Preventive Medicine Reports

Introduction Smoking prevalence remains higher in rural than in urban populations in the United States. To examine recent trends, we assessed state-level differences in cigarette smoking between urban and rural areas from 2018 to 2024. Methods Using repeated cross-sectional data from the Behavioral Risk Factor Surveillance System, we estimated state-specific logistic regression models to examine the relationship between urban-rural county residence and cigarette smoking. Unadjusted models (model 1) included urban-rural county status and year. Subsequent models (model 2) added age, sex, and race/ethnicity. A final model (model 3) included education and an interaction term between urban-rural county status and year to examine whether gaps in urban-rural smoking changed over time. In states with significant interactions, simple effects tests compared trends for urban-rural groups separately. Results Compared to urban adults, rural adults had higher unadjusted odds of cigarette smoking (odds ratio [OR] range:1.07-1.88) in 88.4% (38/43) of states. Adjusting for demographic covariates (model 2) increased the proportion of states with significant marginal effects of rurality to 90.7% (ORs:1.09-1.87). A final model that also controlled for education (model 3) decreased the proportion of states with significant marginal effects of rurality to 60.5% (ORs:1.10-1.54). Among the 14 states with significant interaction terms, the odds of smoking declined faster among urban than rural residents. Conclusion Urban-rural differences in smoking persist across most states. No state showed a reduction in urban-rural disparities over time, and the urban-rural gap widened in 14 states. Demographic variation accounted for some, but not the majority, of observed urban-rural differences.

Background: In the United States, several states have restricted sales of flavoured tobacco products, including popular menthol- and mint-flavoured Oral Nicotine Pouches (ONP). In response, tobacco companies introduced "unflavoured" ONP containing odorless synthetic cooling agents. Since these, in turn, have become targets of legislative bans, the tobacco industry may seek out flavourants with other sensory effects to increase the appeal of "unflavoured" ONP. Methods: Online merchants were searched for "unflavored" ONP marketed to consumers in jurisdictions with flavour bans. Sensory effects of aqueous extracts from identified "heat", "spicy" and "unflavoured" ONP were analyzed by Ca2+ microfluorimetry in HEK293 cells expressing the human heat/chili pepper flavourant (capsaicinoid) receptor, hTRPV1. ONP were analyzed for capsaicinoids and sweeteners by Liquid Chromatography/Mass Spectrometry (LC/MS). Results: A new category of "heat" or "spicy" ONP was identified, including products marketed as "unflavoured". Extracts from all these ONP robustly activated TRPV1, with "unflavoured" Lucy Heat the most potent. Chemical analysis demonstrated that Lucy Heat contained the synthetic capsaicinoid nonivamide at high levels (~675 microgram/pouch), while others contained mixtures of capsaicinoids (5-25 microgram/pouch) combined with other characterizing flavours (tropical, fruit). All tested ONP contained sweeteners. Conclusions: The tobacco industry continues to probe regulatory loopholes by claiming that newly introduced capsaicinoid flavourants and sweeteners in ONP do not represent characterizing flavours. This is contradicted by industry and regulatory determinations assigning characterizing flavour properties to these additives. The toxicological health risks of repeated capsaicinoid exposures due to ONP use, in combination with nicotine and other constituents, need to be assessed.

Introduction: Nicotine Pouches are increasingly used as a smokeless alternative to cigarettes and other nicotine products, yet their acute cardiovascular effects remain poorly documented. While nicotine's impact on heart rate and electrocardiogram (ECG) parameters is well-documented in smoking, no trials have evaluated these effects specifically for nicotine pouches. Methods: This study is a single-center, double-blind, placebo-controlled, crossover trial which will include 20 healthy adult nicotine users. Participants will undergo three sessions, receiving either a placebo, 6 mg, or 14 mg nicotine pouch in random order. Heart rate obtained by an ECG and various other ECG parameters, vital signs, and subjective symptoms will be measured at baseline, and multiple time points over 30 minutes. Conclusions: This study aims to determine whether nicotine pouches cause acute changes in heart rate, ECG parameters, vital signs, and self-reported symptoms. We hypothesize that higher nicotine pouch does will lead to measurable increases in heart rate and other autonomic effects compared to placebo.

