 and the COVID-19 pandemic. METHODS: Using the Population Assessment of Tobacco and Health Study, we applied a multistate transition model to 28 061 adults in waves 4-5 (2017-2019) and 24 584 adults in waves 5-6 (2019-2021), estimating transition rates for initiation, cessation and switching products for each period overall and by age group. RESULTS: Cigarette initiation among adults who never used either product decreased from 2017-2019 to 2019-2021, but ENDS initiation did not significantly change. The persistence of ENDS-only use remained high (75%-80% after 1 year). Cigarette-only use transitions remained similar (88% remaining, 7% to non-current use and 5% to dual or ENDS-only use). In contrast, dual use to ENDS-only transitions increased from 9.5% (95% CI 7.3% to 11.7%) to 20.0% (95% CI 17.4% to 22.6%) per year, decreasing the persistence of dual use. The dual to cigarette-only use transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use. CONCLUSIONS: The persistence of ENDS use among adults remained high in 2019-2021, but a larger fraction of dual users transitioned to ENDS-only use compared with 2017-2019. Because the fraction of cigarette-only users switching to dual use remained low, especially among older adults, the public health implications of this change are minimal.

How Complete Are Tobacco Sales Data? Assessing The Comprehensiveness Of US Tobacco Product Retail Sales Data Through Comparisons To Excise Tax Collections.

INTRODUCTION: Sales data analyses are increasingly used to guide tobacco regulatory science. However, such data do not cover specialist retailers like vape shops or tobacconists. Understanding the extent of the cigarette and electronic nicotine delivery system (ENDS) markets covered by sales data is critical to establishing such analyses' generalizability and potential biases. METHODS: Using retail sales data from Information Resources Incorporated (IRI) and Nielsen, we conduct tax gap analyses comparing states' cigarette and ENDS tax revenue to tax collection estimates based on retail sales data. For the 23 US states in both retail sales datasets, cigarette tax gap analyses were conducted for each year from 2018-2020. Four (Louisiana, North Carolina, Ohio, and Washington) of those 23 states levied per unit ENDS taxes and provided monthly tax revenue data covering January 2018 - October 2021, where we conducted monthly tax gap analyses for both cigarettes and ENDS. RESULTS: Across states covered by both sales datasets, annual mean cigarette sales in IRI and Nielsen account for 92.3% (95% CI 88.3-96.2%) and 84.0% (95% CI 79.3-88.7%) of state cigarette tax revenue, respectively. Monthly average coverage rates for ENDS sales were lower, ranging from 42.3% to 86.1% for IRI and 43.6% to 88.5% for Nielsen, but remained stable over time. CONCLUSIONS: IRI and Nielsen sales data capture almost the entire US cigarette market and a substantial but lower portion of the US ENDS market. With proper care to address shortcomings, sales data analyses can capture changes in the US market for these tobacco products. IMPLICATIONS: Policy evaluations and analyses using e-cigarette and cigarette sales data are often criticized because these data do not cover online sales or sales by specialty retailers like tobacconists.Cigarette sales data consistently cover nearly 90% of taxed sales, while e-cigarette sales data cover around 50% of taxed volumes.Retail sales data capture nearly all cigarette sales and a substantial portion of ENDS sales with relatively stable rates of coverage over time, supporting their continued use in tobacco surveillance and policy evaluation work.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of youth and adults in the PATH Study in 2015-2017 vs 2017-2019.

INTRODUCTION: It is unknown how recent changes in the tobacco product marketplace have impacted transitions in cigarette and electronic nicotine delivery system (ENDS) use. METHODS: A multistate transition model was applied to 24 242 adults and 12 067 youth in waves 2-4 (2015-2017) and 28 061 adults and 12 538 youth in waves 4 and 5 (2017-2019) of the Population Assessment of Tobacco and Health Study. Transition rates for initiation, cessation and product transitions were estimated in multivariable models, accounting for gender, age group, race/ethnicity and daily versus non-daily product use. RESULTS: Changes in ENDS initiation/relapse rates depended on age, including among adults. Among youth who had never established tobacco use, the 1-year probability of ENDS initiation increased after 2017 from 1.6% (95% CI 1.4% to 1.8%) to 3.8% (95% CI 3.4% to 4.2%). Persistence of ENDS-only use (ie, 1-year probability of continuing to use ENDS only) increased for youth from 40.7% (95% CI 34.4% to 46.9%) to 65.7% (95% CI 60.5% to 71.1%) and for adults from 57.8% (95% CI 54.4% to 61.3%) to 78.2% (95% CI 76.0% to 80.4%). Persistence of dual use similarly increased for youth from 48.3% (95% CI 37.4% to 59.2%) to 60.9% (95% CI 43.0% to 78.8%) and for adults from 40.1% (95% CI 37.0% to 43.2%) to 63.8% (95% CI 59.6% to 67.6%). Youth and young adults who used both products became more likely to transition to ENDS-only use, but middle-aged and older adults did not. CONCLUSIONS: ENDS-only and dual use became more persistent. Middle-aged and older adults who used both products became less likely to transition to cigarette-only use but not more likely to discontinue cigarettes. Youth and young adults became more likely to transition to ENDS-only use.

