Addiction

ObjectiveMinimum unit pricing (MUP) aims to reduce use of cheap, high strength alcoholic beverages that drive harm, yet concerns remain about inequitable effects for structurally vulnerable groups. As part of the Costs, Harms, Expenditures and Alcohol Prices (CHEAP) study, we linked individual-level, product-specific alcohol consumption data from a customized survey with provincial retail price data to estimate prices per standard drink (PPSD) and examine their association with alcohol-related outcomes across sociodemographic groups. MethodA cross-sectional survey of past-week drinkers in British Columbia, Canada, was linked to provincial product-level alcohol sales data. The population weighted sample included 1,217 adults aged [≥] 19 years (716 men; mean age 49.34, SD 16.98). Participants reported product-specific consumption, which was matched to retail prices to calculate individual-level PPSD. Survey weighted quasibinomial models then examined associations between PPSD and three outcomes: (1) causing harm to self or others in the past year, (2) scoring [≥] 8 on the Alcohol Use Disorder Identification Test, and (3) consuming [≥] 15 standard drinks per week. Analyses were stratified by income, education, subjective social status, and race/ethnicity. ResultsLower price per standard drink was associated with higher odds of harm (OR 3.05, 95% CI 1.25-7.40) and scoring [≥] 8 on the AUDIT (OR 2.34, 95% CI 1.37-3.99). Associations were stronger among structurally disadvantaged groups, including low-income respondents and Indigenous participants. ConclusionsLower alcohol affordability is linked to risky alcohol use, with the strongest effects among structurally disadvantaged groups. MUP would reduce this risk and promote health equity.

BackgroundThe UK has the fourth highest estimated prevalence globally of maternal alcohol consumption during pregnancy (41%). It is therefore important to understand the long-term impacts of prenatal alcohol exposure (PAE) by examining its impact on the development of adolescent multiple risk behaviours (MRBs) which may increase morbidity and premature mortality across the life-course. MethodsUsing Avon Longitudinal Study of Parents and Children (ALSPAC) cohort data with multiple imputation (n=6,752), we examined the impacts of infrequent, frequent, and binge PAE groups on the development of seven MRBs at 16 years old, encompassing substance misuse, risky sexual behaviour and antisocial behaviour. Data were analysed using multiple regression, using q-statistics to adjust for multiple comparisons. ResultsAdolescents with infrequent and frequent PAE were more likely to develop hazardous alcohol use at 16 years old compared to those without PAE, with the strongest association being for the frequent group (adjusted odds ratio (aOR) 1.45 [1.19-1.76], p<0.001, q-value=0.005). Adolescents exposed to binge drinking prenatally had an increased risk of engaging in underage sexual intercourse (aOR 1.34 [1.09-1.64], p=0.005, q-value=0.044). Binge drinking predicted a higher total MRB score (Coefficient = (+0.21 [+0.08 to +0.33], p=0.001, q-value=0.017). ConclusionsThis study supports the UK Chief Medical Officers Low Risk Drinking Guidelines that the safest approach if pregnant, or if there is a possibility of becoming pregnant, is to avoid drinking alcohol, with the more alcohol consumed during pregnancy the greater the risks of long-term harm to the baby. Given the findings that PAE may increase the risk of adolescent hazardous alcohol use and risky sexual behaviour, this study highlights the need for further research to understand the intergenerational effects of PAE.

BackgroundPractical alcohol risk-reduction strategies are widely recommended in public-facing alcohol guidance, but randomized evidence from socially interactive drinking episodes remains limited. We conducted a pilot cluster randomized trial to evaluate the feasibility and preliminary effects of a package intervention comprising practical drinking-strategy information, participant self-selection of same-day strategies, and a brief commitment declaration in a social drinking laboratory. MethodsThis single-center, parallel-group pilot trial was conducted in Japan. Pre-existing social groups participated. One or two groups scheduled in the same session slot were combined into a time-slot allocation unit, which was randomized 1:1 either to the package intervention or to alcohol-related knowledge only. The primary outcome was total pure alcohol intake during the first 120 min. Session satisfaction on a Visual Analog Scale (VAS) was a prespecified secondary participant-experience outcome. ResultsOf 83 interested individuals, 63 were randomized and 59 participants in 17 social groups and 12 allocation units were included in the modified intention-to-treat analysis. The mean paired intervention-control difference for 120-min alcohol intake was-8.84 g (95% confidence interval [CI]-27.92 to 10.23; exact sign-flip p = 0.281). The corresponding exploratory 0-30 min difference was-4.90 g (95% CI-10.48 to 0.68; exact sign-flip p = 0.094). In a genotype-adjusted participant-level sensitivity analysis, the intervention coefficient for 120-min intake was-16.0 g (95% CI-30.9 to-1.1; p = 0.036). Session satisfaction was high in both arms with no clear between-arm difference. Next-day follow-up was 100%, and no adverse-event-related discontinuations occurred. ConclusionsThe intervention was feasible to deliver in a socially interactive drinking setting, and session satisfaction was high in both arms. Primary allocation-unit estimates favored lower alcohol intake but were imprecise. Larger trials are needed to estimate effects more precisely, while considering the potential influence of genotype imbalance on effect estimation in East Asian samples. Trial registrationUniversity Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) UMIN000060685. Registered 17 February 2026.

