American Journal of Preventive Medicine

Importance: With a recent shift towards summer seasonal predominance of COVID-19 across much of the US, debate continues over optimal COVID-19 vaccination strategies regarding timing (including summer vaccination), eligibility, and dosing frequency. We evaluated the population-level impact of alternative vaccine strategies to inform US and state vaccine policy. Objective: To compare reductions in COVID-19 hospitalizations under different vaccination timing, eligibility, and dosing frequency. Design: Decision analytical model using a stochastic individual-based model of SARS-CoV-2 transmission, calibrated to US COVID-19 hospitalization incidence from May 2024-April 2025. Setting: Simulated US national population, with additional scenarios representing state-level seasonal patterns. Participants: Simulated population of 5 million individuals with US age structure, stratified by risk group (immunocompetent, high risk with comorbid conditions, or immunocompromised). Exposures: Vaccination timing, universal or age- and risk-based eligibility, and dosing frequency, including a hybrid strategy of universal annual vaccination with a second dose for adults [≥]65 years and immunocompromised adults (US vaccine policy during the study period). Main Outcomes and Measures: COVID-19 hospitalization risk per 100,000 persons by age-risk group, measured among vaccinated individuals and in the total population. Results: If summer COVID-19 vaccination timing is feasible, annual universal vaccination in July minimized risk (441 [95% UI: 423-463] COVID-19 hospitalizations per 100,000 persons among adults [≥]65 years) compared to a counterfactual scenario with no additional vaccination given during the study period (578 [553-601]). If timing does not change, hybrid vaccination minimized risk, followed by semiannual risk-based vaccination (460 [440-487] and 477 [454-499] hospitalizations per 100,000 in adults [≥]65 years, respectively). The advantage of summer timing diminished if vaccine coverage decreased by 5-10 absolute percentage points (25-50% relative decrease). The magnitude of benefit from summer-timed vaccination and semiannual doses in the highest-risk groups varied regionally. Conclusions and Relevance: Although annual COVID-19 vaccination has historically been timed for winter transmission, summer vaccination may avert more hospitalizations if coverage is maintained, especially in states with predominantly summer transmission including Western and Southern states. The comparative impact of vaccination strategies, especially the benefit of a semiannual dose in the highest-risk groups, may vary regionally. COVID-19 vaccination timing and eligibility may warrant reconsideration.

Introduction: Monitoring transitions in cigarette and electronic nicotine vapor product (ENVP) use is important for understanding how marketplace and regulatory changes have affected product use patterns, but information from national surveys is often delayed by several years. Methods: The Rutgers Omnibus Study is a quarterly serial, rapid-response, web-based convenience survey. Using a Markov multistate transition model, we estimated transition rates and one-year transition probabilities between never, non-current, ENVP-only, cigarette-only, and dual use among 5,292 adults aged 18-45 who participated in at least two of Waves 1-16 (February 2022-February 2026), as well as overall transition hazard ratios by sex, age group, and race & ethnicity in a multivariable model. Results: About 40% of individuals using cigarettes (39.5%; 95% CI: 36.9-42.0) or ENVP (40.1%; 95% CI: 36.4-43.7), and 60% of those using both products (60.8%; 95% CI: 58.3-63.2) were predicted to remain in those states after one year. Female participants began using cigarettes from never use (adjusted hazard ratio [aHR] 0.44; 95% CI: 0.29-0.66) or non-current use (aHR 0.65; 95% CI: 0.48-0.88) at lower rates than male participants. Participants aged 35-45 years initiated ENVP-only use from non-current use (aHR 0.34; 95% CI: 0.23-0.51) at a lower rate than those aged 18-34 years. Compared to non-Hispanic White participants, non-Hispanic Black participants initiated ENVP-only use from never use at a higher rate (aHR 4.39; 95% CI: 2.09-9.25). Conclusion: Rapid response surveys can provide important preliminary information on tobacco use transition patterns while we wait for the slower release of nationally representative survey data.