Differences in Cancer Screening Responses to State Medicaid Expansions by Race and Ethnicity, 2011‒2019.

Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011-2016 and 2018-2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630-1639. https://doi.org/10.2105/AJPH.2022.307027).

Do Local Tobacco-21 Laws Reduce Smoking Among 18 to 20 Year-Olds?

INTRODUCTION: States and municipalities are increasingly restricting tobacco sales to those under age 21, in an effort to reduce youth and young adult smoking. However, the effectiveness of such policies remains unclear, particularly when implemented locally. METHODS: Analyses use 2011-2016 data from the Behavioral Risk Factor Surveillance System's Selected Metropolitan/Micropolitan Area Risk Trends dataset. Difference-in-differences and triple-difference regressions estimate the relationship between local tobacco-21 policies and smoking among 18- to 20-year-olds living in MMSAs (metropolitan/micropolitan statistical areas and metropolitan divisions). RESULTS: Current smoking rates fell from 16.5% in 2011 to 8.9% in 2016 among 18- 20-year-olds in these data. Regressions indicate that a tobacco-21 policy covering one's entire MMSA yields an approximately 3.1 percentage point reduction in 18- to 20-year-olds' likelihoods of smoking (confidence interval [CI] = -0.0548 to -0.0063). Accounting for partial policy exposure-tobacco-21 laws implemented in some but not all jurisdictions within an MMSA-this estimate implies that the average exposed 18- to 20-year-old experienced a 1.2 percentage point drop in their likelihood of being a smoker at interview relative to unexposed respondents of the same age, all else equal. CONCLUSIONS: Local tobacco-21 policies yield a substantive reduction in smoking among 18- to 20-year-olds living in MMSAs. This finding provides empirical support for efforts to raise the tobacco purchasing age to 21 as a means to reduce young adult smoking. Moreover, it suggests that state laws preempting local tobacco-21 policies may impede public health. IMPLICATIONS: Although states and municipalities are increasingly restricting tobacco sales to under 21-year-olds, such policies' effectiveness remains unclear, particularly when implemented locally. Using quasi-experimental methods, this article provides what may be the first evidence that sub-state tobacco-21 laws reduce smoking among 18- to 20-year-olds. Specifically, considering metropolitan and micropolitan areas from 2011 to 2016, the average 18- to 20-year-old who was exposed to these policies exhibited a 1.2 percentage point drop in their likelihood of being a current established smoker, relative to those who were unexposed. These findings validate local tobacco-21 laws as a means to reduce young adult smoking.

Socioeconomic Disparities in Electronic Cigarette Use and Transitions from Smoking.