ObjectivesUptake of evidence-based smoking cessation support remains limited. Digital interventions offer the prospect of scalable and highly accessible support. Smoke Free, a digital mobile application using established behaviour change techniques, has shown promise, but no large-scale randomised controlled efficacy trial has yet been conducted. We assessed its effectiveness for smoking cessation. DesignIn this prospective, randomised, controlled, two-arm, parallel clinical trial with 6-month follow-up, study personnel and patients were blinded. SettingThe trial was conducted nationwide in Germany, utilising a decentralised, fully remote trial design. Enrolment took place digitally after receiving brief advice from a healthcare professional, following guidelines for primary care. ParticipantsOut of a volunteer sample of 1850 patients assessed for eligibility, 1466 adult cigarette smokers who had at least moderate cigarette dependence (F17.2, FTCD[&ge;]3) were recruited between August 2023 and February 2024; 84.1% (1233 participants) completed the primary outcome measure. InterventionsThe intervention group (IG) received the Smoke Free app including behaviour-change missions and gamification elements, while the control group (CG) received a text-only cessation information app. Both groups received brief advice from a healthcare professional. Main outcome measuresThe prespecified primary outcome was self-reported 7-day point-prevalence abstinence from combustible tobacco at 6 months post-randomisation; secondary outcomes included biochemical validation of abstinence in participants providing a saliva sample (59% of eligible participants). ResultsSelf-reported abstinence (primary outcome) was significantly higher in the IG compared with the CG (283 [39.3%] vs. 182 [24.4%], OR=2.01, 95% CI 1.60 to 2.50, p<0.0001). The NNT was 6.7 (5.1 to 9.8). The effect was consistent with biochemical validation (OR=1.76, 95% CI 1.27 to 2.44, p<0.0001) and across secondary outcomes and sensitivity analyses. The 6-month follow-up rates for the primary outcome did not differ between groups (IG: 601 [83.5%]; CG: 632 [84.7%]; p=0.52). Eighty-four serious adverse events were reported by 75 participants (IG: 31, 4.3%; CG: 44, 5.9%; p=0.53); none were treatment-related. ConclusionsThe Smoke Free app is effective for aiding smoking cessation in at least moderately dependent cigarette smokers compared with an informational app when provided as an adjunct to brief advice from a healthcare professional. Trial registrationThe trial was registered with the German Clinical Trials Register (DRKS00031140). FundingSmoke Free 23 GmbH (for-profit company).

IntroductionTobacco smoking remains a leading cause of preventable death in the UK. Although e-cigarettes are promoted as a harm-reduction option, longitudinal evidence on short-term health outcomes across different smoking transition pathways is limited. This study examined short-term associations between transitions to exclusive e-cigarette use, dual use, or cessation and physical health, mental health, and health-related quality of life, compared with continued smoking. MethodsA target trial emulation framework was applied to Waves 7-14 (2015-2024) of the UK Household Longitudinal Study, including 18,011 participant-wave observations from baseline smokers. Propensity score matching (1:3) was used to create comparable exposure groups. A doubly robust analysis-combining matching with Ordinary Least Squares regression-estimated outcomes using the SF-12 Physical (PCS) and Mental (MCS) Component Summary scores and a mapped EuroQol 5-Dimensions 3-Level version (EQ-5D-3L) index. The SF-12 is a validated generic health measure, where PCS and MCS are norm-based scores (mean = 50, SD = 10). The EQ-5D-3L index (range: 0 to 1) reflects overall health utility. ResultsCompared with continued smokers, exclusive e-cigarette users had higher short-term mental health scores (SF-12 MCS {beta} = 1.042; 95% CI: 0.229 to 1.855). In contrast, dual users had lower mental health scores ({beta} = -1.023; 95% CI: -1.574 to -0.472). Short-term physical health scores (SF-12 PCS) were lower among both exclusive switchers ({beta} = -0.670; 95% CI: - 1.287 to -0.053) and quitters ({beta} = -0.486; 95% CI: -0.853 to -0.119), with no evidence of short-term physical health improvement for any transition group. Dual users also had lower health-related quality of life (EQ-5D-3L {beta} = -0.016; 95% CI: -0.025 to -0.008). Subgroup analyses suggested heterogeneity by age and socioeconomic position, with poorer outcomes among older and more disadvantaged smokers. Sensitivity analyses produced directionally consistent findings. ConclusionExclusive switching to e-cigarettes was associated with higher short-term mental health scores, whereas dual use was associated with poorer mental health and health-related quality of life. These findings underscore the importance of distinguishing complete switching from dual use when designing harm-reduction policies and smoking cessation support.