Introduction: Tobacco use during pregnancy increases risks for adverse birth outcomes. In the US, tobacco use during pregnancy is associated with several poverty-related social determinants of health (fewer years of education, housing and food insecurity, substance abuse) that also contribute to adverse birth outcomes. In the Smoke-free Household and Parent (Smoke-free HOPE) pilot feasibility study, we designed and tested a theory-based intervention (socio-ecological framework) that leverages our group's ten years of experience enrolling and evaluating the largest maternal smoking cessation program in San Bernardino County. The Smoke-free HOPE intervention is delivered by community health workers (CHW) and integrates tobacco cessation support into the other support services that are typically offered during perinatal CHW visits. To our knowledge, this is the first US-based study to test a CHW-delivered prenatal tobacco cessation intervention. Methods: The Smoke-free HOPE intervention is a two-arm RCT that randomizes pregnant adults (n=32) who use tobacco products (combustible, e-cigarettes/vapes) to one of two CHW-delivered interventions: brief behavioral advice or patient navigation to community-based tobacco cessation services (i.e., state quitline). Both intervention arms were delivered during up to eight CHW visits (home, telehealth). Primary feasibility and acceptability outcomes are reported. Results: At baseline, we found that the predominant form of habitual tobacco use was e-cigarettes (53%) and that co-use of cannabis occurred in 69%. Two participants switched from cigarettes/cigars (blunts) to e-cigarettes during the trial. For feasibility, we met our recruitment and retention progression criteria by achieving the following: a county-based enrollment of four consenting participants per month, 87% initiating CHW support (i.e., dropout rate of <13%), and 66% completing all eight CHW visits. For post-intervention acceptability, 91% were very satisfied with the program, and 100% would recommend it to their peers. Post-intervention key informant interviews revealed that participants valued the trust, flexibility, and nonjudgmental support of CHW visits. Seventy-five percent [95% CI = 60% to 90%] set a quit date, and 50% [95% CI = 33% to 67%] achieved 30-day point-prevalence abstinence from nicotine. Conclusions: We have documented the feasibility and acceptability of a CHW-delivered intervention to provide cessation support for all major tobacco products used by pregnant adults in our community. Scaling the intervention to multiple sites will help us measure its efficacy.

Background: While health system costs of COVID-19 are well documented, evidence on out-of-pocket costs to patients and families, including non-medical and time burden, is limited. This study aimed to estimate out-of-pocket medical, non-medical, and time burden of COVID-19 illness directly from patients and caregivers. Methods: Two cross-sectional surveys were fielded to national nonprobability samples of U.S. adults in Fall 2023: a personal burden survey (adult sample) and a caregiver burden survey (child sample). Surveys collected data on care setting, visit duration including travel and wait time, and medical and non-medical out-of-pocket costs. After applying quality-based exclusion criteria, 409 adult sample and 52 child sample responses were analyzed. Results: Over 87% of respondents were insured. Median out-of-pocket medical costs per visit were low, ranging from $5 (emergency department) to $10 (urgent care) in the adult sample, and from $0 (emergency department) to $75 (hospitalization) in the child sample. Median non-medical costs were $28 or less across care settings. Median time spent receiving care ranged from 90 minutes (primary care, child sample) to 300 minutes (emergency department, adult sample). Despite the relatively low reported out-of-pocket costs, COVID-related financial challenges were reported by 34% of the adult sample and 29% of the child sample, with the most common difficulty being paying non-medical bills (11% and 15%, respectively). Twelve percent in both groups reported problems paying COVID-19-related medical bills. Conclusions: In this post-pandemic non-probability sample, individual out-of-pocket costs for COVID-19 illness were relatively modest. However, time burden was substantial and one-third of respondents reported financial hardship. These estimates, including non-medical and time burden not captured in administrative data, can support more robust economic evaluations of COVID-19 prevention and treatment interventions.

BackgroundAlcohol use disorder (AUD) is an established contributor to neurocognitive impairment and a major modifiable risk factor for dementia. However, the extent to which lifetime AUD interacts with aging to accelerate subtle cognitive trajectories prior to overt clinical dementia remains unclear. ObjectiveTo investigate whether a lifetime history of DSM-5 AUD and correlated indices of alcohol consumption are associated with accelerated age-related cognitive decline in middle-aged and older adults. MethodsParticipants (N = 1,421) were drawn from the Collaborative Study on the Genetics of Alcoholism (COGA) prospective longitudinal study. Lifetime AUD status (defined as 2 or more DSM-5 criteria endorsed at peak drinking) and drinking patterns were derived from the Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA). Cognitive performance across multiple domains was evaluated using the NIH Toolbox Cognition Battery to yield Total, Fluid, and Crystallized Composite Scores. Linear mixed-effects models examined main effects of AUD and age, as well as an AUD-by-age interaction, controlling for testing site. ResultsAt the time of cognitive assessment, the overall sample had a mean age of 52.5 years (SD = 14.5) with a mean longitudinal observation period of 25.0 years (SD = 4.7). The sample was 60% female, 40% male, 7% Hispanic, 23% non-Hispanic Black, 68% non-Hispanic White, 2% other race/ethnicity. 64% met lifetime criteria for AUD (n = 908). While baseline mean cognitive composite scores were similar between those with and without AUD, lifetime AUD was significantly associated with steeper age-related decline for both the Total Composite score (interaction estimate = -0.092, 95% CI [-0.173, -0.010], p = 0.03) and Fluid Composite score (interaction estimate = -0.13, 95% CI [-0.220, -0.040], p = 0.005). No significant AUD-by-age interaction was observed for Crystallized Composite scores (interaction estimate = -0.026, 95% CI [-0.092, 0.041], p = 0.449). Based on model projections, the AUD-associated cognitive deficit on Total Composite scores was equivalent to 7.1 additional years of cognitive aging at age 60 (95% CI [-0.5, 14.7]) and 13.8 additional years at age 75 (95% CI [0.2, 27.3]). Measures of current (past-year) drinking status and current drinks per week showed no significant interaction with age. ConclusionsA lifetime history of AUD acts as a catalyst for cognitive aging, significantly steepening the trajectory of age-related decline in total and fluid cognitive functioning well before the onset of clinical dementia. Cross-sectional measures of current drinking failed to capture these effects, demonstrating that evaluating cumulative lifetime drinking history is important for assessing alcohol-related cognitive decline.