INTRODUCTION: Socioeconomic disparities have been established for conventional cigarette use, but not for electronic cigarettes. This study estimates socioeconomic gradients in exclusive use of conventional cigarettes, electronic cigarettes, and dual use (ie, use of both products) among adults in the United States. METHODS: Analyses consider nationally representative data on 25- to 54-year-old respondents to the 2014-2016 National Health Interview Surveys (N = 50306). Demographically adjusted seemingly unrelated regression models estimate how two socioeconomic status measures-respondent education and household income-relate to current exclusive use of conventional cigarettes, electronic cigarettes, and dual use. RESULTS: Conventional cigarette use exhibits negative education and income gradients, consistent with existing research: -12.9 percentage points (confidence interval [CI]: -14.0, -11.8) if college educated, and -9.5 percentage points (CI: -10.9, -8.1) if household income exceeds 400% of the federal poverty level. These gradients are flatter for dual use (-1.4 [CI: -1.8, -0.9] and -1.9 [CI: -2.5, -1.2]), and statistically insignificant for electronic cigarette use (-0.03 [CI: -0.5, 0.4] and -0.3 [CI: -0.8, -0.2]). Limiting the sample to ever-smokers, higher education is associated with a 0.9 percentage point increase in likelihood of exclusive electronic cigarette use at interview (CI: 0.0, 1.9). CONCLUSIONS: Education and income gradients in exclusive electronic cigarette use are small and statistically insignificant, contrasting with strong negative gradients in exclusive conventional cigarette use. Furthermore, more educated smokers are more likely to switch to exclusive e-cigarette use than less educated smokers. Such differential switching may exacerbate socioeconomic disparities in smoking-related morbidity and mortality, but lower the burden of tobacco-related disease. IMPLICATIONS: Research has not yet established whether socioeconomic disparities in electronic cigarette (e-cigarette) use resemble those observed for conventional cigarettes. This article uses nationally representative data on US adults aged 25-54 to estimate income and education gradients in exclusive use of conventional cigarettes, e-cigarettes, and dual use. Both gradients are steep and negative for conventional cigarette use, but flat and statistically insignificant for e-cigarette use. Repeating the analysis among ever-smokers indicates that more educated smokers are more likely to transition toward exclusive e-cigarette use than less educated smokers. Such differential substitution may exacerbate disparities in smoking-related morbidity and mortality.

Coverage of Indoor Smoking and Vaping Restrictions in the U.S., 1990-2021.

INTRODUCTION: Secondhand smoke exposure increases the risk of premature death and disease in children and non-smoking adults. As a result, many U.S. states and local jurisdictions have enacted comprehensive indoor smoking restrictions (ISR). Indoor vaping restrictions (IVR) have also been adopted to protect against exposure to secondhand e-cigarette aerosol. This study aimed to quantify state and national U.S. coverage of policies restricting indoor cigarette and e-cigarette use over time. METHODS: Data from the American Nonsmokers Rights' Foundation on U.S. ISR from 1990 to 2021 and IVR from 2006 to 2021 were analyzed. Combining these data with 2015 U.S. Census population estimates, the percentage of state and national residents covered by partial and comprehensive restrictions in bars, restaurants, and workplaces, were calculated (analysis in 2023-2024) over time. RESULTS: Between 1990 and 2021, national coverage of comprehensive ISR increased for bars (0% to 67.3%), restaurants (0%-78.2%), and workplaces (0%-77.5%). Partial ISR coverage decreased for bars (14.8%-13.9%), restaurants (40.2%-15.4%) and workplaces (40.2%-22.5%). From 2006 to 2021, comprehensive IVR coverage increased for bars (0%-43.5%), restaurants (0%-51.5%), and workplaces (0%-53.2%). Despite these increases in coverage, by the end of 2021, <50% of the population was protected by comprehensive ISR for bars, restaurants, and workplaces in 19, 12, and 14 states, respectively. DISCUSSION: The percentage of the U.S. population protected by ISR and IVR has increased over time. However, gaps in coverage remain, which may contribute to disparities in tobacco-related disease and death.

HOW COMPLETE ARE TOBACCO SALES DATA? ASSESSING THE COMPREHENSIVENESS OF TOBACCO PRODUCT RETAIL SALES DATA THROUGH COMPARISONS TO EXCISE TAX COLLECTIONS.

Introduction: Sales data analyses are increasingly used to guide tobacco regulatory science. However, such data do not cover specialist retailers like vape shops or tobacconists. Understanding the extent of the cigarette and electronic nicotine delivery system (ENDS) markets covered by sales data is critical to establishing such analyses' generalizability and potential biases. Methods: Sales data from Information Resources Incorporated (IRI) and Nielsen Retail Scanner data are used to conduct a tax gap analysis, comparing state tax collections based on cigarette and ENDS sales data to states' annual 2018-2020 cigarette tax collections and monthly ENDS and cigarette tax revenue data for January 2018 to October 2021. Cigarette analyses consider the 23 US states covered by both IRI and Nielsen. ENDS analyses consider the subset of those states with per unit ENDS taxes: Louisiana, North Carolina, Ohio, and Washington. Results: Across states covered by both sales datasets, IRI's mean cigarette sales coverage was 92.3% (95% CI 88.3-96.2%), while Nielsen's was 84.0% (95% CI 79.3-88.7%). Coverage rates for average ENDS sales were lower, ranging from 42.3% to 86.1% for IRI and 43.6% to 88.5% for Nielsen, but remained stable over time. Conclusions: IRI and Nielsen sales data capture almost the entire US cigarette market and, while coverage rates are lower, a substantial portion of the US market for ENDS as well. Coverage rates are relatively stable over time. Thus, with proper care to address shortcomings, sales data analyses can capture changes in the US market for these tobacco products.

