Preventive Medicine

BackgroundThe initiation of tobacco and nicotine product use often occurs in adolescents. This necessitates monitoring of this behaviour in this population, particularly in countries such as the Democratic Republic of the Congo (DRC) where approximately 58% of the population is under 19 years of age. Our study assessed the prevalence of, and factors associated with use in the DRC. MethodsWe conducted a nationally representative, cross-sectional, household survey between March and May 2024 among adolescents aged 10 to 17 years. We estimated the prevalence of use of smoked and smokeless tobacco products, heated tobacco products, and nicotine products (i.e., electronic cigarettes and nicotine pouches). We used logistic regression to identify factors associated with current use of any tobacco product, smoked tobacco, and smokeless tobacco using adjusted odd ratios. All analyses included 95% confidence intervals (CI). ResultsOf the 4,675 adolescents who completed the survey, the prevalence of current use of any tobacco or nicotine product was 11.87% (95% CI: 6.93-19.58). This was 7.98% (95% CI: 4.23-14.55) for smoked tobacco products, 5.86% (95% CI: 3.42-9.87) for smokeless tobacco products, 0.11% (95% CI: 0.11-0.11) for heated tobacco products and 0.60% (95% CI: 0.10-3.40) for nicotine products. Boys were more likely to use tobacco than girls. Being enrolled in school and having both parents alive were protective from tobacco use. Having a male household head, a household head education level of at least secondary school, and exposure to tobacco smoking in public places increased the odds of being a tobacco user. ConclusionsThe DRC should strengthen policies that make tobacco and nicotine products less accessible or appealing to adolescents. This includes raising excise taxes; banning the sale of single cigarette sticks, small packets and flavoured products; and comprehensive smoke-free laws. Policies should account for factors that make adolescents more vulnerable product use. Key messagesO_ST_ABSWhat is already known on the topicC_ST_ABSO_LIThe last survey on tobacco use among adolescents in the DRC was a school-based survey among 13-15-year-olds conducted in 2008, and only covered Kinshasa and Lubumbashi. C_LI What this study addsO_LIThis survey provided national-level estimates that cover adolescents aged 10-17years, includes out-of-school adolescents, and covers both tobacco and nicotine products. C_LIO_LIIt also identifies individual-, household-, and environmental-level factors that are associated with tobacco and nicotine product use among adolescents in the DRC. C_LI How this study might affect research, practice or policyO_LIBy providing current and more comprehensive data, our study enhances policymakers ability to design evidence-based tobacco control interventions that are aimed at preventing the initiation and use of tobacco and nicotine products among adolescents in the DRC and other similar settings. C_LI

Background: Over half of U.S. women have hypertension, a strong but modifiable risk factor for cardiovascular diseases. Personal care products (PCPs) are widely used in daily life and contain endocrine disrupting chemicals that can alter hormonal regulation of blood pressure. However, the relationship between PCPs and hypertension has not been well studied. We investigated whether patterns of PCP use were associated with incident hypertension in a large prospective cohort study of U.S. women. Methods: Sister Study participants were recruited in 2003-2009 and followed until September 30, 2021. Usage frequency of 41 PCPs in the 12 months before baseline was self-reported. Latent class analyses identified groups with similar PCP use patterns ("infrequent," "moderate," or "frequent"). At baseline, we excluded women with prevalent hypertension, antihypertensive medication users, or those missing hypertension status. Multivariable Cox regression was used to estimate associations between PCP use and incident self-reported hypertension. Results: During a mean follow-up of 11.4 years, 10,099 women developed hypertension. Frequent PCP use was associated with higher hypertension risk [HR=1.08 (95% CI: 1.03, 1.13); p-trend=0.003], with a 4.1% population attributable risk. Frequent users of beauty products had higher risk than infrequent users [HR=1.11 (95% CI: 1.05, 1.16)]. Moderate and frequent users of hygiene products also had increased risk [HR=1.07 (95% CI: 1.01, 1.13); HR=1.13 (95% CI: 1.08, 1.19)]. Conclusions: Frequent PCP use, especially beauty and hygiene products, was associated with incident hypertension. Our findings implicate everyday chemicals as modifiable cardiovascular risk factors and highlight the need to identify pathogenic components in widely used consumer products.