Importance: Oral nicotine pouches (ONPs) are tobacco-leaf-free nicotine products that have experienced a substantial increase in sales in recent years. Objective: To determine how ONP experimentation, initiation, and cessation rates differ by other tobacco product use and sociodemographic characteristics. Design: Nationally representative longitudinal cohort study; data from Waves 7 and 8 (2022-2024) of the Population Assessment of Tobacco and Health (PATH) Study. Setting: US civilian, non-institutionalized population. Participants: Adults in Waves 7 and 8 of PATH. Of 27,800 eligible participants, 24,640 with complete information on the exposure and outcome were included. Exposures: Other tobacco product use (cigarette-only, electronic nicotine delivery system [ENDS]-only, smokeless tobacco [SLT]-only, and multiproduct use) and sociodemographic characteristics (sex, race and ethnicity, age, and educational attainment). Main Outcomes: Hazard rates and ratios of transitioning between never, current, and non-current ONP use, defined by ever and past-30-day use, overall and by exposure group. Rates are estimated in univariable weighted multistate transition models. Results: Among 24,640 participants, 23,555 (96.7%) never used, 802 (2.5%) non-currently used, and 283 (0.8%) currently used ONPs in 2022. From 2022-24, ONP initiation was higher among those using cigarettes only (HR 3.34, 95% CI 1.59-7.02), ENDS only (HR 9.68, 95% CI 2.89-32.5), SLT only (42.4, 95% CI 22.3-80.7), or multiple products (HR 18.4, 95% CI 7.11-47.8) compared to those who did not use these tobacco products. Those who used cigarettes only (HR 3.02, 95% CI 1.24-7.34), ENDS only (HR 2.03, 95% CI 1.11-3.71), or multiple products (HR 2.61, 95% CI 1.12-6.09) discontinued ONPs at higher rates than those using no other products. Men had higher ONP initiation and lower cessation rates than women, adults ages 35+ years had lower initiation rates than those ages 18-24, and non-Hispanic Black participants had higher cessation rates than non-Hispanic White participants. Conclusions and Relevance: Initiation of ONPs was higher among those who used other tobacco products, highlighting the need to investigate whether ONPs replace these products or lead to poly-tobacco use. Higher cessation rates among those using cigarettes only or ENDS only may suggest experimentation rather than sustained use.

Background: Risk of recurrent overdose is elevated following non-fatal overdose (NFOD) survival; timely interventions may reduce this risk. The specific role of mental health care in reducing recurrence is relatively underexplored, and post-overdose care has seldom been examined for sex differences. This study examined sex differences in the association between mental health-related primary care contacts following NFOD and overdose recurrence risk among people in British Columbia (BC) with a documented depression diagnosis history. Methods: This was a nested case-control study using linked administrative health data from the Provincial Health Services Authority Platform for Analytics and Data. The source cohort (n=7,022) comprised BC residents with a history of a documented depression diagnosis between 2010-2014 and at least one NFOD between 2015-2024. Cases experienced a recurrent overdose within one year of their index overdose; controls were selected using incidence density sampling. Exposures were the presence and number of mental health related primary care contacts in the 30- or 90-day window following the index overdose. Conditional logistic regression models were used to estimate adjusted incidence rate ratios (aIRRs) and confidence intervals (CI), overall and by sex. Secondary analyses were conducted using psychiatrist contacts. Results: Mental-health related primary care contact rates were low, with only 16.3% and 28.1% of the cohort with any contact within 30 and 90 days, respectively. Mental health-related primary care contacts were more strongly associated with reduced recurrence risk in the 30-day window (any contact aIRR: 0.57 [CI: 0.46-0.71]) than in the 90-day window (aIRR: 0.78 [CI: 0.65-0.94]). Any contact within 30 days was more strongly associated with lower recurrence risk among males (aIRR: 0.53 [CI: 0.39-0.72]) than among females (aIRR: 0.67 [CI: 0.50-0.91]), whereas associations between the number of contacts and recurrence risk were similar for males and females. Any psychiatrist contact within 30 days was more strongly associated with lower recurrence risk among females (aIRR: 0.50 [CI: 0.34-0.73]) than males (aIRR: 0.70 [0.52-0.95]). Discussion: Mental health-related care contacts shortly following NFOD were associated with lower overdose recurrence risk among people with a documented depression diagnosis history, with modest sex differences that varied by provider type. Low rates of contacts overall suggest gaps in access to care following NFOD, particularly among males. Further research on sex differences in post-overdose care are warranted.