Tobacco use disorder (TUD) remains a leading cause of preventable mortality, and existing pharmacotherapies yield 12-month abstinence rates below 30%. As cannabis legalization expands, approximately 18-22% of people who use tobacco report concurrent cannabis use, yet the impact of co-use on cessation outcomes and the therapeutic potential of endocannabinoid system (ECS) modulation remain unclear. We conducted a translational systematic review and meta-analysis following PRISMA 2020 guidelines, searching Ovid MEDLINE, Embase, APA PsycInfo, and Web of Science through January 2026 (PROSPERO: CRD420250652724). Three study categories were eligible: observational studies of cannabis co-use and cessation outcomes; preclinical studies of cannabinoid modulators on nicotine-related behaviors; and human experimental studies of ECS-targeted interventions. Of 4,869 records screened, 52 studies met inclusion criteria. Meta-analysis of 18 observational studies (N=229,630) revealed that cannabis use was associated with 35% lower odds of achieving tobacco smoking cessation (OR=0.65; 95% CI: 0.55-0.78; p<0.0001; I{superscript 2}=88.1%). Preclinical evidence (15 studies) demonstrated that CB1 receptor antagonists robustly reduced nicotine self-administration and reinstatement, while cannabidiol (CBD) attenuated both nicotine intake and withdrawal without affecting food reinforcement. Clinical translation of CB1 receptor inverse agonists failed due to psychiatric adverse effects, but CBD showed promise by reducing cigarette consumption by 40%, reversing attentional bias to smoking cues, and alleviating withdrawal severity. These findings distinguish naturalistic cannabis exposure from potentially beneficial targeted ECS modulation, and support CBD as a promising candidate for adequately powered tobacco cessation trials.

BackgroundOral nicotine pouches (ONPs) have become the second most commonly used nicotine product among U.S. youth. However, little is known about how ONP use is distributed across population subgroups and how strongly it is patterned by use of other tobacco or nicotine products. MethodData were drawn from the 2021-2023 waves of the National Youth Tobacco Survey (NYTS), a nationally representative survey of U.S. middle and high school students (N = 66,349). We estimated the annual survey-weighted prevalence of current ONP use ([&ge;]1 day in the past 30). Using 2023 data (N = 20,174), we estimated prevalence by demographics and other tobacco/nicotine product use, and fitted survey-weighted Poisson regression models to estimate associations of current ONP use with demographics and other nicotine/tobacco product use. ResultsIn 2023, 1.6% reported current ONP use (95% confidence interval [CI] 1.0-2.1), up from 0.8% in 2021 (95% CI 0.5-1.0). Prevalence in 2023 was higher among males (2.3%, 95% CI 1.5-3.1) than females (0.8%, 95% CI 0.4-1.3), and among students who used any other tobacco or nicotine product (13.4%, 95% CI 10.3-16.5) than those who did not (0.4%, 95% CI 0.1-0.8). In fully adjusted models, use of nicotine products other than cigarettes or e-cigarettes showed the strongest association with ONP use (APR 21.1, 95% CI 13.0-34.0), followed by cigarette smoking (APR 2.0, 95% CI 1.1-3.7) and e-cigarette use (APR 1.9, 95% CI 0.8-4.5). Most current ONP users also used other tobacco/nicotine products (75.0%), though 16.6% reported no lifetime use of other products. ConclusionsOverall ONP prevalence among U.S. youth remains low but is increasing. While ONP use is largely concentrated in youth who use other nicotine/tobacco products, it is also increasing among adolescents who are otherwise nicotine-naive. These findings highlight the need for continued monitoring and targeted regulations that balance harm reduction for people who smoke against the risk of expanding nicotine dependence among youth. Key Points QuestionWhat are the prevalence, demographic patterns, and tobacco/nicotine co-use profiles of oral nicotine pouch users among US middle and high school students? FindingsIn this cross-sectional study of 66,349 students from the 2021-2023 National Youth Tobacco Survey, current oral nicotine pouch use doubled from 0.8% in 2021 to 1.6% in 2023. Most users also used other tobacco or nicotine products, but the proportion of current users with no lifetime use of other products increased from 7.4% to 16.6%. MeaningAlthough oral nicotine pouch use among US youth remains low, increasing uptake among adolescents without prior tobacco or nicotine exposure suggests a need for targeted prevention efforts alongside continued surveillance.