Introduction: Research has documented that obesity and morbidity are associated. Black persons in the United States (U.S.) incur higher financial costs of obesity-related multimorbidity (ORM). However, lifetime healthcare costs (LHCs) remain underexamined for these populations. Objective: We quantified racial differences in 1) LHCs and 2) lifetime healthcare cost differential (LCD) associated with ORM for ages > 40 years. Methods: We used the 2008- 2012 Medical Expenditure Panel Survey Household Component to examine unique obesity-related diseases (ORDs): high blood sugar, hypertension, coronary heart disease, and stroke. We used a prior published Markov model to simulate a person's life history of ORDs and compute LHCs among ages > 40 years. We computed LCD-associated ORM as the difference in LHC for those with ORM and LHC for members without ORDs. We quantified differences in race as the difference between LHC or LCD among White and Black men and women. Results: Our analytic sample included 53,035 Black and White persons representing 97,229,611 (S.E., 2,104,365), 12.4% as Black and 87.6% as White persons. ORM was more prevalent in the Black (21.2%) than the White group (13.4%). LHCs by race (Black/White) for women/men with ORM and LCDs associated with ORM (2012$) were $3 1,035/43,595 and $11,350/26,948 for age 40-49, $2 1,567/25,6 115 and $3,846/9,808 for 50-59, $9,863/18,515 and -$2,566/7,426 for 60-69, -$8,220/16,285 and -$11,524/3,865 for 70-79. Conclusions: Racial Differences in LHCs and LCDs related to ORM persist and vary across subpopulations. Future interventions designed to prevent/manage ORM are crucial for prioritizing populations with high LHCs and advancing health equity.

Aims To estimate the prevalence of past-year smoking quit attempts in Great Britain and examine variation by sociodemographic and socioeconomic characteristics, mental health, alcohol use, smoking-related characteristics, and geographic area. Design Cross-sectional analysis of data from a nationally representative household survey (the Smoking Toolkit Study) conducted October 2020 to May 2026. Setting Great Britain. Participants 24,786 adults ([≥]18y) who reported past-year tobacco smoking. Measurements The outcome was self-reporting having made at least one serious attempt to stop smoking in the previous 12 months. Associations with age, gender, ethnicity, social grade, health-related economic inactivity, mental health conditions, psychological distress, alcohol consumption, use of non-combustible nicotine, cigarette type and consumption, strength of urges to smoke, and motivation to stop smoking were assessed. We calculated weighted prevalence estimates and odds ratios (ORs) adjusted for survey year. Findings Overall, 36.7% [95%CI=36.0-37.4] of adults who had smoked in the past year self-reported making at least one quit attempt. Annual prevalence was relatively stable over the study period (range: 35.5% [33.9-37.1] to 37.6% [35.9-39.3]). Making a past-year quit attempt was more common among younger adults (48.0% among 18-24-year-olds) and declined progressively with age (24.6% among [≥]65-year-olds; OR=0.35, 95%CI=0.31-0.39). Compared with White adults, making a past-year quit attempt was more common among Black (OR=1.31, 1.11-1.55) and Asian (OR=1.40, 1.21-1.62) adults. Adults with a history of diagnosed mental health conditions (OR=1.27, 1.17-1.38) and moderate (OR=1.31, 1.20-1.43) or severe psychological distress in the past month (OR=1.39, 1.25-1.56) had greater odds of reporting a past-year quit attempt than those without. Those reporting increasing/higher risk alcohol consumption had lower odds than non-drinkers (OR=0.88, 0.82-0.95). Current use of nicotine replacement therapy (OR=2.59, 2.36-2.83) and vapes (OR=2.15, 2.02-2.30) were positively associated with reporting a past-year quit attempt. Odds were lower among those with greater cigarette consumption (OR range 0.79-0.86 among those smoking >10 vs. [≤]5 cigarettes per day). Motivation to stop smoking showed the strongest gradient (OR range 2.95-29.09). Geographic differences were modest, with prevalence ranging from 32.1% [29.9-34.3] in Wales to 39.4% [35.9-43.1] in North East England. Conclusions Between 2020 and 2026, around one in three adults in Great Britain who smoked in the past year reported making a serious attempt to quit, corresponding to approximately 3.5 million people annually. Making a past-year quit attempt was more strongly associated with smoking-related factors than sociodemographic characteristics.