Electronic cigarettes are the most commonly used tobacco product among U.S. adolescents. Schools most often respond to student e-cigarette use with exclusionary discipline such as suspension, which removes students from school and does not address potential underlying nicotine dependence. Web-based alternatives to suspension offer a way to keep students in school while providing cessation-focused support, but evidence on their effects is limited. This study examined changes in e-cigarette-related attitudes and motivation among adolescents who completed ReFresh, a self-paced, web-based alternative-to-suspension program completed in approximately 3 hours. Using a single-group pre-post design, we analyzed data from 173 middle and high school students (grades 6 to 12; mean age 15.0) referred after being caught using e-cigarettes on school grounds across 24 delivery sites (e.g., schools, afterschool programs, and health centers). The program comprises five interactive online lessons grounded in the 5 A's clinical framework (Ask, Advise, Assess, Assist, Arrange), motivational interviewing, and cognitive and behavioral skills training. Changes were analyzed with non-parametric tests. After completing ReFresh, participants reported greater motivation to quit ({chi}2 (6) = 22.79,OR = 3.80, 95% CI [2.2,8.8], p < .001) and rated quitting as more important (V = 3037.50,95% CI [1.00, 2.00], p < .001, r = 0.2). They also viewed e-cigarette use as more harmful and more risky (V = 8137.00, 95% CI [0.50, 0.63, p < .001, r = 0.62; V = 7734.50, 95% CI [0.50,0.80), p < .001, r = 0.65)), with the largest shifts in perceived harm relative to cigarettes and perceived risk of mental health problems. Most students reported comfort and confidence seeking help for e-cigarette use or mental health concerns, ranging from 71.10% of students agreeing they felt "More confident asking a trusted adult for help at school" to 80.50% of students agreeing they felt "More confident encouraging a peer to seek help". This study suggests that a brief, web-based alternative to suspension may shift the attitudes and motivation that precede quitting while keeping students in school, offering schools a non-exclusionary way to respond to e-cigarette use. Controlled studies measuring actual e-cigarette behavior are needed to confirm whether these programs reduce use.

Background/Objectives: Older adults are at high risk of influenza-related severe disease and complications. HD-IIV, currently recommended for adults [&ge;]65 years, is egg-based and may be subject to egg-adapted mutations. An mRNA-based vaccine for influenza, mRNA-1010, has been approved by the Food and Drug Administration. Given the clinical benefits observed in mRNA-1010 clinical trials and potential to avoid egg-adapted mutations, this analysis explores the clinical impact of mRNA-1010 compared to HD-IIV in those [&ge;]65 years in the United States. Methods: This study used a decision-analytic model of influenza infection and downstream outcomes to project influenza burden with each vaccine over a one-year timeframe. Vaccine coverage, HD-IIV vaccine effectiveness (VE) and influenza epidemiology was estimated based upon Centers for Disease Control and Prevention data. The relative VE (rVE) for mRNA-1010 vs. HD-IIV was modelled based on data from the clinical trial and published literature on the impact of egg adaptation. Results: The base-case analysis suggests mRNA-1010 may prevent an additional 232,200 symptomatic influenza infections, 130,000 outpatient cases, 21,100 influenza-related hospitalizations, and 2,200 influenza-related deaths compared to HD-IIV. The number needed to vaccination to prevent one hospitalization was 514 or mRNA-1010 vs no vaccine and 404 for HD-IIV versus no vaccine, for an incremental NNV of 110. Scenario and deterministic sensitivity analyses results indicate that clinical outcomes prevented by mRNA-1010 are most sensitive to influenza incidence and VE. Conclusions: mRNA-1010 may improve protection against influenza in US adults aged [&ge;]65 years, leading to meaningful reductions in the clinical influenza-related disease burden in older adults.

