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.

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.

Background HPV-vaccination prevents HPV-related cancers, but uptake remains suboptimal. In the Netherlands, a catch-up campaign invited 18-27-year-olds for an additional cost-free opportunity to initiate or complete their HPV-vaccination in 2023-2024, which led to 24% of this invited population getting vaccinated. As young adults increasingly seek health information online, understanding online questions, concerns and misinformation in response to the campaign may help improve future vaccination efforts. Supplemental to overall evaluation of the vaccination campaign, we piloted online social listening processes to generate an insight report for Public Health Service (PHS) Amsterdam. Objective This study piloted online social listening processes at the PHS Amsterdam to identify actionable insights into questions, concerns and misinformation surrounding the HPV-vaccination catch-up campaign among young adults. Methods Upon inventory of potential platforms and data sources, a retrospective online social listening analysis was conducted across the platforms Instagram, Facebook, and X, collecting data from PHS, the National Public Health Institute for Public Health and the Environment (RIVM), the Dutch public broadcasting foundation (NOS), and LINDA.meiden sources from January 1, 2023, to June 1, 2024. Publicly available posts, comments, and engagement concerning HPV-vaccination were manually collected, and inductively coded. Themes were assessed for risk, based on expected potential harm and observed reach, and used to develop recommendations. Results A total of 821 posts and 5157 comments were collected and analysed. Ten recurring themes were identified across varying levels of risk. Two themes were classified as high risk: an information gap regarding the effectiveness of HPV-vaccination and concerns about the transparency on HPV-vaccine side effects. Three themes were classified as medium risk: questioning HPV-vaccine effectiveness under certain circumstances, reduced general vaccine trust following COVID-19, and accessibility issues related to vaccination locations and service times. Two themes were classified as neutral risk: questions regarding eligibility criteria for the campaign and calls for broader HIPV-prevention measures. Finally, three low risk themes concerned questions regarding HPV-vaccine brand specifics, campaign choices, and questions about scheduling or rescheduling HPV-appointments. Comments also referred to subsequent information sources, including reliable sources (public health institutes), false narratives and misinformation. Recommendations focused on addressing questions and information gaps (i.e. improving HPV risk perception and providing more detailed HPV-vaccine information), improving communication about HPV-vaccination, and reducing practical barriers to vaccination. Conclusions Manual social listening across selected online sources provided actionable insights into the public discourse during the HPV-vaccination catch-up campaign. Results mostly reflected questions, concerns and information gaps. Although some themes were critical of HPV-vaccination, false narratives and misinformation did not dominate the discourse. Recommendations aim to reduce practical barriers and address information needs. This pilot showed that online social listening can be effectively implemented even with limited resources.

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.

Introduction The role of population-wide smoking cessation campaigns is uncertain as smoking prevalence reaches historically low levels. We examined whether the Power to Quit campaign in England, which aimed to increase uptake of evidence-based cessation support, particularly digital aids, was associated with changes in quitting behaviour. Methods We analysed nationally-representative cross-sectional surveys of adults in England who smoked in the past year, conducted immediately before (n=803) and after (n=1,713) the campaign (February-April 2026). Logistic regression estimated associations with quit attempts, digital cessation support, local Stop Smoking Services (SSS), and quit success, overall and by social grade. Exploratory analyses examined participants recognising campaign materials (n=799). Smoking Toolkit Study (STS) data (January 2023-June 2026; n=11,442) were used to contextualise findings against longer-term trends. Results In the primary pre/post analysis, there were increases in quit attempts (48.4% to 52.3%, aOR=1.16 [95%CI=0.97-1.38]), attempts involving digital support (16.0% to 18.4%, aOR=1.18 [0.92-1.50], and attempts involving SSS (2.4% to 3.6%, aOR=1.53 [0.89-2.65]), although estimates were uncertain. Associations were larger among participants recognising campaign materials (quit attempts: 64.9%, aOR=1.82 [1.47-2.26]; digital support: 28.7%, aOR=1.88 [1.44-2.45]; SSS: 5.4%, aOR=2.14 [1.19-3.88]). Increases in support uptake were particularly evident among less advantaged adults. There was no clear evidence of a change in quit success. STS data showed increases in support uptake continued from before the campaign. Conclusions Power to Quit coincided with increased engagement with cessation support, particularly among less advantaged adults and those recognising campaign materials. Increases in support continued pre-campaign trends, indicating that the contribution of the campaign occurred within a broader period of changing cessation behaviour.