Introduction: Childrens exposure to second hand tobacco smoke is a preventable global public health issue, yet there is no consensus on how best to support families to create a smoke free home. This pilot randomised controlled trial tested the feasibility of use of free nicotine replacement therapy combined with telephone delivered support to reduce childrens exposure to second hand smoke in the home, and inform a future full scale trial. Methods: Parents and carers aged 18 and over, who smoke in the home and care for one or more children aged 0 to 16 years were recruited through existing initiatives and social media. Participants were randomised to either the intervention or control arm. Group A received free posted to home nicotine replacement therapy, alongside fortnightly telephone calls to support smoking abstinence in the home. Group B were signposted to the Scottish Government Take it Right Outside website which provides interactive advice on creating a smoke free home. To measure second-hand smoke levels, participants installed an air quality monitor in their living room for 7 days to measure fine particulate matter at baseline and 12 week follow-up. Results: Approximately one-quarter (27 of 100) of the intended sample size was recruited. Median fine particulate matter concentrations reduced in both the intervention (by 36mg per cubic metre) and control (by 16mg per cubic metre) groups. Retention rates and adherence rates to nicotine replacement therapy were 70 percent and above, with no risks and or safety concerns reported, suggesting this approach is feasible and acceptable to participants. The estimated cost of delivering this 12 week intervention was two hundred and forty four pounds per individual. Conclusions: Although recruitment rates were insufficient to recommend progression to a larger trial to test effectiveness of this approach in Scotland, this study could inform trial development in other countries where smoking in the home is commonplace. Insights regarding the alignment of smoke free home interventions with broader smoking cessation initiatives could inform future policy and public health approaches.

Objectives: Healthcare data can reveal actionable opportunities to prevent asthma hospitalizations. Limited national-level data exist regarding social determinants of health (SDOH) and asthma hospitalizations. We examined SDOH-related International Classification of Diseases, Tenth Revision (ICD-10) Z-codes in national administrative data on asthma hospitalizations and described patient- and hospital-level characteristics associated with documented SDOH Z-codes. Methods: Pooled cross-sectional analysis of 2016-2022 Nationwide Inpatient Sample for 200,452 U.S. hospitalizations (all ages) with a primary diagnosis of asthma. Presence of SDOH Z-codes (codes Z55-Z65) assessed by descriptive statistics and multivariable logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs) for associations between SDOH Z-codes and patient- and hospital-level characteristics. Results: In unweighted analyses, 3,149 asthma hospitalizations had SDOH Z-codes (1.57%). The most common SDOH Z-codes were homelessness (Z59.0; n=942) and unemployment (Z56.0; n=349). Weighted chi-square analyses found all selected variables were associated with asthma hospitalization SDOH Z-code documentation. Logistic regression results varied; adjusted odds for SDOH Z-code documentation were higher for asthma hospitalizations involving male patients (aOR=1.51; 95% CI, 1.39-1.63; P < .001) compared to female patients. Asthma hospitalizations involving rural hospitals had lower odds of SDOH Z-codes documentation (aOR=0.57; 95% CI, 0.47-0.70; P < .001) compared to urban teaching hospitals. Conclusions: National 2016-2022 data indicate housing- and employment-related Z-codes were the most commonly documented SDOH within asthma hospitalizations. Future analyses could consider establishing causality and exploring how relationships between these SDOH may be used by public health practitioners and others to improve program interventions.

Objective This study evaluated how well subjective life expectancy (SLE) predicts mortality and actual life expectancy (ALE), along with factors associated with inaccurate expectations. Methods Using panel data on approximately 2,000 individuals with up to 28 years of follow-up from a nationally representative sample of older Japanese adults, we examined relationships among SLE, actual mortality, and ALE by survival analysis. We also evaluated health and socioeconomic disparities using concentration indices and investigated factors influencing SLE and ALE discrepancies and focal-point (i.e. rounded or anchored estimates) and do-not-know responses. SLE was measured as a self-reported point estimate, whereas ALE mainly came from official records and family reports. Results SLE was significantly associated with both actual mortality and ALE, even after accounting for demographic and socioeconomic variables. Nonetheless, significant inaccuracies remain: approximately 59% of individuals surpassed their expected lifespan. SLE was positively associated with ALE; however, the association was inelastic. Women and those with higher education levels were more likely to outlive their SLE, whereas those in poorer health were less likely to do so. Higher education correlated with fewer focal point responses to the SLE question. Discussion SLE effectively predicts ALE; however, gaps are non-negligible and differ across gender and socioeconomic groups. Offering more precise data, such as sex- and age-specific remaining life expectancy, can enhance SLE formation and lead to more informed economic choices.