Introduction Social media is a central part of young people's lives, yet research on its mental health effects remains mixed. We posit that these inconsistencies stem in part from treating youth as a homogeneous group, obscuring distinct behavioral patterns associated with divergent mental health and wellbeing trajectories. Objectives This study aimed to: (1) explore heterogeneity in social media engagement styles among U.S. youth aged 15-24; and (2) examine how these engagement styles are embedded within a broader system of mental health, wellbeing, emotional regulation, belonging, family and neighborhood context, and stress and adversity. Methods Data were drawn from a 2024 nationally representative cross-sectional survey of 2,563 U.S. youth, conducted as part of the Youth Mental Health Tracker initiative. We employed unsupervised clustering to identify five distinct social media engagement profiles. Subsequently, we used Bayesian network-based causal discovery to examine (a) upstream factors that emerge as drivers of engagement styles and (b) downstream outcomes influenced by profile membership in the learned system. Results Five profiles were identified: the Perpetually Plugged-In (31.3%), characterized by near-constant multifaceted social media use, for both positive and negative purposes across multiple domains of life; the Burned-Out Browsers (21.9%), with high exposure to negative and comparison-based content with frequent attempts to disengage; the Practical Navigators (20.7%) who engage in structured, goal-oriented use focused on learning, hobbies, and maintaining connections; the Positive Engagers (13.6%) with high social and identity-driven engagement; and the Light Touch Users (12.5%) who have low overall engagement and limited reliance on social media for connection, identity, or support. Causal analyses revealed that the Perpetually Plugged-In and Burned-Out Browsers had the worst mental health and wellbeing, with their engagement driven by different reasons. While both engagement profiles were influenced by similar psychosocial risk factors, they were distinguished by their dominant drivers: contemporaneous social stressors (bullying, discrimination, and emotional dysregulation) for Perpetually Plugged-In youth, versus adverse childhood experiences for Burned-Out Browsers. In contrast, Positive Engagers reported high social media engagement alongside the highest levels of social wellbeing, using social media for identity exploration and social support within a context of low cumulative stress and adversity. Conclusions Findings suggest that youth social media risk is not driven by intensity of use alone, but by the interaction between engagement style and offline emotional and social conditions. Policies focused solely on restricting access risk overlooking these differences and may inadvertently sever important sources of connection for many youth. Strategies should identify experiential risk signals while strengthening supportive contexts that enable healthier engagement. Overall, youth social media use is best understood as part of a broader psychosocial system, and recognizing this heterogeneity is essential for designing more targeted, equitable, and evidence-based interventions.

BackgroundLoneliness is common and deleterious to health. Yet little is known about its population burden and health correlates in the US. We aimed to determine the prevalence of loneliness and characterize its health and social functioning correlates among US adults. MethodsWith data from the National Health Interview Study (2024), we used survey-weighted Poisson regression to estimate relative risks (RR) and 95% confidence intervals (CI) for frequent loneliness by levels of self-reported general health, social/emotional support, social functioning, and healthcare utilization, adjusted for age, sex, race/ethnicity, number of people in household, marital status, and psychological distress. Results12 million US adults reported usually or always feeling lonely, which was associated with worse general health and social/emotional support, work and social participation limitations, and healthcare disengagement. ConclusionsLoneliness affects millions of US adults, with substantial health and social functioning burden.

Background: Self-reported confidence in health information seeking does not reliably predict accurate health knowledge, yet the population-level distribution of this discordance and its demographic predictors have received limited direct study. This study aimed to identify and characterize a Confident-Incorrect phenotype among U.S. adults: individuals with high perceived health information competence who simultaneously hold inaccurate or fatalistic beliefs about cancer. Methods: Cross-sectional analysis of HINTS 7 (N = 7,278). A Confidence Index (3-item digital literacy composite (Cronbach's = 0.674) and an Evidence-Consistent Knowledge Score (factual cancer knowledge minus a cancer fatalism composite; fatalism subscale = 0.563) were computed and combined into a discordance framework. Median-split classification produced four phenotypes. Gaussian Mixture Model clustering with four components provided moderate independent validation (inter-method agreement = 65.2%). Survey-weighted multinomial logistic regression (n = 5,771; McFadden pseudo-R2 = 0.129) examined phenotype predictors. Results: An estimated 20.3% of U.S. adults were classified as Confident-Incorrect. They reported confidence levels similar to Well-Informed adults (z = 0.72 vs. 0.82) but scored 2.8-fold lower on objective cancer knowledge (0.74 vs. 2.06 out of 4) and exhibited the highest cancer fatalism of any phenotype (3.17 vs. 1.65 out of 4). Only 14.3% correctly identified alcohol as a cancer risk factor (vs. 58.8% of Well-Informed adults). Cancer screening rates did not differ meaningfully across phenotypes. Lower education (OR = 0.754), Hispanic ethnicity (OR = 1.788), non-Hispanic Black race (OR = 1.893), higher social media use (OR = 1.097), and lower trust in scientists (OR = 0.749) independently predicted Confident-Incorrect membership. Conclusions: An estimated one in five U.S. adults is overconfident in health information competence while holding substantially inaccurate beliefs about cancer prevention. Cancer screening rates did not follow the expected gradient across phenotypes, a null finding that cautions against inferring immediate behavioral impact from observed belief gaps. Interventions targeting specific factual errors and cancer fatalism are more likely to reach this group than general health literacy programs.