Introduction No widely adopted guidelines exist for collecting and reporting donor-level metadata in tissue-based research, limiting interpretability, reproducibility, and potentially introducing bias. This study aimed to inform ethical and appropriate metadata practices. Methods Semi-structured interviews were conducted with 16 investigators from the Human BioMolecular Atlas Program. Thematic analysis using inductively derived codes identified metadata elements and perspectives on their collection and reporting. Results Participants identified 80 metadata variables across six domains: demographic, sociodemographic, medical history, personally identifying information, cause of death, and tissue/organ data. Most supported routine collection and reporting of demographics and medical history, whereas views on cause of death and sociodemographic data were mixed. Conclusion We recommend routinely collecting and reporting demographics and medical history, while restricting cause of death and sociodemographic variables to situations with explicit consent or justification. These findings provide initial evidence to inform ethical donor metadata guidelines, with further stakeholder engagement and consensus-building needed.

Background: COVID-19 vaccination uptake is influenced by various sociodemographic and psychological factors. Previous studies have suggested that the relationship between personality traits and vaccination is context-dependent. However, this association has not been investigated in Japan, a unique sociocultural context characterized by historically low vaccine confidence but exceptionally high COVID-19 vaccine uptake. We examined the association between the Big Five personality traits and completion of the primary COVID-19 vaccination series, exploring potential gender-personality interactions. Methods: A web-based, cross-sectional survey was conducted among 7,210 Japanese adults (aged 20-85 years) in December 2021. Personality was assessed using the Japanese version of the Ten-Item Personality Inventory. Multivariable Poisson generalized estimating equations were used to calculate adjusted prevalence ratios (PRs) and assess gender-personality interactions. Results: Higher extraversion and lower openness were significantly associated with vaccination completion across genders. A significant gender-agreeableness interaction was observed: agreeableness (PR = 1.016, 95% CI: 1.008-1.024) was positively associated with vaccination completion among men but not women. A similar, though only marginally significant, interaction pattern was observed for neuroticism (PR = 1.011, 95% CI: 1.004-1.019 among men). Conclusions: Personality traits act as modest but meaningful, gender-specific psychological modifiers of vaccination behavior in Japan. Public health campaigns should transition from traditional "one-size-fits-all" messages to personality-tailored and gender-responsive communication strategies to optimize vaccine uptake and bolster psychological resilience in future pandemics.

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: 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.

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.

Importance: In the US, Human papillomavirus (HPV) related cancers cause significant morbidity and mortality, yet HPV vaccine is underutilized. Vaccination is recommended routinely at age 11-12 years but can be given at 9 years. There is controversy about whether earlier introduction would increase completion of the HPV series before by age 13 years or whether it might decrease rates of delivery of other routinely recommended vaccines at 11-12-years [quadrivalent meningococcal conjugate (MenACWY) vaccine, and tetanus-diptheria-acellular pertussis (Tdap) vaccine]. Objective: To determine whether introduction of the HPV vaccine at ages 9-10 versus 11-12 years, results in earlier median age of series completion (primary outcome) and higher rates of initiation and completion by age 13 years. We also examined the effect of earlier introduction of HPV on rates of Tdap and MenACWY initiation and completion by age 13 years. Design: Two-arm cluster-randomized trial involving 31 pediatric practices in Colorado and California between 10/2021-4/2026. Practices were randomized using covariate constrained randomization within each state to Intervention (introduction of HPV vaccination at ages 9-10) or Control (introduction at ages 11-12). Both study groups received similar annual training about best practices for HPV vaccination with recommended initiation age as the only difference. Results: Age at HPV series completion was substantially earlier in the Intervention group (median 12.2 v. 13.3 years; adjusted hazard ratio [aHR] 2.37; 95% CI 1.94-2.89). Key secondary outcomes were also improved in the intervention group: age at series initiation (median 11.0 v. 11.8 years; aHR 2.19; 95% CI 1.84-2.62), series completion by 13 years (61.6% v. 45.1%; RR 1.37; 95% CI 1.04-1.74), and vaccine initiation by age 13 years (77.1% v. 67.0%; RR 1.15; 95% CI 1.00-1.33). The intervention group was more likely to receive Tdap (aHR 1.47;95%CI 1.13, 1.92) during the trial; receipt of both vaccines by age 13 years did not differ. Conclusions: Earlier introduction of HPV vaccination resulted in earlier age of series completion, and more adolescents initiating and completing the series by age 13 without decreasing rates of other routinely recommended vaccines. Our findings support a preferential recommendation at 9-10 years. Trial registration number: NCT04722822 ClinicalTrial.gov