Background: Depression is a risk factor for overdose and is more commonly diagnosed among females. However, sex-differences in the association between depression, in isolation and in combination with substance use disorder (SUD), and overdose have not been examined at the population level in British Columbia (BC). This study described sex-and-age differences in associations between documented history of depression and/or SUD diagnoses and risk of fatal (FOD) and non-fatal overdose (NFOD). Methods: This study used linked administrative health data from the Provincial Health Services Authority Platform for Analytics and Data. The sample included BC residents aged 19-79 as of January 1st, 2015 (n=3,996,690). Exposures were classified as documented diagnosis history of 1) depression; 2) substance use disorder (SUD); 3) depression and SUD; and 4) neither condition, using physician billing and hospitalization records from 2010-2014. FOD (BC Coroners Service records) and NFOD (BC Emergency Health Services records) were ascertained from 2015 to 2024. Incidence rates per 10,000 person-years and unadjusted incidence rate ratios (IRRs) and 95% confidence intervals (CI) were estimated using Poisson regression, with neither diagnosis as reference, overall and stratified by sex and age. Results: There were 14,281 FOD (78.59% male) and 43,555 NFOD (69.45% male) cases. FOD incidence was higher among males overall; however, relative associations between diagnosis history and FOD risk were stronger among females. Depression diagnosis history was associated with a FOD IRR of 3.95 (CI: 3.56-4.38) among females and 2.46 (CI: 2.32-2.61) among males. IRRs for SUD and for depression and SUD were larger among females (108.07 [CI: 95.83-121.73] and 116.70 [CI: 106.51-127.96]) than males (26.69 [CI: 25.57-28.18] and 31.21 [CI: 29.81-32.67]). NFOD findings were similar but attenuated (depression IRR: 3.22 [CI: 3.08-3.38]) in females; 2.29 [CI: 2.21-2.37] in males). Conclusion: A documented history of depression and/or SUD was more strongly associated with FOD and NFOD risk among females, despite higher incidence overall among males. Future research should consider the potential role of other sociodemographic factors in explaining sex differences in associations between diagnosis history and overdose risk.

Background: Nicotine pouches (NPs) are increasingly popular tobacco-free nicotine products, particularly among young people. Despite growing use, evidence regarding their oral health effects remains limited. Methods: We employed a mixed-methods approach comprising: (1) a national cross-sectional survey of NP users, (2) a survey of UK dental professionals, and (3) in-person clinical assessments of NP users. Survey data explored patterns of NP use, oral and dental side effects, and perceptions of risk. Clinical assessments included comprehensive oral examinations, periodontal assessments, and histopathological investigation of lesions where indicated. Results: A total of 3,659 NP users completed the public survey. Participants were predominantly male (89%) and aged 16-22 years (78%). Overall, 45% reported at least one oral or dental side effect. The most commonly reported effects were gingival recession (60%), burning sensations (41%), white patches (30%), and dry mouth (29%). Higher nicotine exposure was associated with increasing numbers of reported side effects. Among 126 dental professionals, oral lesions associated with NP use were commonly observed clinically, while only 17% reported seeing no oral or dental effects. Thirty-three NP users underwent in-person assessment. Ten lesions were biopsied; six demonstrated hyperkeratosis and four showed oral epithelial dysplasia (three mild, one moderate). All dysplastic lesions occurred at pouch placement sites. In two cases, clinical follow-up demonstrated partial or complete resolution of lesions following cessation of NP use. Periodontal assessments demonstrated generally low levels of periodontal disease and gingival recession across the cohort. Conclusions: Oral and dental side effects associated with NP use were commonly reported by users and observed by dental professionals. Histopathological assessment identified biopsy-confirmed oral epithelial dysplasia in lesions occurring at pouch placement sites, representing, to our knowledge, the first such report associated with NP use. Evidence of lesion improvement following discontinuation of use suggests that at least some NP-associated oral changes may be reversible. Although causality cannot be established, these findings highlight the need for vigilance among dental professionals and urgent longitudinal research to determine the incidence, progression, and reversibility of NP-associated oral lesions.

Background: Psychological health is an important aspect of health and well-being among adults with irritable bowel syndrome, yet the interrelationships among individual vulnerabilities, social experiences, perceived stress, and psychological health outcomes remain poorly understood. Objective: To characterize psychological health and examine direct and indirect associations of childhood adversity and adult attention-deficit/hyperactivity disorder-related symptoms within an adapted Stress Process Model. Design: Cross-sectional secondary analysis. Setting: The United States All of Us Research Program. Participants: 2,417 adults with electronic health record-documented irritable bowel syndrome and complete data on the primary analysis variables and covariates. Methods: Separate structural equation models examined childhood adversity and adult attention-deficit/hyperactivity disorder-related symptoms in relation to perceived stress, anxiety and depressive symptoms, and positive psychological well-being, with loneliness and perceived social support as psychosocial pathways. Models adjusted for sociodemographic and social-context factors. Results: The median age was 54.39 years; 80.7% were female and 84.4% were White. Moderate-to-high perceived stress was reported by 56.2%, at least moderate anxiety symptoms by 21.0%, and at least moderate depressive symptoms by 24.3%. Higher ACE-8 scores were associated with greater perceived stress, anxiety symptoms, and depressive symptoms and lower psychological well-being ({beta} = 0.063, 0.089, 0.116, and -0.100, respectively); corresponding associations for higher ASRS-6 scores were {beta} = 0.299, 0.355, 0.390, and -0.260. Loneliness-specific indirect associations were positive for perceived stress, anxiety, and depressive symptoms (ACE-8: {beta} = 0.023-0.034; ASRS-6: {beta} = 0.043-0.075) and negative for psychological well-being (ACE-8: {beta} = -0.039; ASRS-6: {beta} = -0.089; all p < .001). Social support-specific indirect associations were not significant in the ACE-8 model and were small and significant only for anxiety and depression in the ASRS-6 model ({beta} = 0.003-0.004). Conclusions: Psychological health among adults with irritable bowel syndrome was associated with interconnected individual and social factors within an adapted Stress Process Model. Childhood adversity and adult attention-deficit/hyperactivity disorder-related symptoms showed direct and indirect associations with psychological health, with loneliness emerging as the most consistent social factor. These findings support prospective investigation of individual vulnerabilities and social experiences in psychological health. The cross-sectional design does not establish temporal ordering or causal mediation.