BackgroundCommercial motorcycle riders are among the most vulnerable road users in low- and middle-income countries and contribute substantially to the burden of road traffic injuries. The use of personal protective equipment (PPE), including helmets and protective clothing, reduces injury severity; however, uptake remains suboptimal. This study evaluated the effectiveness of a theory-driven health education intervention in improving knowledge, attitudes, and use of PPE among commercial motorcycle riders in Cameroon. MethodsA quasi-experimental, non-randomized controlled before-and-after study was conducted in Limbe (intervention) and Tiko (control) Health Districts between August 4, 2024, and April 6, 2025. Participants were recruited from a cohort of commercial motorcycle riders and followed over an eight-month intervention period. The intervention, guided by the Health Belief Model and developed using the Intervention Mapping framework, combined face-to-face sensitization sessions with mobile phone-based educational messaging adapted to participants literacy levels and communication preferences. Data were collected at baseline and endline using structured questionnaires and direct observation checklists. Intervention effects were estimated using difference-in-differences analysis with generalized estimating equations, adjusting for socio-demographic factors. ResultsA total of 313 riders were enrolled at baseline (183 intervention, 130 control), with 249 retained at endline (149 intervention, 100 control). The intervention was associated with significant improvements in PPE knowledge ({beta} = 2.91; 95% CI: 2.14-3.68; p < 0.001) and attitudes ({beta} = 5.76; 95% CI: 4.32-7.21; p < 0.001) compared with the control group. No statistically significant effect was observed for PPE practice scores ({beta} = 0.21; 95% CI: -0.09-0.52; p = 0.171). Among individual PPE items, helmet use increased significantly in the intervention group relative to the control group (AOR = 2.38; 95% CI: 1.19-9.45; p = 0.036), while no significant effects were observed for gloves, trousers, eyeglasses, or closed-toe shoes. ConclusionThe theory-driven health education intervention significantly improved knowledge and attitudes toward PPE and increased helmet use among commercial motorcycle riders but did not lead to broader improvements in the uptake of other protective equipment. These findings highlight the need for complementary structural and policy interventions to address persistent barriers to PPE use in similar low-resource settings. Trial registrationClinicalTrials.gov Identifier: NCT07087444 (registered July 28, 2025, retrospectively)

IntroductionMonitoring trends in transitions in the use of electronic nicotine delivery systems (ENDS) and cigarettes among youth is important for understanding the potential public health impacts of these products. MethodsUsing a weighted Markov multistate transition model accounting for complex survey design, we estimated transition rates and one-year transition probabilities between never, non-current, ENDS-only, and cigarette use (with or without dual use of ENDS) among 26,744 youth aged 12-17 years who participated in at least two consecutive waves from Waves 2-7.5 (approximately 2015-2023) of the nationally representative Population Assessment of Tobacco and Health (PATH) Study. We also estimated transitions stratified by ages 12-14 and 15-17 years. ResultsThe one-year probability of ENDS-only initiation from never use among youth peaked in 2017-19 (Waves 4-5) at 4.0% (95%CI: 3.6-4.3%) and was higher for 15-17-year-olds at 5.8% (95%CI: 5.2-6.4%) than 12-14-year-olds at 2.2% (95%CI: 1.8-2.6%). In the following years, ENDS-only initiation rates declined and plateaued, with 2.6% (95%CI: 2.3-3.0%) initiation in 2022-23. Cigarette initiation from never use decreased over 2015- 23 from 0.8% (95%CI: 0.6-1.0%) in 2015-16 to 0.1% (95%CI: 0.0-0.2%) in 2022-23. There was an increase in the fraction of youth who transitioned from non-current product use to ENDS-only use from 13.7% (95%CI: 7.5-20.0%) in 2015-16 to 35.1% (95%CI: 25.4-44.8%) in 2022-23, paired with a decrease in non-current use to cigarette use from 20.9% (95%CI: 11.8-30.0%) to 6.3% (95%CI: 1.7-10.8%). Transitions from ENDS-only or cigarette use to non-current use remained relatively constant over time at around 25% and 15% per year, respectively. ConclusionENDS-only use initiation has changed over time, peaking around 2019 and subsequently decreasing and plateauing, but cessation rates for both ENDS and cigarettes have remained relatively stable. Thus, interruption of tobacco product initiation may be the most effective approach to reducing tobacco product use among youth. What this paper addsWhat is already known on this topic: O_LITransitions in cigarette and ENDS use have changed over time, with youth more likely to adopt ENDS and less likely to adopt cigarettes than older age groups. C_LI What this study adds O_LIWe found that ENDS initiation among youth peaked around 2019 and was higher for those 15-17 years than 12-14 years. There were few significant differences between the two age groups for other transitions. C_LIO_LICigarette initiation among youth declined over this period. Cessation rates for both ENDS and cigarettes have remained relatively stable. C_LI How this study might affect research, practice or policy O_LITobacco control efforts should prioritize preventing all tobacco and nicotine product initiation among youth. C_LI