Introduction: Breast, cervical, and colorectal cancer screening guidelines changed substantially between 2010 and 2019. We examined trends in the annual utilization of these screenings among commercially insured enrollees in the United States from 2010 to 2019 by age group, geographic region, and screening modality. Methods: We conducted a retrospective, serial cross-sectional analysis of the MarketScan Commercial Claims Database from 2010 through 2019, comprising approximately 141.2 million privately insured enrollees. Annual screening rates, defined as the proportion of eligible enrollees receiving a given test within each calendar year, were estimated for cervical, breast, and colorectal cancer using procedure codes, stratified by age group, screening modality, and geographic residence. These reflect annual utilization rather than up-to-date (guideline-concordant) screening. Temporal trends were evaluated using two-sided Poisson regression, and urban-rural disparities in 2019 were assessed using multivariate generalized estimating equations. Results: Cancer screening utilization remained stagnant or declined across all three cancer types over the study period. Among women aged 30-64 years, cervical cytology alone declined substantially from 28.2% in 2010 to 8.8% in 2019, while co-testing increased from 11.4% to 20.3%. Screening mammography among women aged 50-64 showed minimal change, remaining stable at 45.7% in 2010 and 45.8% in 2019. Colorectal cancer screening across enrollees aged <64 decreased modestly from 7.7% in 2010 to 6.5% in 2019, with a more pronounced decline among adults aged 45-49 years. Across all three cancer types, screening utilization was higher among urban residents than rural residents, with incidence rate ratios ranging from 1.02 to 1.05 in 2019. Conclusions: Utilization of cervical, breast, and colorectal cancer screening among commercially insured adults did not improve between 2010 and 2019. Persistent urban-rural disparities highlight ongoing gaps in preventive care delivery. Targeted interventions may help improve screening utilization, particularly in rural and underserved populations.

Background: Adverse events (AEs) after hospitalization are common and disproportionately affect adults with multiple chronic conditions (MCC). Capturing patient-reported symptoms and self-assessed health may enable earlier detection of post-discharge AEs. Objective: To identify and test user requirements for an automated remote monitoring system to enhance AE surveillance during the transition home following discharge. Methods: We conducted a mixed-methods study using an iterative, user-centered design approach. Semi-structured interviews with patients and clinicians informed system requirements, followed by real-world field testing in 20 patients who used the system for up to 7 days after discharge. The prototype leveraged interoperable electronic health record data services, delivered automated post-discharge check-ins using a combined questionnaire assessing new or worsening symptoms and patient-reported outcomes (PROs), provided risk-stratified health advice (when and with whom to initiate contact), and escalated high-risk symptoms to clinicians in real-time. Descriptive statistics assessed feasibility and utilization; conventional content analysis identified user needs and implementation considerations. Results: Thirty-seven patients with MCC and 23 clinicians participated. Key requirements for patients included clear communication of personalized risk based on red-flag symptoms, and actionable guidance aligned with discharge instructions. Key requirements for clinicians included explicit delineation of responsibility across inpatient and outpatient setting, and selective escalation to minimize burden. Field testing patients completed 60% of the combined questionnaires. Seven patients received Level 2 or Level 3 health advice after reporting new or worsening symptoms. Three patients triggered Level 3 alerts, resulting in one-time, secure escalation emails to clinicians. Four of the 7 patients who received Level 2 or 3 health advice had chart-confirmed emergency department visits within 1 week of discharge. Patients found the system understandable and helpful, while clinicians noted challenges interpreting PRO trends. Conclusions: These observations support the feasibility and acceptability among patients and clinicians of collecting patient-reported symptoms and PROs during the early post-discharge period. Future iterations should prioritize clear risk communication, role clarity, and interpretable patient-reported data. Formal validation is required to assess predictive performance and clinical utility of symptom-based escalation for post-discharge AE surveillance.