Objective: To examine associations of health insurance status, household income, and cost-related healthcare barriers with receipt of a routine medical checkup among U.S. adults. Methods: This cross-sectional study analyzed 2024 Behavioral Risk Factor Surveillance System data. Survey-weighted descriptive estimates and multivariable logistic regression incorporated sampling weights, strata, and primary sampling units. The outcome was a routine medical checkup within the previous 12 months. Results: Among 321,592 complete cases, 78.0% of U.S. adults reported a recent routine checkup. Cost-related barriers (adjusted odds ratio [AOR], 0.56; 95% confidence interval [CI], 0.54-0.57) and uninsurance (AOR, 0.28; 95% CI, 0.27-0.29) were associated with lower checkup utilization. Lower household-income groups generally had lower adjusted odds than adults with incomes of $200,000 or more. Conclusions: Insurance, income, and reported cost barriers were independently associated with routine checkup utilization. Findings are descriptive and do not establish causal effects. Keywords: health insurance; household income; cost-related barriers; routine medical checkup; healthcare utilization; BRFSS

Background Tobacco use during adolescence is an important public-health concern because early initiation increases the likelihood of continued tobacco use and dependence. This study assessed the prevalence of tobacco smoking and factors associated with ever smoking among high school students in Harar town, eastern Ethiopia. Methods A school-based cross-sectional study was conducted among 467 students in grades 9-12 from selected public and private high schools in Harar town. Data were collected using a self-administered questionnaire adapted from the Global Youth Tobacco Survey. Descriptive statistics and binary logistic regression were used. Variables were entered into a multivariable logistic regression model based on the prespecified analytical approach, and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. Statistical significance was declared at p<0.05. Results Among 467 students, 64 (13.7%; 95% CI 10.9-17.1%) reported ever smoking tobacco, while 25 (5.4%; 95% CI 3.7-7.8%) were current smokers. In the SPSS multivariable logistic regression model, grade 11 (AOR 10.61, 95% CI 3.52-31.97) and grade 12 (AOR 12.18, 95% CI 3.95-37.53), alcohol drinking (AOR 2.60, 95% CI 1.25-5.40), khat chewing (AOR 9.57, 95% CI 4.04-22.65), and access to tobacco (AOR 3.18, 95% CI 1.58-6.43) were independently associated with ever smoking. Male sex, age [&ge;]18 years, and grade 10 were not statistically significant in the adjusted model. Conclusion Ever smoking was reported by approximately one in seven students and current smoking by about one in twenty. Alcohol drinking, khat chewing, access to tobacco, and higher grade were independently associated with ever smoking. School- and community-based tobacco prevention should address substance use and the availability of tobacco products around schools.

Introduction Within the Tobacco and Vapes Act 2026, the UK Government is considering restricting retail displays of vaping and other nicotine products to discourage youth uptake. We explored how adult nicotine users and adolescents responded to conventional and restricted displays. Methods Two UK-wide cross-sectional online surveys were conducted April-June 2026, with current and former adult nicotine users (n=2,851), and adolescents (11-17 years; n=2,123). Participants rated images of vape and nicotine pouch point-of-sale (POS) displays (two conventional, two restricted) across 10 items. Other measures included demographics, smoking/vaping/nicotine pouch use, vaping susceptibility, and product choice. Results Ratings of two conventional POS images were consistently favourable. Two restricted POS images were almost exclusively rated unfavourably. GEE analyses, controlling for demographics and behaviour, indicated that a display with standardised white packs (versus a conventional display) consistently had lower odds of favourable ratings (adults range:0.13-0.31; adolescents range:0.11-0.32). A fully covered display had even lower odds of favourable ratings on all items (adults range:0.06-0.19; adolescents range:0.05-0.10). Presented with hypothetical restricted displays, most adults using nicotine remained consistent with their product choice. Favourable ratings of conventional displays were positively associated with adolescents' vaping susceptibility. Those favourably rating a large, branded display were more likely to be susceptible than those giving unfavourable/neutral ratings (AOR=2.73, 95%CI [2.16-3.45] p<0.001). No association was found between favourable ratings of restricted displays and susceptibility. Conclusion Restricting POS displays could reduce positive messaging around vaping and adolescent susceptibility. The potential impact of restrictions on adult users' perceptions of harm and accessibility should be considered.