BackgroundDisparities in injury and death indicate that Latinos and Hispanics are disproportionately affected by firearm violence. Understanding the factors that impact Latino and Hispanic engagement with firearm safety is integral to developing nuanced interventions, yet these factors remain largely understudied. This study explores the social ecological factors related to firearm safety engagement among Latino and Hispanic adults residing in New Mexico. MethodsThe study used a convergent mixed-methods design with quantitative and qualitative components. Data were collected from a predominantly Latino-Hispanic community experiencing high rates of firearm violence near Albuquerque, New Mexico. Quantitative data (n=303) were collected using a community-based survey with a non-random sample on firearm safety engagement, collective efficacy, and sociodemographic characteristics. Qualitative data (n=18) included semi-structured interviews from a subset of the survey population who expressed interest in participating. Quantitative data was used to explore descriptive statistics and correlations between reported levels of collective efficacy and firearm safety engagement. Qualitative data were used to explore the firearm safety experiences of Latino and Hispanic participants. AnalysesMultivariate regression analyses examined associations between collective efficacy (exposure) and engagement with firearm safety (outcome). I also explored associations across key domains: collective efficacy, neighborhood characteristics, individual characteristics, and sociodemographic factors. Interviews were analyzed using framework analysis to generate a cohesive thematic structure informed by a social ecological model. The results from the quantitative and qualitative data were then integrated to develop a robust understanding of social ecological factors related to firearm safety engagement using a mixed methods joint display. ResultsThere were 303 survey participants (40.6% male; 55.1% female; 4.3% other gender identity) and 18 interview participants in this study. 57.1% of survey participants reported engaging with at least one firearm safety practice or initiative. Results from multivariate regression indicated that higher collective efficacy ({beta} = 0.082, p = 0.002), higher informal social control ({beta} = 0.174, p = 0.001), stronger endorsement of gun safety principles ({beta} = 0.079, p < 0.001), being married vs. unmarried ({beta} = -0.334, p < 0.001), speaking Spanish in the home vs. English ({beta} = 1.048, p < 0.001), and not owning a gun ({beta} = - 0.638, p = 0.006) were significantly and positively associated with firearm safety engagement. Themes from the qualitative data included barriers (insecure environment; lack of meaningful engagement) and facilitators (location-specific contributors to safety; collective identity and pride) to firearm safety engagement, organized by social ecological domain. Mixed methods findings indicate factors associated with participants individual firearm safety engagement, while providing insights into the perceived barriers and facilitators across social ecological domains. DiscussionFindings from this mixed-methods study suggest that processes of empowerment and collective efficacy may contribute to greater firearm safety engagement within Latino and Hispanic communities. Findings expand injury prevention research by exploring the factors influencing firearm safety engagement among a marginalized and hard-to-reach population who have disproportionate experiences with firearm victimization, perpetration, and injury. ConclusionThis study offers unique methodological approaches by using concurrent mixed methods and collecting complementary data sources to understand firearm safety engagement among Latinos and Hispanics. Findings highlight the need for culturally specific and community-engaged interventions that address social ecological disparities to strengthen safety practices and reduce firearm-related harms.