Nationally representative surveys on cannabis use lack product details relevant to public health.

Objectives: Many annual, nationally representative US surveys that assess cannabis use do not collect information on product characteristics despite varying health risks and benefits. Capitalizing on a rich dataset of primarily medical users, the purpose of this study was to describe the degree of potential misclassification in clinically relevant cannabis use measures when primary mode of use is recorded but not product type. Methods: Analyses consider user-level data from the Releaf App™ database on product types, consumption modes, and potencies in a non-nationally representative sample of 26,322 cannabis administration sessions occurring in 2018, across 3,258 users. Proportions, means, and 95% confidence intervals were calculated and compared across products and modes. Results: Primary consumption modes were smoking (47.1%), vaping (36.5%), and eating/drinking (10.4%), with 22.7% of users reporting multiple modes of use. Moreover, mode of use did not signify a single product type: users reported vaping both flower (41.3%) and concentrates (68.7%). Of those who smoked cannabis, 8.1% reported smoking concentrates. Concentrates averaged 3.4 times higher tetrahydrocannabinol (THC) potency and 3.1 times higher cannabidiol (CBD) potency than flower. Conclusions: Cannabis consumers employ multiple consumption modes, and product type cannot be inferred from mode of use. With THC potencies markedly higher in concentrates, these findings underscore the importance of including information on cannabis product types and mode of use in surveillance surveys. Clinicians and policymakers need these data to inform treatment decisions and assess cannabis policies' implications for population health.

Intended and unintended effects of e-cigarette taxes on youth tobacco use.

Over the past decade, rising youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) has contributed to aggressive regulation by state and local governments. Between 2010 and mid-2019, ten states and two large counties adopted ENDS taxes. We use two large national surveys (Monitoring the Future and the Youth Risk Behavior Surveillance System) to estimate the impact of ENDS taxes on youth tobacco use. We find that ENDS taxes reduce youth ENDS consumption, with estimated ENDS tax elasticities of -0.06 to -0.21. However, we estimate sizable positive cigarette cross-tax effects, suggesting economic substitution between cigarettes and ENDS for youth. These substitution effects are particularly large for frequent cigarette smoking. We conclude that the unintended effects of ENDS taxation may considerably undercut or even outweigh any public health gains.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021.

Introduction: The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the outbreak of lung injuries related to vaping THC, flavor bans, and the COVID pandemic. We analyzed patterns of initiation, cessation, and transitions between cigarettes, ENDS, and dual use before and after 2019. Methods: Using the Population Assessment of Tobacco and Health (PATH) Study, we applied a multistate transition model to 28,061 adults in Waves 4-5 (2017-19) and 24,751 adults in Waves 5-6 (2019-21), estimating transition rates for initiation, cessation, and switching products for each period overall and by age group. Results: Cigarette initiation among adults who never used either product decreased from 2017-19 to 2019-21, but ENDS initiation did not significantly change. Persistence of ENDS-only use remained high, with 75-80% still using ENDS only after 1 year. Cigarette-only use transitions remained similar, with about 88% remaining, 7% transitioning to non-current use, and 5% transitioning to dual or ENDS-only use. In contrast, dual use to ENDS-only transitions increased from 9.5% (95%CI: 7.3-11.7%) to 20.1% (95%CI: 17.5-22.7%) per year from 2017-19 to 2019-21, decreasing the persistence of dual use. The dual use to cigarette-only transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use. Conclusions: Persistence of ENDS use among adults remained high in 2019-21, but a larger fraction of dual users transitioned to ENDS-only use compared to 2017-19. Because the fraction of cigarette-only users switching to dual use remained low, the public health implications of the increased dual use to ENDS-only transition are minimal.

Young adult responses to taxes on cigarettes and electronic nicotine delivery systems.