Background: Since Michigan's legalization of recreational adult-use cannabis in December 2018, health care providers in the city of Kalamazoo, Michigan, have informally observed an increase in cannabinoid hyperemesis syndrome (CHS) presentations, although the extent of this increase has not been formally characterized locally. CHS is frequently underrecognized and misdiagnosed, often resulting in repeated emergency department (ED) visits and substantial diagnostic costs before a diagnosis is reached. Despite this clinical and financial burden, it is unclear whether consumers are adequately informed of this risk through point-of-sale or public health resources. Methods: A cross-sectional environmental scan was conducted to identify publicly available educational content about CHS on the websites of licensed cannabis retailers in Kalamazoo and relevant public health agencies. Provisioning centers and public health websites were screened using a structured coding rubric developed specifically for the environmental scan to assess the presence, depth, web page placement, and intended audience of CHS-related content. Additionally, the electronic medical records at a local teaching hospital in Kalamazoo were queried to identify ED visits with a primary diagnosis of CHS from January 1, 2010 to December 31, 2025. Results: Before the legalization of marijuana, the hospital recorded six ED encounters with the primary diagnosis of CHS between January 2010 and November 2018, and 274 ED encounters between December 2018 and December 2025 (mean age: 29 years; 157 females, 123 males). The incidence rate of CHS-related ED encounters was 57.2 times higher during the post-legalization period than during the pre-legalization period (95% CI, 26.0-157.3; exact Poisson rate-ratio test, p < 0.0001). Among the licensed Kalamazoo provisioning centers reviewed, only one mentioned CHS as a warning but did not describe symptoms or offer medical guidance. CHS content was not identified on the websites of the state or local health departments. Conclusion: Despite the growing clinical concern regarding CHS, consumer-facing educational resources remain scarce. Although this study cannot establish a causal relationship between the availability of CHS-related educational content and the observed increase in ED encounters following legalization, it identifies a substantial lack of CHS-specific warnings in the evaluated consumer-facing resources. Given the clinical and potential economic burden associated with delayed CHS recognition, we recommend that Michigans existing point-of-sale pamphlet requirement be amended to include CHS-specific warning language.

Background: Real-world evidence on food-as-medicine programs for irritable bowel syndrome (IBS) is scarce, and single-arm evaluations overstate improvement because of regression to the mean (RTM). We estimated change in the IBS Symptom Severity Scale (IBS-SSS, 0-500) in a multi-omics personalized digital health food-as-medicine program, unadjusted and RTM-corrected. Methods: Retrospective single-arm cohort. Of 15,933 members with a valid baseline, 2,254 had a follow-up reading and 1,683 one at least 14 days after baseline. Change at 4, 12 (primary) and 26 weeks was estimated by baseline severity stratum, unadjusted and RTM-corrected by analysis of covariance. A responder fell by at least 50 points (the minimal clinically important difference benchmark). Sensitivity analyses covered equity, inverse-probability weighting and tipping-point analyses for members without a reading in each landmark window, a negative-control stratum and medication. The association of weight loss and dietary nutrient density with symptom change was evaluated within and between members. Results: At 12 weeks (n = 430) IBS-SSS fell by 43.88 points unadjusted (95% confidence interval [CI] -52.44 to -35.32; p < 0.001) and by 47.73 RTM-corrected (-55.48 to -39.98; p < 0.001); 720 of 1,339 symptomatic members (53.8%; 95% CI 51.1 to 56.4) fell by at least 50 points. Larger improvement in more severe members persisted after RTM correction (severe stratum, n = 37: unadjusted -127.43, RTM-corrected -60.71, 95% CI -97.75 to -23.68, p = 0.001). A higher meal nutrient density was associated with lower IBS-SSS within a member's own trajectory (p = 0.018) while weight change was not (p = 0.361). Improvement was similar across groups in spite of baseline differences by age and sex: RTM-corrected 12-week change did not differ by age (p = 0.458), body-mass index (p = 0.328), sex (p = 0.749), income (p = 0.486) or ethnicity (p = 0.170). Estimates were robust to weighting for members without a reading in the landmark window (RTM-corrected estimates moved by less than 2 points), and the change of those members would have had to be 39 to 73 points worse than observed before the mean change reached zero. Baseline medication use and starting a GLP-1 receptor agonist did not explain symptom changes. Conclusions: IBS-SSS fell significantly among program participants, with steeper improvement in the more severe group, even after RTM correction. The improvement was comparable across socioeconomic characteristics, age and sex and robust to the confounders and missing-data assumptions evaluated. These associations from a self-selected single-arm cohort warrant replication in independent studies.