Background: The nicotine analog 6-methyl nicotine (6-MN) has appeared in commercial e-cigarette liquids, and other products, spurring interest in determining the extent to which it conveys similar effects to those of nicotine. Objective: To determine if 6-MN acts like nicotine to decrease body temperature, decrease nociception, suppress wheel activity and reinforce operant behavior when delivered by vapor inhalation using an Electronic Nicotine Delivery System (ENDS; "e-cigarette") approach in a rat model. Methods: Male and female (N=8 per sex) young adult Sprague-Dawley rats were evaluated for rectal temperature and nociceptive responses (warm water tail-withdrawal) to the inhalation of vapor from (-)-6-MN or (-)-nicotine in concentrations ranging from 5-30 mg/mL in the propylene glycol vehicle. Rats were then assessed for the reinforcing effects of nicotine and 6-MN using a vapor self-administration procedure and the rate suppressing effects of nicotine and 6-MN on wheel activity following injection. Results: Inhalation of nicotine or 6-MN for 30 minutes decreased the rectal temperature and increased tail-withdrawal latency of female and male rats in a concentration-dependent manner. The magnitude of the effects of 6-MN and nicotine were similar at similar vapor concentrations. Operant responding for 6-MN vapor was increased by pre-treatment with the antagonist mecamylamine. 6-MN was more potent than nicotine at suppressing wheel activity after injection. Conclusions: 6-MN induces effects very similar to those of nicotine, at a similar potency when inhaled and at a slightly increased potency when injected.

Objective To measure the accuracy of clinical coding, clinician review, and a locally deployed large language model (LLM) in identifying alcohol, drug, and self-harm involvement in emergency department (ED) attendances, and quantify prevalence. Design Two-phase diagnostic accuracy study. In a validation week, the identification strategies were assessed against a conflict-adjudicated reference standard (n=2,256); the LLM was then applied to n=105,096 annual attendances at the same site. Setting UK Type 1 Emergency Department treating patients [&ge;]16yrs. Main outcome measures Prevalence quantification compared with the reference standard; sensitivity, specificity, and balanced accuracy of each strategy; monthly identification rates and adjusted annual prevalence. Results The reference standard identified 12.1% of attendances as involving alcohol, drugs, or self-harm (coding 6.0%; clinician 10.0%, LLM 15.6%). LLM balanced accuracy matched or outperformed clinician review in all three domains (alcohol 0.942 v 0.930, p=0.635; drug 0.959 v 0.791, p<0.001; self-harm 0.982 v 0.908, p=0.004). Coding recorded 1.07 domains per identified patient against 1.32 in the reference standard. Adjusted annual prevalence corresponded to 12,890 domain involvements per year not identifiable in coded data. Subdomain classification found at least 81.6% of self-harm attendances required medical assessment for injury or overdose before psychiatric review. Conclusions Clinical coding identified fewer than half of presentations involving alcohol, drugs, and self-harm and rarely captured co-occurring domains; under-recording was present across a full year. A locally deployed LLM generated more complete structured data from existing clinical text within NHS infrastructure, at a scale which is not feasible for manual review.

Seasonal Influenza and COVID-19 vaccination programmes are critical for reducing morbidity and mortality in older adults, yet uptake remains uneven across populations. We aimed to profile vaccination attitudes and examine predictors of COVID-19/influenza vaccination uptake among a UK participatory surveillance system - FluSurvey. We analysed FluSurvey data from participants aged [&ge;]65 years who were eligible for both vaccines in the 2023-2024 and 2024-2025 Autumn - Winter seasonal campaigns. Descriptive analyses examined self-reported attitudes to influenza vaccination. Logistic regression examined factors (age, sex, socioeconomic status, education, employment, transport, smoking and chronic conditions) associated with influenza and COVID-19 vaccination uptake in each season, adjusting for confounders. Belonging to a risk group and reducing risk of influenza were frequently reported motivations for influenza vaccination, while building natural immunity and concerns around safety and adverse effects were frequently reported barriers. Individuals vaccinated against COVID-19 were more likely to receive an influenza vaccination (aOR2023-2024=13.90 [9.28-21.17]; aOR2024-2025=8.54 [5.82-12.60]), and vice-versa (aOR2023-2024=13.91 [9.30-21.19]; aOR2024-2025=8.52 [5.81-12.58]). Lower educational attainment was associated with lower odds of COVID-19 vaccination (aOR2023-2024=0.59 [0.45-0.78], aOR2024-2025: 0.56 [0.39-0.79]). Other results were weaker or demonstrated variation by season. Our findings highlight recent attitudes and barriers to influenza and COVID-19 vaccination among the FluSurvey cohort, which may inform approaches to improve vaccination coverage in the population.