Alcohol use disorder (AUD) remains a major public health problem, with few effective medications and suboptimal adherence. L-type calcium channel blockers (LTCCBs) have genetic and preclinical support as potential treatments for AUD. We evaluated whether brain penetrant (BP)-LTCCBs are associated with reduced alcohol consumption by conducting two preregistered (https://osf.io/huawv) observational cohort studies using electronic health records (EHRs) from the US Department of Veterans Affairs (VA) and Kaiser Permanente Northern California (KPNC). New users of BP-LTCCBs (nifedipine or felodipine) were compared with new users of a non-BP-LTCCB (amlodipine) and with unexposed patients sampled from the same clinics, following a 180-day washout and requiring at least 60 days supply. Propensity score matching was conducted separately for BP-LTCCB versus unexposed, non-BP-LTCCB versus unexposed, and BP-versus non-BP-LTCCB. The primary outcome was change in drinks per week from the most recent pre-index screen to end of follow-up, estimated using difference-in-differences (DiD) models. Prespecified subgroup analyses were conducted by AUD diagnosis, baseline drinking level, and sex. Across both health systems, BP-LTCCB initiation was not associated with greater reductions in drinks per week than either comparator, with broadly consistent findings across all subgroups. In two large, preregistered EHR-based cohorts with rigorous confounding control, BP-LTCCBs were not associated with reduced drinking relative to comparators. Despite compelling genetic and preclinical evidence, these results do not support repurposing BP-LTCCBs for AUD, highlighting the need to prioritize alternative pharmacologic targets, potentially within etiologically informed subgroups.

BackgroundCannabis use is highly prevalent among people who use unregulated drugs. While daily cannabis use has been hypothesized to provide protective effects through substitution or tolerance mechanisms, the relationship between cannabis use frequency and overdose risk remains poorly understood, particularly for infrequent users. MethodsWe conducted a secondary analysis of cross-sectional interview data from people who use unregulated drugs in Vancouver, British Columbia, collected during the fentanyl crisis (November 2019-July 2021; n=657). Binary logistic regression examined associations between self-reported cannabis use frequency (five categories: less than monthly, 1-3 times per month, weekly, more than weekly and daily) and non-fatal overdose in the preceding six months. Daily use served as the reference category. Models adjusted for age, gender, ethnicity, homelessness, mental health, HIV status, incarceration and daily use of alcohol, opioids, fentanyl, cocaine and stimulants. ResultsAmong 657 participants, 95 (14.5%) reported non-fatal overdose in the past six months. In adjusted models with daily cannabis use as the reference, infrequent cannabis use was associated with significantly increased odds of overdose: use 1-3 times per month (aOR=3.17, 95% CI: 1.50-6.69, p=.002) and more than weekly use (aOR=3.13, 95% CI: 1.70-5.76, p<.001) showed approximately three-fold increased odds compared to daily use. Less frequent use showed non-significant trends in the same direction (less than monthly: aOR=1.73, 95% CI: 0.89-3.37, p=.109; weekly: aOR=1.44, 95% CI: 0.59-3.51, p=.421). Sensitivity analysis restricted to participants with daily stimulant or fentanyl use (n=148) revealed even stronger associations. ConclusionsInfrequent cannabis use was associated with substantially increased overdose risk compared to daily use. This frequency-dependent relationship, with infrequent users at highest risk, likely reflects tolerance differences: infrequent users lack tolerance to synergistic cannabis-opioid effects. These findings were completely obscured in preliminary analyses that dichotomized cannabis use as daily versus less-than-daily, demonstrating how analytical choices can mask critical public health insights. Current harm reduction approaches, including cannabis distribution programs, should incorporate frequency-dependent risk communication and develop strategies to protect infrequent users who may be at heightened overdose risk.

Background and AimsAlcohol use disorder (AUD) remains a major public health concern, with persistent disparities in access to evidence-based treatment. This study aimed to examine associations between perceived discrimination in healthcare settings (PDHS), patient-clinician communication (PCC), and receipt of treatment for AUD, and compared these with sociodemographic and insurance-related factors. DesignCross-sectional analysis using structural equation modeling (SEM), logistic and multinomial logistic regression, and machine learning approaches including SHapley Additive exPlanations (SHAP). SettingUnited States, using data from the National Institutes of Health All of Us Research Program. ParticipantsA total of 5,287 adults with AUD (mean age 61 years; 57% men), including 71.6% non-Hispanic White, 12.2% Black, and 8.6% Hispanic participants. Insurance coverage included 52% government (Medicaid/Medicare), 37% private, and 21% military with 19% reporting more than one type. MeasurementsPrimary outcomes were receipt of Food and Drug Administration-approved pharmacotherapy and/or psychotherapy for AUD, examined as binary and multinomial outcomes. The primary exposure was PDHS, measured using a 7-item scale (range 7-35), with higher scores indicating more frequent discrimination. PCC, assessed using a 2-item scale (range 2-8) with higher scores indicating poorer communication, was examined as a potential mediator. Models were adjusted for age group, sex at birth, race/ethnicity, insurance type (government, private, military), household income, and Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scores (range 0-12). FindingsPDHS was associated with poorer PCC ({beta} = 0.209, p < 0.001), although communication was not independently associated with treatment receipt. The indirect pathway from discrimination to treatment via communication was not supported. Military insurance was the strongest predictor of treatment receipt, with 6-7 times higher odds compared with other insurance types. Higher AUDIT-C scores and greater PDHS were also associated with increased likelihood of treatment. In analyses restricted to civilian participants, PDHS showed a stronger association with treatment receipt, while PCC demonstrated more modest effects. Machine learning models identified PDHS, AUDIT-C, and PCC as strong contributors, with the impact of poor communication most pronounced among individuals with lower income. ConclusionsAccess to treatment for alcohol use disorder is most strongly associated with insurance coverage, particularly military insurance. PDHS and PCC also contribute to treatment engagement, with differential effects across socioeconomic groups. These findings highlight the importance of addressing structural and interpersonal barriers to improve equitable access to evidence-based AUD treatment.