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: Medical students face significant mental health challenges, yet psychological distress and post-traumatic stress remain insufficiently characterized in lower-resource settings like Vietnam. Among potential stressors, sexual violence (SV) exposure represents a critical but understudied risk factor. This study evaluated the severity of psychological distress (PD) and post-traumatic stress symptoms (PTSS) among medical students in Northern Vietnam and examined their associations with past-year non-contact and contact SV exposure. Methods: A cross-sectional survey was conducted in May 2025 using REDCap among a probability sample of 555 medical students (years 2 to 5). Mental health outcomes were evaluated using validated instruments: the 21-item Depression, Anxiety, and Stress Scales (DASS-21) for past-week PD and the PTSD Checklist for DSM-5 (PCL-5) for past-month PTSS. Past-year non-contact and contact SV exposures were measured using the Sexual Experiences Survey-Victimization (SES-V). Multivariable linear regression modeled adjusted associations between SV exposure types and mental health symptom severity, testing for sex-specific differences. Results: Overall mental health symptom scores escalated significantly with SV exposure. Median PTSS scores increased from 11 among unexposed students to 20 for non-contact SV and 30 for contact SV (p < 0.001). Similarly, median PD scores increased from 7 (unexposed) to 11.5 (non-contact SV) and 21 (contact SV) (p < 0.001). Adjusted linear models demonstrated robust associations where both non-contact and contact SV exposure were strong independent predictors of heightened PD and PTSS severity, with no significant moderation by sex. In terms of exposure prevalence, 21.26% of students reported non-contact SV (higher in females: 26.24% vs. males: 16.12%) and 10.66% reported contact SV. Conclusions: Vietnamese medical students exposed to sexual violence experience a heavy mental health burden marked by elevated psychological distress and post-traumatic stress symptoms. To protect student mental health in lower resource settings, medical institutions must establish comprehensive trauma-informed psychological support, confidential counseling services, and targeted intervention strategies addressing both contact and non-contact stress exposures. Keywords: psychological distress, post-traumatic stress, non-contact sexual violence, contact sexual violence, university students, Vietnam

Objectives To investigate the association between time spent in NHS Type 1 emergency departments (EDs, consultant led 24 hour services with full resuscitation facilities) and risk of leaving employment and hospitalisation after leaving the department alive up to two years after attendance. Methods We conducted a retrospective cohort study using linked administrative data from the NHS Emergency Care Dataset, Hospital Episode Statistics, Census 2021, and mortality records. ED length of stay was categorised from under 2 hours to 12 hours or more. Cox proportional hazards models were fitted to estimate the association between ED length of stay and subsequently leaving employment or being hospitalised over a two year follow-up period, adjusting for demographic, socioeconomic, and clinical characteristics. Results Our study population comprised 3,347,008 individuals aged 25 to 64 who attended a Type 1 ED in England between April 2021 and March 2023. For leaving employment, adjusted hazard ratios (aHRs) increased from 1.04 (95% CI 1.03 to 1.06) for stays of 2 to <4 hours to 1.21 (1.17 to 1.24) for 12 hours or more, compared with stays under 2 hours. A similar but more pronounced gradient was observed for post-discharge hospitalisation, with aHRs rising from 1.06 (1.04 to 1.07) at 2 to <4 hours to 1.95 (1.91 to 1.99) for stays of 12 hours or more. Conclusions Prolonged time spent in the ED is associated with poorer outcomes among working-age employees, including reduced labour market participation and increased hospital use. These findings suggest that long ED stays may have wider and longer-term implications beyond immediate clinical outcomes, including potentially for national labour markets and economic growth.