Objectives: To describe age-group differences in inability to afford dental treatment and cost related dental delay, among the US community-dwelling population. Study design: Descriptive analysis of nationally representative survey data. Methods: Using nationally representative Medical Expenditure Panel Survey data (2018-2021), we examined trends in inability to afford dental treatment and cost-related dental treatment delays across four age groups (2-17, 18-39, 40-64, [&ge;]65 years). Weighted analyses accounted for the complex survey design; statistical significance was set at p<0.001. Results: Cost-related delays declined modestly from 2018 to 2021 but remained most prevalent among adults aged 40-64 (4.8% for ages 40-64, 3.4% for ages 18- 64, 2.2% for ages>65 in 2021; p<0.001). Conclusion: Middle-aged adults seem to experience delays due to cost, underscoring the need for dental coverage to expand dental coverage for this group and to reduce their out-of-pocket costs.

Background YouTube highlights packages are a major and growing route to football consumption, particularly among children and young people, but brand exposure within them has not been quantified. We measured unhealthy commodity brand exposure in English Premier League (EPL) and FIFA World Cup (WC) highlights. Methods We coded brand appearances lasting two or more seconds in 10 Sky Sports EPL highlights (final 10 games of the 2025/26 season) and 19 official FIFA 2026 WC highlights, recording commodity category, placement, and match moment, alongside pre-roll YouTube adverts. Data were collected between 4 June and 27 July 2026. Five highlights were double-coded (Cohen's kappa 0.85). Results Overall brand density was similar across competitions (13.1 vs 13.9 references per minute), but composition differed markedly. Unhealthy commodity branding occupied 38.0% of EPL screen time versus 18.7% at the WC, a difference driven almost entirely by gambling (32.6% vs 1.5%). Gambling appeared in every EPL package, mainly on pitchside boards and LED screens (50.4%), with front-of-shirt accounting for 27.1%. WC exposure was more evenly spread across HFSS food (13%), alcohol (4%) and trading/crypto/prediction markets (3.7%), and appeared almost exclusively pitchside. Gambling brands accounted for ten of twelve pre-roll EPL adverts (123 of 153 seconds); no gambling adverts preceded WC highlights. Conclusions Gambling dominates unhealthy commodity exposure in EPL highlights, both in-video and in pre-roll advertising. Because most appearances occur away from the front of shirt, the voluntary front-of-shirt sponsorship withdrawal will leave the majority of this exposure intact. The WC comparison shows that tighter central control of the advertising environment produces lower and more diffuse exposure, and that governments and governing bodies with such control could restrict unhealthy categories altogether.

Introduction: Extreme heat increasingly threatens older adults, particularly those with chronic conditions, yet generic heat-health advice may not be sufficiently timely or relevant to individual needs. This feasibility study describes a prototype and assesses the feasibility of a location-triggered, disease-specific heatwave short message service (SMS) intervention tailored to common heat-vulnerability conditions, compared with generic heatwave SMS advice. Methods: Mixed-methods feasibility study comprising a parallel two-arm 1:1 randomised controlled trial and post-heatwave focus groups. Community-dwelling Australians aged [&ge;]65 years in New South Wales, Victoria or South Australia with at least one eligible chronic condition (cardiovascular diseases, respiratory conditions, diabetes, and chronic kidney diseases) and a smartphone were recruited in summer 2026. Based on an initial codesign, participants received a 'prepare' SMS after enrolment and, when Bureau of Meteorology heatwave warnings were triggered, messages before, during and after heatwaves. Control participants received generic 'standard care' heat-health advice; intervention participants received condition-tailored messages and could request additional information via SMS codes. Outcomes were collected via baseline and post-heatwave surveys and thematic analysis of focus groups. Results: Seventy-three participants enrolled (36 control; 37 intervention); attrition was 9.6%. Intervention engagement was strong: 61% requested additional information, with frequent free-text replies and multi-condition requests indicating preference for more conversational interaction. Eight participants were heatwave-exposed and completed post-heatwave surveys (4 per arm), with a high usability score (median of 85/100). Among these 8 participants, 7 reported adopting heat-protective health behaviours; the most common were drinking more water (6/7). More total actions were reported in the intervention group (11 vs 8). No adverse effects were reported. Conclusion: A location-triggered, disease-tailored heatwave SMS system for older adults with chronic conditions was feasible, acceptable and highly usable, with high engagement and no harms. Findings support a larger trial and suggest benefits from tailored messaging.