Objectives: Quantify hazardous alcohol consumption prevalence among individuals at risk of acquiring HIV infection and its association with high-risk sexual behaviors and incident HIV in 11 Eastern and Southern African countries. Design: Secondary analysis of 16 nationally-representative household surveys (2015-2023). Methods: The study included sexually active individuals aged [&ge;]15 years. Alcohol use patterns were classified using the AUDIT-C (non-drinkers/low-risk drinkers/hazardous non-binge drinkers/hazardous binge drinkers). Outcomes included high-risk sexual behaviors, recent HIV infection, and undiagnosed HIV infection. Survey-weighted alcohol use prevalence and logistic regression were estimated by gender, adjusting for sociodemographic covariates. Model outputs were used to estimate change in incident infections when removing excess risks associated with alcohol use patterns. Results: Analyses included 251,931 participants. Across countries, 5.8%-21.1% reported hazardous binge drinking, and 3.7%-15.7% reported hazardous non-binge drinking, with large gender differences. Sexual risk behaviors increased with drinking severity among men and women. Compared with non-drinkers, alcohol use was associated with higher odds of undiagnosed HIV infection; adjusted odds ratios ranged from 1.32 (1.16-1.50) for low-risk drinkers to 1.52 (1.34-1.72) for hazardous binge drinkers among men, and 1.28 (1.13-1.46) to 1.55 (1.31-1.82) among women. Simulated removal of alcohol-associated excess risk reduced undiagnosed HIV by 15.1% (10.9%-19.4%) among men and 5.8% (4.0%-7.9%) among women. Estimates for recent HIV infection followed a similar pattern but with larger uncertainty. Conclusions: Hazardous alcohol use was associated with sexual risk and HIV infection in Eastern and Southern Africa. Reaching individuals who use alcohol with effective HIV prevention may reduce HIV acquisition risk across the region.

Abstract Importance: The overall prevalence of youth nicotine and tobacco product use has declined over recent years, but the product landscape continues to evolve rapidly, particularly with new disposable e-cigarettes and oral nicotine pouches. Objective: To examine changes between 2024 and 2025 in the prevalence of nicotine and tobacco product use among US middle and high school students and describe shifts in product characteristics among current e-cigarette and nicotine pouch users. Design, Setting, and Participants: Repeated cross-sectional study using nationally representative data from the 2024 and 2025 National Youth Tobacco Survey (NYTS), a school-based survey of US students in grades 6-12 (approximately ages 11-18). The analytic sample included 29,678 students in 2024 and 23,557 students in 2025. Exposures: Survey year (2025 vs 2024). Main Outcomes and Measures: Past 30-day use of nicotine/tobacco products, including e-cigarettes, nicotine pouches, cigarettes, and other combustible and non-combustible products. Among current e-cigarette and nicotine pouch users, frequency of use, device type, brands, and flavors were assessed. Results: In 2025, 7.2% (95% CI, 6.4-8.2%) of US middle and high school students reported past 30-day use of any nicotine/tobacco product, compared with 8.1% (7.4-8.9%) in 2024. E-cigarettes remained the most commonly used product (5.2%, 4.5-5.9%); 1.7% (1.4-2.1%) used nicotine pouches, 1.7% (1.4-1.9%) smoked cigarettes, and 2.7% (2.4-3.1%) smoked any combustible tobacco product. Among current e-cigarette users, 40.7% (36.7-44.9%) reported frequent use and 27.0% (24.0-30.2%) reported daily use in 2025. Disposable e-cigarette use increased from 55.8% (52.6-59.0%) in 2024 to 66.7% (62.5-70.7%) in 2025, while pod/cartridge device use declined. Flavored product use was reported by 90.0% of e-cigarette users and 88.0% of nicotine pouch users. The most commonly reported brands were Geek Bar among e-cigarette users (61.1%) and ZYN among nicotine pouch users (69.4%). Conclusions and Relevance: Overall youth nicotine and tobacco use remains relatively low, but the product landscape is evolving rapidly, with increasing disposable device use and shifting brand preferences. These findings highlight the importance of ongoing, product-specific surveillance to inform public health strategies and regulatory policies.