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.

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.

Background: Hepatitis B virus (HBV) seroprevalence reaches 10--12% among out-of-school youths in urban Southwest Nigeria, yet fewer than three in ten in this demographic have ever undergone HBV testing. E-health self-testing applications offer an accessible alternative delivery modality for hepatitis screening, but direct evidence comparing their acceptance against traditional laboratory-based delivery in informal commercial settings is lacking. Objective: To determine whether e-health app-guided hepatitis self-testing achieves equivalent disease detection and superior acceptance outcomes compared with traditional laboratory-based screening among out-of-school youths in a high-footfall commercial site in Ibadan, Nigeria. Methods: A cross-sectional parallel-arm pilot study recruited 120 out-of-school youths at commercial premises on Iwo Road, Ibadan (test group: n=60, e-health app-guided hepatitis B and C self-testing; control group: n=60, traditional laboratory-based testing using identical rapid diagnostic kits). Pre- and post-test structured questionnaires assessed technology readiness, behavioural intention, perceived ease of use, and adoption barriers. The Technology Acceptance Model (TAM) and Unified Theory of Acceptance and Use of Technology (UTAUT) provided the analytical framework. Group comparisons used chi-square and Fisher's exact tests (=0.05). Results: HBV seroprevalence was 10.0% in the test group and 11.7% in the control group (X2=0.087, p=0.769), confirming statistically equivalent detection across modalities. Hepatitis C virus was undetected in both groups. The test group demonstrated greater willingness to use e-health testing over traditional laboratory services (81.6% vs 70.0%), higher comfort with mobile health technology (75.0% vs 71.7%), and equivalent recommendation intent (93.3% vs 95.0%). Prior e-health service use was significantly higher in the test group (28.3% vs 13.3%; X2=4.09, p=0.043). Anticipated ease of use (75.0% "very comfortable") substantially exceeded experienced ease post-use (41.7% "very or extremely easy"). Privacy concern was the leading adoption barrier in both groups (30.0% vs 36.7%), outranking cost (25.0% vs 15.0%). Conclusions: E-health self-testing achieves non-inferior hepatitis B detection compared with traditional laboratory delivery while generating comparable acceptance outcomes. The gap between anticipated and experienced ease of use identifies usability as the primary design target. Privacy-centred tool design, not cost reduction alone, is the critical condition for scaling hepatitis e-health self-testing among out-of-school youths in urban Nigeria.

Objective A diversity of approaches and cohorts have been published in research literature for suicide risk estimation, leading to some uncertainty around which factors and conditions are most strongly contributing to risk. Methods exist for weighting estimates by propensity score, removing simplifying the interpretation of model effects. Few studies have explored the use of these tools to assess when the effect of certain factors is uncertain or inconsistent. Method A mix of 1,001,737 suicide decedents and living patients were evaluated for suicide risk, relying on a subset of commonly identified factors: demographics, psychiatric conditions, substance use disorders, and social needs. Care utilization patterns were then assessed controlling for these factors in a hospital care setting. Four methods were considered for controlling multivariate confounding of odds predicting death by suicide: multivariate logistic regression, 1-to-1 sample matching, inverse propensity weighting (IPTW), and entropy balancing (EBAL). Results Test statistics showed suicide decedents were much more likely to have various psychiatric and substance use diagnoses, social needs and more likely to heightened care utilization across sampling intervals. Greater utilization was found close to date of death. Effect sizes after IPTW and EBAL weighting were also generally greater than would have been documented by regression alone. Conclusions Propensity weighting is a useful alternative to exploring nuanced effects, especially when the direction and strength of an association differ from traditional statistics. By weighting, the overall imbalance of cases remains consistent and effect terms might reflect more nuanced associations than regression or sample matching alone.

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.

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