BackgroundObservational comparisons of former smokers who use non-combusted nicotine products with former smokers who quit without them require that two quantities be measured precisely: which product is being used, and how long ago cigarette smoking stopped. Neither quantity is recorded by the National Health Insurance Service (NHIS) screening instrument used in a recent Korean cohort study of post-cessation e-cigarette use and lung cancer risk. We characterized both quantities in a contemporaneous, nationally representative survey of the same population. MethodsWe analyzed the public-release microdata of the Korea National Health and Nutrition Examination Survey (KNHANES), 2018 to 2023, restricted to adults aged 19 years and older. Former smokers were identified by smoking status, and cessation duration was taken from the item recording months since the last cigarette. Former smokers currently using a heated tobacco product (HTP) or an e-cigarette (EC) were compared with former smokers using neither. KNHANES 2018 asked a generic e-cigarette question and, separately, a checklist naming HTP brands, allowing the two product classes to be separated. Distributions were compared with rank-based methods, the age-duration relationship with Theil-Sen regression, and residual imbalance by restricting the comparison group to respondents age-matched to within two years. ResultsThe 2018 analytic sample comprised 1,348 former smokers, of whom 43 currently used HTP or EC and 1,305 used neither. Among the product-using former smokers, 58% reported HTP use without e-cigarette use, 21% reported both, and 21% reported e-cigarette use without HTP use; 79% reported any HTP use. Median cessation duration was 0.7 years (IQR 0.25 to 1.5) among product users and 12.0 years (IQR 5.0 to 20.0) among those using neither (Kolmogorov- Smirnov D = 0.76, P < 0.001), with the product user having quit more recently in 92% of cross-group pairs. The separation persisted within the short-term (<5 year) stratum (D = 0.34, P < 0.001; 73% of pairs) and after age matching, where the residual gap was 9.3 years. Cessation duration rose with age among those using no product (Theil-Sen slope +0.30 years per year) but was flat among product users (-0.01). Restricting to the screening-eligible stratum used in the cohorts high-risk analysis did not attenuate the imbalance: among those aged 50 to 80, median cessation among no-product quitters rose to 15.5 years (n = 858), and adding a 20 pack-year criterion left 421 no-product quitters with a median of 11.0 years against three HTP/EC users who had quit 0.25, 1.0 and 2.0 years earlier, despite closely matched cumulative exposure (mean 37.6 vs 37.7 pack-years). The overall contrast reproduced in every wave from 2018 to 2023, with an age-matched residual of 9 to 11 years. ConclusionsIn a nationally representative survey of the same population and the same calendar year as the NHIS screening cohort analyzed by Kim et al., Korean former smokers using non-combusted nicotine products differed from other former smokers in two respects that bear directly on how such comparisons should be read. First, they were predominantly HTP users: 79% reported any HTP use, and only 21% reported e-cigarette use without HTP use. Second, they had stopped smoking approximately a decade more recently, a difference that survived stratification at five years and exact age matching. Neither quantity is recorded in the NHIS screening instrument. Cohort estimates comparing post-cessation product users with other quitters should therefore be interpreted with caution if they do not precisely characterize product composition and to time since cessation, and future studies should measure both directly.