Introduction: Monitoring trends in transitions in the use of electronic nicotine delivery systems (ENDS) and cigarettes among youth is important for understanding the potential public health impacts of these products. Methods: Using a weighted Markov multistate transition model accounting for complex survey design, we estimated transition rates and one-year transition probabilities between never, non-current, ENDS-only, and cigarette use (with or without dual use of ENDS) among 26,744 youth aged 12-17 years who participated in at least two consecutive waves from Waves 2-7.5 (approximately 2015-2023) of the nationally representative Population Assessment of Tobacco and Health (PATH) Study. We also estimated transitions stratified by ages 12-14 and 15-17 years. Results. The one-year probability of ENDS-only initiation from never use among youth peaked in 2017-19 (Waves 4-5) at 4.0% (95%CI: 3.6-4.3%) and was higher for 15-17-year-olds at 5.8% (95%CI: 5.2-6.4%) than 12-14-year-olds at 2.2% (95%CI: 1.8-2.6%). In the following years, ENDS-only initiation rates declined and plateaued, with 2.6% (95%CI: 2.3-3.0%) initiation in 2022-23. Cigarette initiation from never use decreased over 2015-23 from 0.8% (95%CI: 0.6-1.0%) in 2015-16 to 0.1% (95%CI: 0.0-0.2%) in 2022-23. There was an increase in the fraction of youth who transitioned from non-current product use to ENDS-only use from 13.7% (95%CI: 7.5-20.0%) in 2015-16 to 35.1% (95%CI: 25.4-44.8%) in 2022-23, paired with a decrease in non-current use to cigarette use from 20.9% (95%CI: 11.8-30.0%) to 6.3% (95%CI: 1.7-10.8%). Transitions from ENDS-only or cigarette use to non-current use remained relatively constant over time at around 25% and 15% per year, respectively. Conclusion. ENDS-only use initiation has changed over time, peaking around 2019 and subsequently decreasing and plateauing, but cessation rates for both ENDS and cigarettes have remained relatively stable. Thus, interruption of tobacco product initiation may be the most effective approach to reducing tobacco product use among youth.

BackgroundPsychotherapy is proven efficacious for the treatment of alcohol use disorder (AUD). However, the patient-perceived importance of its effect is not fully appreciated in the evidence base. The smallest worthwhile difference (SWD) represents the smallest beneficial effect of an intervention that patients deem worthwhile in exchange for the harms, expenses, and inconveniences associated with the intervention, and facilitates the interpretation of patient perceived worthiness of an intervention. MethodsThe proposed study will estimate the SWD of NIAAA recommended psychotherapies for AUD treatment with English-speaking American respondents aged 18 and older. Primary participants will be recruited using the Prolific research crowdsourcing site. The SWD will be estimated using the Benefit-Harm Trade-off Method, presenting survey respondents with variable, hypothetical magnitudes of psychotherapy outcomes to find the smallest acceptable effect over a natural remission alternative. The overall average SWD, and subgroup distributions by participant AUD treatment experiences and AUD symptomology will be described. Secondary findings will estimate the smallest recommendable risk difference for AUD psychotherapy from providers and criminal justice professionals. Expected ResultsWe expect to find an estimate of the SWD for AUD psychotherapy. Further, we expect that the SWD will vary between clinical subgroups based on AUD symptomology and treatment experiences. We expect differences in SWDs between the general population and those of providers and criminal justice professionals. Findings from this project will inform the treatment decision process about psychotherapy during the clinical consultation for people with AUD.

Introduction: The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is a widely utilized screening tool in large-scale electronic health record (EHR) biobanks. However, its categorical, range-based survey responses present a significant challenge for epidemiological research, especially where continuous quantitative variables may be preferred. Standard workarounds, such as assigning categorical midpoints or utilizing aggregate ordinal scores for regression mapping often introduce false mathematical precision or obscure critical behavioral nuances between drinking frequency and quantity. This report presents a novel framework for presenting and bounding categorical alcohol survey data. Materials and Methods: I developed two complementary descriptive techniques: (1) a two-dimensional cross-tabulation matrix that preserves the interaction between drinking frequency and typical quantity, and (2) a systematic bounding algorithm that applies time-interval correction factors to calculate strict lower and upper estimates of average daily alcohol consumption. To demonstrate the real-world utility of this framework, I applied these methods to three analytical descriptive scenarios within a European ancestry (EUR) cohort of the All of Us Research Program: Generalized Anxiety Disorder (GAD) prevalence (n=104,893), minor allele frequency (MAF) for the rs1229984 genetic variant (n=104,890), and self-reported active duty military service history (n=104,893). Results: Application of the cross-tabulation matrix revealed patterns across all three descriptive scenarios. For example, participants reporting the highest frequency ("4 or more times a week") combined with the highest quantity ("10 or More" drinks) demonstrated a GAD prevalence of 13.5%, compared to 5.8% among those reporting the same frequency but a low quantity ("1 or 2" drinks). A general trend of increased anxiety in higher quantity drinkers contrasts with a general trend of decreased anxiety in higher frequency drinkers. Bounding estimates for average daily consumption ranged from 0.299 to 0.730 drinks for individuals with GAD, and 0.303 to 0.787 for those without. Those who reported having been active duty in the US Armed Forces demonstrated a general trend toward more frequent drinking and higher average daily consumption estimates (0.339 to 0.875) than those who had not (0.297 to 0.770). The minor allele of the genetic variant rs1229984 exhibited a clear effect reducing both frequency and quantity, resulting in lower average daily consumption estimates. Conclusions: This bounding and mapping framework provides researchers with an additional method to traditional midpoint and aggregate scoring methods. By explicitly defining the uncertainty inherent in categorical survey instruments and visualizing cohort distributions across intersecting behavioral axes, this methodology improves the resolution, reproducibility, and interpretability of lifestyle exposure data.