BACKGROUND AND AIMS: Although over half of United States states have passed taxes on electronic nicotine delivery systems (ENDS), recent evidence links ENDS tax rates to increases in smoking, suggesting potentially substantive health costs. Overall health implications will depend on how these taxes affect transitions from experimentation to regular smoking and vaping. Current analyses have not assessed ENDS tax rates' effects in young adulthood (ages 18-25). This study measures the relationship between ENDS and cigarette tax rates and ENDS use and smoking in young adulthood, a key period for initiation of regular tobacco use. DESIGN: Observational study of data from the Current Population Survey's 2010-2019 Tobacco Use Supplements. SETTING: The United States. PARTICIPANTS/CASES: A total of 38 906 18 to 25 year-olds MEASUREMENTS: Multivariable linear regressions estimated two-way fixed effects analyses to assess ENDS and cigarette tax rates' relationships to recent and daily smoking and vaping, adjusting for an array of potential sociodemographic and policy confounders along with state and year fixed effects. FINDINGS: A $1 increase in ENDS taxes yielded significant reductions in young adults' daily vaping ( ß Ì‚ = -0.025; 95% CI, -0.037, -0.014) alongside increases in recent smoking ( ß Ì‚ = 0.037; 95% CI, 0.013, 0.061), primarily reflecting greater dual use ( ß Ì‚ =2.078; 95% CI, 0.890, 4.852; P = 0.09). A $1 cigarette tax increase yielded 2.1 and 2.5 percentage point increases in recent and daily vaping, with 95% CIs of (0.004, 0.038) and (0.018, 0.032) respectively. CONCLUSIONS: In the United States, higher ENDS tax rates are associated with decreased ENDS use but increased cigarette smoking among 18- to 25-year-olds, with associations reversed for cigarette taxes.

Association of vaping-related lung injuries with rates of e-cigarette and cannabis use across US states.

BACKGROUND AND AIMS: Responses to the 2019 US outbreak of 'e-cigarette or vaping product use-associated lung injury' (EVALI) ranged from temporary restrictions on nicotine e-cigarette sales to critiques of state cannabis policies. However, if either mass-marketed nicotine e-cigarettes or cannabis use per se drove this outbreak, as opposed to an additive in regionally available black-market e-liquids, states' rates of vaping and/or cannabis use should predict their EVALI prevalence. This study tests that relationship. DESIGN: Observational study of EVALI data from US states' health departments SETTING: United States. PARTICIPANTS: All US states (n = 50). MEASUREMENTS: The outcome of interest was each state's total EVALI cases per 12-64-year-old resident-an age group covering most EVALI patients-as reported in the second week of January 2020. Predictors are 2017-18 rates of adult e-cigarette use and past-month cannabis use by state. FINDINGS: The average state EVALI prevalence was 1.4 cases per 100 000 12-64-year-olds. Maps suggest a high-prevalence cluster comprising seven contiguous states in the northern Midwest. EVALI cases per capita were negatively associated with rates of vaping and past-month cannabis use, with the preferred specification's coefficients at -0.239 [95% confidence interval (CI) = -0.441, -0.037; P = 0.02] and -0.086 (95% CI = -0.141, -0.031; P = 0.003), respectively. Robustness checks supported this finding. CONCLUSIONS: In the United States, states with higher rates of e-cigarette and cannabis use prior to the 2019 'e-cigarette or vaping product use-associated lung injury' (EVALI) outbreak had lower EVALI prevalence. These results suggest that EVALI cases did not arise from e-cigarette or cannabis use per se, but rather from locally distributed e-liquids or additives most prevalent in the affected areas.

Chilling Effects: US Immigration Enforcement And Health Care Seeking Among Hispanic Adults.

Aggressive deportation policy enforcement in the US may make undocumented immigrants and those close to them reluctant to seek medical care. With 68 percent of undocumented immigrants coming from Mexico or Central America, US deportation policies particularly affect Hispanic residents. To examine how deportation enforcement relates to health care use in the Hispanic population in general, we matched survey data from the 2011-16 Behavioral Risk Factor Surveillance System to measures of Immigration and Customs Enforcement (ICE) activity. Quasi-experimental analyses demonstrated that Hispanic respondents were less likely to report having had a regular provider or annual checkup following increased ICE activity in their state. In contrast, these behaviors were unchanged among non-Hispanic adults, a group less likely to be affected by deportation enforcement. Parallel results were found among Hispanic and non-Hispanic adults with diabetes, for whom lapses in care may confer significant health risks.