Importance: Chronic stress may contribute to adverse health outcomes through cumulative physiologic dysregulation. Allostatic load (AL), a composite measure of multisystem physiologic burden, may capture biologic effects of structural, social, and psychosocial stress not reflected by self-reported measures. Objective: To evaluate racial and ethnic differences in AL among women with familial cancer risk and examine how socioeconomic status, psychosocial factors, clinical characteristics, and health behaviors contribute to variations in AL. Design: Cross-sectional study of underrepresented minority participants enrolled in the HERSTORY cohort from October 2023 through September 2025, with comparison participants from the UCLA ATLAS biobank. Setting: UCLA academic health system. Participants: The study included 303 racially and ethnically diverse female HERSTORY participants aged [&ge;]35 years with a family history of cancer and matched non-Hispanic White female ATLAS participants (n=709). Exposures: Race and ethnicity, age, neighborhood deprivation, cancer history and stage, depression, perceived stress, cancer worry, and physical activity. Main Outcomes and Measures: The primary outcome was AL, calculated from cardiometabolic and organ-function measures. A secondary index incorporated race- and ethnicity-specific neutrophil-to-lymphocyte ratio (NLR) derived from 326,826 women in the UCLA Health population. Multivariable regression models evaluated factors associated with elevated AL. Results: Compared with matched non-Hispanic White participants, Black and Asian/Pacific Islander HERSTORY participants had significantly higher AL after adjustment. Hispanic/Latina participants did not have significantly elevated AL. Older age, greater area-level socioeconomic deprivation, and depression were independently associated with higher AL. Prior cancer diagnosis, cancer worry and perceived stress were not significantly associated with AL, whereas regular physical activity was associated with lower AL. Among cancer patients, advanced stage was associated with greater AL. Conclusions and Relevance: This study demonstrates elevated AL among understudied racial/ethnic minority groups with familial cancer risk and identifies associations with neighborhood deprivation, depression, and physical activity. The association between cancer stage and AL suggests that physiologic stress may reflect variation in cancer burden. The lack of association with perceived stress and cancer worry further indicates that physiologic and self-reported psychosocial measures capture distinct dimensions of stress. The development of race/ethnicity-specific NLR thresholds derived from large population samples provide a benchmark for future studies.

Objectives. To assess how digital inclusion factors and physical access barriers are associated with user trust in smartphone-based remote photoplethysmography (rPPG) hypertension screening, and to identify implications for digital health pol- icy, procurement and implementation in low-resource settings. Methods. Cross-sectional mixed-methods survey in five outpatient clinics in Kebbi State, northern Nigeria (N =287). Trust was measured using comfort, confidence and perceived usefulness Likert scales. Primary analyses used binary logistic models with HC3 robust standard errors; sensitivity analyses are reported in supplementary material. Free-text responses were thematically analysed. Results. Smartphone ownership was 51.2%; Transsion-brand devices comprised 56.5% of owners. Greater distance to a blood pressure facility was independently associated with lower perceived usefulness (OR 0.51, 95% CI 0.30-0.87; p=0.013) and lower comfort (OR 0.61, 0.37-0.98; p=0.042). Among owners, Transsion versus Samsung showed higher confidence odds (OR 3.82, 1.02-14.27; p=0.046). Qualitative themes supported the implementation interpretation: platform-fit and device speed requests among Transsion owners; connectivity and offline-first concerns among those with greater travel distance. No brand contrast achieved FDR-adjusted significance; brand findings are exploratory. Conclusions. Digital health policy and health technology assessment for smartphone-based screening should incorporate local device ecology, connectivity constraints, physical access burden and trust-calibration safeguards. Pre-implementation assessment of these factors is necessary for equitable and safe rPPG adoption in low-resource health systems.

Background People with lower levels of literacy or health literacy may struggle to understand conventional health information. Video animations show promise as information tools, yet it is unclear whether video animations help reduce these inequalities in understanding. This study examined whether the effectiveness of video animations in health settings differs according to level of literacy or health literacy. Methods We drew on trials from a recent systematic review of video animations about healthcare or public health topics for patients or the public. We extracted available data on literacy, health literacy, or proxy indicators. One reviewer extracted data and a second checked all entries. Where possible, we conducted subgroup analyses of low and high literacy levels or interaction meta-analyses comparing low versus high literacy groups; otherwise, results were summarised narratively. Results From 88 eligible trials, we extracted health literacy data for 12. Across nine trials reporting knowledge, animations mostly improved knowledge compared with controls in both lower and higher health literacy groups. Effects on attitudes and behaviours were mixed and often small, with few studies reporting results by health literacy level. Across the subgroup analyses available, there was no consistent evidence of a pooled interaction effect of animations according to low and high literacy groups, but both statistical heterogeneity and small subgroup sizes limited precision of estimates. Across 88 trials, 54 (61%) reported education level, 22 (25%) did not, and 12 (14%) involved children or adolescents likely to have similar education levels. Conclusions Overall, the available data suggest that video animations can improve knowledge outcomes in both lower and higher health literacy groups, but their impact on attitudes and behaviour is less clear. Because literacy was rarely reported or analysed in the trials, it remains uncertain whether animations help to reduce literacy-related inequalities in access to, and use of health information.