ABSTRACT Background and aims: Mental and behavioral disorders due to use of tobacco (MBDT) present a critical challenge to global health, yet modifiable lifestyle factors for reducing its risk remain poorly understood. Given that dietary fibre can affect mental health through gut-brain communication, we sought to explore how fibre intake relates to MBDT risks in smokers. Methods: We specifically evaluated the link between dietary fibre intake and MBDT within a smoking population. Utilizing the UK Biobank (UKB) database, we performed cross-sectional (N=19,943) and prospective cohort (N=19,885) evaluations applying logistic and Cox proportional hazards models, respectively. To determine potential causality, two-sample Mendelian randomization (MR) was applied, relying on GWAS summary data derived from the IEU Open GWAS Project and FinnGen repositories. Results: Cross-sectional findings indicated that individuals in the top quartile (Q4) of fibre intake exhibited decreased MBDT risks relative to the bottom quartile (Q1) (OR: 0.32, 95% CI: 0.13-0.79). Over a median observation time of 12.84 years, the prospective evaluation demonstrated a notable inverse correlation (Q4 HR: 0.46, 95% CI: 0.40-0.54). Non-linear modeling via restricted cubic splines uncovered an L-shaped dose-response curve. Furthermore, MR results confirmed a genetically predicted protective causality (IVW OR: 0.68, 95% CI: 0.49-0.95), which remained consistent across sensitivity validations. Conclusions: Among smokers, higher dietary fibre intake is robustly associated with a reduced risk of mental and behavioral disorders due to the use of tobacco, offering a modifiable dietary target for public health interventions.

Background and AimsOn April 1st, 2024, Germany implemented the Act on the Handling of Cannabis for Non-Medical Use (KCanG), allowing adults to cultivate and possess recreational cannabis. We assessed whether this policy shift was associated with a change in the prevalence of cannabis use in the general population and in daily or almost daily cannabis use. DesignA series of 21 repeated cross-sectional surveys conducted between April/May 2022 and October/November 2025 (covering the period approximately two years before and one and a half years after the KCanG). SettingPopulation of Germany. ParticipantsA total of 32,991 people aged 14-64 years, including 2,092 (6.3%) people who used cannabis in the past 12 months. MeasurementsPast 12-month cannabis use (at least once). In past 12-month users: daily or almost daily use. To test a potential change in prevalence following the KCanG, we used piecewise binomial logistic regression models using the exact date of each wave as the predictor variable, allowing for a change in the slope at the first full wave after implementation of the KCanG in April 2024, with a random effect for wave. We conducted this analysis for the total sample as well as stratified by gender (male vs. female), age (14-24 vs. 25-64 years), and for daily or almost daily cannabis use in the subgroup of people who used cannabis in the past 12 months. Sensitivity analyses used alternate intervention dates (in-time placebo tests). FindingsThe prevalence of cannabis use and the share of (almost) daily users among 12-month users remained largely stable before and after the law reform. None of the slope coefficients before the introduction of the KCanG were statistically significant (all p [&ge;] .08), and none of the coefficients for the change in the slope were statistically significant (all p [&ge;] .31). Results of sensitivity analyses confirmed the stable trends for both outcomes. ConclusionsThe legislation of cannabis introduced in Germany in April 2024 was not associated with a change in trends of 12-month cannabis use prevalence early (1.5 years) after implementation, and also not with a change in the proportion of heavy users among past-12-month users. We recommend continued close monitoring of trends using multiple data sources and over a longer post-implementation period, as the effects of the legislation may not have fully unfolded yet.