Background. Cannabidiol (CBD) products are sold in many forms for many purposes, but it is largely unknown which characteristics of real-world use relate to how users evaluate their experience. Methods. We analyzed an anonymous web-based survey of 377 CBD product users in Japan. We evaluated perceived-effect (0-5) and satisfaction (0-6) scores using main regression models of use frequency adjusted for age, sex, and body mass index. Separate supplementary models examined estimated daily CBD amount and other-cannabinoid co-use, purposes of use, or specific CBD amount-reporting status. Results. Use frequency was positively associated with perceived effects (B = 0.148, 95% CI 0.091 to 0.205) and satisfaction (B = 0.113, 95% CI 0.049 to 0.177; both p < 0.001). Estimated daily amount showed no clear association with either outcome after adjustment, whereas participants who reported specific milligram information had higher scores on both (B = 0.543, p < 0.001 and B = 0.559, p = 0.002). Amount-reporting status was associated with product form (tincture 48.5% vs 30.8%; smoking or inhalation 58.5% vs 75.7%; both FDR-adjusted p = 0.009), whereas no statistically significant group differences were found for age, sex, body mass index, use frequency, or sleep timing. Purposes of use and sleep-timing indicators showed no clear associations with the outcomes. Conclusions. Subjective evaluation of CBD use was more consistently related to how often CBD was used and whether a specific milligram amount was reported than to how much was reportedly taken, and amount-reporting status was related to product form. Specific CBD amount-reporting status may be a useful complementary dimension for characterizing real-world CBD use.

Background. Tandem colonoscopy meta-analyses estimate adenoma miss rates, which have been used as a proxy for colonoscopy sensitivity. Doing so overstates sensitivity because it ignores lesions missed by both exams. Methods. We introduce Bayesian and frequentist approaches to estimate white-light colonoscopy (WLC) sensitivity from tandem colonoscopy meta-analyses. Neither approach assumes that the second colonoscopy is perfect. We apply both approaches to reanalyze data from a recent tandem colonoscopy meta-analysis, overall and across ten subgroups. Sensitivity analyses assess how assumptions about the relative performance of enhanced colonoscopy versus WLC affect estimates. Results. Under our Baseline specification, overall WLC sensitivity estimated by the Bayesian model was 0.54 [0.41, 0.63] (posterior mean and 95% credible interval). Sensitivity rose with lesion size: 0.49 [0.35, 0.60] for 1-5 mm adenomas, 0.64 [0.43, 0.78] for 6-9 mm adenomas and 0.84 [0.70, 0.93] for lesions 10 mm or larger. The frequentist plausible range encompassed the Bayesian estimate. The model-implied miss rate (0.35 [0.30, 0.40]) matched the original meta-analysis estimate and was stable across prior specifications. Assuming enhanced colonoscopy was perfect overstated overall sensitivity by 0.12 [0.06, 0.20]. Limitations. Tandem colonoscopy data identify the miss rate but not WLC sensitivity, so estimates depend on an external assumption about the relative performance of enhanced colonoscopy versus WLC. As a result, WLC sensitivity estimates varied with the prior specification, especially for small and flat adenomas. Conclusions. WLC sensitivity may be meaningfully lower than previously assumed in CRC screening cost-effectiveness analyses. Modelers should use colonoscopy sensitivity estimates that do not assume a second colonoscopy exam is perfect.

Introduction In July 2025, WHO launched the 3 by 35 Initiative calling on countries to increase real prices of tobacco, alcohol, and sugary drinks by at least 50% by 2035 to secure an additional $ 1 trillion in public revenue. While the effectiveness of excise taxes and prices in reducing tobacco use is well-documented, the feasibility of this call to action has not been evaluated empirically across the world. Methods Trend changes in countries nominal and inflation-adjusted retail prices were investigated using the most-sold brand of cigarettes over windows ranging from 2 to 16 years over the period 2008-2024, derived from nine editions of the World Health Organization Report on the Global Tobacco Epidemic. Statistical models of the association of cigarette excise taxes and prices from the panel of 195 countries were estimated. The frequencies of cigarette prices rising by at least 20% and 50% over preceding periods was estimated, and the length of time countries would need to reach these targets based on past trends were predicted. Results Over one- fifth of nominal cigarettes prices (and up to 40% in WHOs African region) were sticky across successive periods, even in countries with high overall consumer price inflation. Between 2008 and 2024, inflation-adjusted international dollar cigarette prices rose at a least squares annual trend growth rate of 2.9% (95% UI 2.8-3.0%) Excise tax increases strongly predict price increases. One-third of countries saw real prices at least 50% higher than 10 years prior. Conclusion Many of the instances of real price increases of 50% or more over 10-year periods occurred without countries implementing a conscious strategy to raise taxes. It is feasible to achieve and even surpass WHOs 3 by 35 call to action for tobacco if countries strategize and accelerate tobacco tax increases.