OBJECTIVEUsing two cohorts and synthetic datasets, we estimated effects of prospectively reported alcohol use on memory outcomes across middle age. METHODSData were from National Longitudinal Study of Youth 1979 (NLSY79, n=7540, alcohol reports from ages 18-26), Health and Retirement Study (HRS age 50-56 at enrollment, n=13,090), and a synthetic cohort matching early life exposure information from 3,259 NLSY79 participants to later life memory information from 5,451 HRS participants. Covariate-adjusted linear mixed models regressed memory (word list recall) on alcohol use (none, light/moderate, heavy). RESULTSIn NLSY, we found no evidence that associations between light/moderate drinking in early adulthood and mid-life memory score significantly differed from associations between drinking abstention ({beta} = -0.09 (95% CI: -0.30, 0.11)) or heavy drinking ({beta} = -0.26 (-0.48, -0.04)) with memory score. In HRS, both abstaining from alcohol ({beta} = -0.14 (-0.25, -0.02)) and heavy drinking ({beta} = -0.25 (-0.42, -0.07)) were negatively associated with cognitive level. Results from the synthetic cohort mirrored NLSY, suggesting no significant association between abstention ({beta} = 0.13 (-0.10,0.36)) nor heavy drinking ({beta} = 0.02 (-0.25,0.28)) with mid-to-late life memory score. DISCUSSIONAlcohol consumption may not have an effect on memory until later life, though associations may be affected by residual confounding.

Importance: Understanding patterns of substance use and environmental exposures to tobacco, cannabis, and electronic nicotine delivery systems (ENDS) among youth is critical for developing targeted prevention strategies, particularly as co-use of tobacco, ENDS, and cannabis becomes more prevalent. Objective: To identify latent classes of tobacco, ENDS, and cannabis use, and environmental exposures to these products among adolescents and emerging adults. Design, Setting, and Participants: Data from the Environmental influences on Child Health Outcomes (ECHO) consortium (3rd data release, 2018 to 2022) were analyzed from March 2025 to January 2026. The sample (N=2,786) included early adolescents (ages 11 to 13; n=226, 7.9%), middle adolescents (ages 14 to 17; n=1,248, 43.4%), and late adolescents/emerging adults (ages 18 to 24; n=1,402, 48.7%) from 19 ECHO cohorts. Main Outcomes and Measures: The Youth Risk Behavior Survey, Substance Use module measured experimental and current use of cannabis, ENDS, and tobacco products, as well as daily environmental exposure to tobacco smoke, nicotine aerosols, and cannabis smoke within home and social contexts. A multiple group latent class analysis was used to identify distinct latent classes of substance use and environmental exposure to tobacco smoke, nicotine aerosols, and cannabis smoke and compared class prevalences across early, middle, and late adolescence. Results: Four latent classes were identified, including: No Use/No Exposure (53%), No Use, Polyexposure (10%), Experimental Use/Low Exposure (22%), and Polysubstance Use/High Polyexposure (14%). Cannabis was the most used substance (34% experimental or current use) and the most common source of environmental exposure (20%), followed by ENDS use (26% experimental or current use; 19% environmental exposure) and combustible tobacco (15% use; 19% environmental exposure). The No Use/No Exposure and No Use/Polyexposure classes were primarily made up of early and middle-aged adolescents, whereas the Experimental Use/Low Exposure and Polysubstance Use/High Polyexposure classes primarily consisted of late adolescents and emerging adults. Conclusions: Our study revealed distinct, developmentally patterned groupings of substance use and environmental exposure among US adolescents and emerging adults, highlighting the need for developmentally tailored interventions, messaging, and policies that address both active use and environmental exposure across adolescence.

Objectives: This meta-review compares methodological and reporting approaches between systematic reviews examining alcohol dose and cardiovascular disease (CVD) and assesses whether alcohol industry involvement is associated with divergent conclusions. Methods: KSR Evidence was searched 6 May 2025 to update a cohort of 60 systematic reviews from previous review. Reviews were included if they examined any dose-response relationship between alcohol consumption and CVD. Two reviewers independently screened records and extracted data on review characteristics, and citations. Methodological quality was appraised using AMSTAR 2. For a matched sample of reviews with and without known alcohol industry funding, the overlap of included primary studies was compared using Corrected Covered Area (CCA) analysis. Results: Thirty additional systematic reviews met the inclusion criteria, yielding 90 systematic reviews (1996-2025). Most (60.0%, 54/90) concluded that alcohol had a cardioprotective effect, whereas 31.1% (28/90) concluded no evidence of protection, and 8.9% (8/90) were inconclusive. Twenty reviews (22.0%) had declared or inferred alcohol industry funding or author connection; all but one reported a protective effect at lower doses, the other was inconclusive. Industry-connected reviews were cited more often (mean 575.9 vs 193.0, p=0.0002) and more commonly examined overall CVD rather than specific conditions (such as hypertension or stroke). Study overlap was low (CCA 2.59%) and 99% of reviews were rated as critically low quality. Conclusions: The fragmented evidence base is of poor methodological quality with selective inclusion of studies. Alcohol industry connections are strongly associated, with conclusions favouring alcohol consumption, highlighting the need for independent high-quality systematic reviews.