BackgroundSurgery is a widely used treatment option but the impact of surgery on long-term disease across socioeconomic groups is unknown. MethodsLongitudinal population study using linked primary and secondary care data describing adults ([&ge;]18 years) in England recorded in the Clinical Practice Research Datalink (CPRD) between 1st January 2012 and 31st December 2021. Socioeconomic deprivation was defined using the Index of Multiple Deprivation (IMD). The exposure was surgery and primary outcome was long-term disease. Data are presented as n (%), median (IQR), and adjusted hazards ratios (HR) with 95% confidence intervals. FindingsOf 18,329,659 people, 8,951,145 (48{middle dot}8%) underwent surgery. 78{middle dot}6% of index surgeries were elective (n=7,032,475), 21{middle dot}4% were emergency (n=1,918,670). Amongst surgical patients, 4,741,188 (52{middle dot}0%) were women, 3,540,136 (39{middle dot}6%) from the most deprived deciles (IMD 1-4) and 994,595 (11{middle dot}1%) from a minority ethnic group. Age-standardised rates of surgery were higher in deprived individuals (comparative rate ratio IMD 1 vs. IMD 10 elective: 1{middle dot}11 (95% CI 1{middle dot}11-1{middle dot}11), emergency: 1{middle dot}54 (1{middle dot}54-1{middle dot}54)). Age at first surgery was 42 (27-60) years for elective and 42 (25-65) years for emergency surgery overall, but lower for people from IMD 1-4 (elective: 39 (26-57) years, emergency: 38 (24-60) years). Rates of long-term disease increased following both elective (baseline 19{middle dot}6%, three years 24{middle dot}5%) and emergency surgery (baseline 10{middle dot}3%, three years 12{middle dot}3%). Risk of new long-term disease following surgery increased with increasing levels of deprivation (IMD 1 vs. IMD 10 elective: HR 1{middle dot}46 (1{middle dot}45-1{middle dot}48), emergency: HR 1{middle dot}46 (1{middle dot}44-1{middle dot}48)). InterpretationSurgical treatment is strongly associated with the onset of long-term disease and factors which limit healthy life expectancy. Surgery occurs at a younger age among socioeconomically deprived groups and may be linked to health inequalities. Similar but more complex patterns of inequality were seen in minority ethnic groups. FundingBarts Charity and UK Academy of Medical Sciences. Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSThe impact of surgery on long-term health outcomes beyond mortality and surgical complications such as persistent pain is unknown. People from deprived socioeconomic and minority ethnic groups experience increased risks of postoperative complications, readmissions, and death. We searched PubMed, for English language publications in adults aged over 19 years, over the last 10 years to 10th February 2026 using the following search terms: (surg* OR operat*) AND (long-term outcome OR chronic disease OR comorbidit* OR co-morbidit* OR multimorbidit* OR multi-morbidity*) AND (ethnic* OR race OR racial OR socio* OR depriv* OR ineq* OR disparit*). We identified 7,979 reports. To our knowledge, no previous studies have examined the development of long-term disease following surgery or differences in long-term outcomes following surgery between different socioeconomic and ethnic groups. Added value of this studyThis large national cohort study is to our knowledge the first to examine the relationship between surgery and onset of long-term disease. We included over 18{middle dot}3 million individuals, of whom 48{middle dot}8% underwent a surgical procedure during the study period. 5% of elective surgical patients and 2% of emergency surgical patients developed new long-term disease within three years of surgery. Accounting for differences in age, people from the most deprived decile experienced 11% higher rates of elective and 54% higher rates of emergency surgery compared to the least deprived. People in the most deprived decile underwent their first surgery nearly ten years earlier than those in the least deprived decile with a 46% higher risk of developing new long-term disease within three years of surgery. Although age standardised rates of surgery were lower, people from minority ethnic backgrounds underwent surgery for the first time up to sixteen years earlier that those from white backgrounds and had similarly had higher risk of developing new long-term disease at three years. Implications of all the available evidenceSurgical treatments are associated with onset of long-term disease. This unexpected consequence should be considered when managing patients expectations when planning surgery with them. There are important inequalities in rates of both elective and emergency surgery, and the age this first occurs, between different socioeconomic and ethnic groups. Those from socioeconomically deprived backgrounds and minority ethnic groups undergo surgery at a younger age and are also at greater risk of developing long-term disease and hence reduced healthy life expectancy. One explanation for this may be differences in lifestyle and disease prevention behaviour. Surgery is therefore an important marker for inequalities in healthy life expectancy. The perioperative period is a key opportunity to better manage long-term health to reduce further inequalities. The patterns of these relationships are complex, and a more detailed understanding is needed to ensure that surgery can be better utilised as an opportunity to improve societal health.

BackgroundYoung sexual and gender minorities of color face compound health risks shaped by interlocking systems of racism, cisgenderism, and class inequality. Spatial health research documents that place shapes health, but existing methods cannot specify the mechanisms through which spatial configurations produce different health outcomes for differently positioned people. This gap prevents targeted intervention. ObjectiveTo develop and pilot test the Spatial Intersectionality Health Framework (SIHF), which specifies three mechanisms through which space produces intersectional health inequities: Layered (multiple oppressive systems activating simultaneously), Positional (the same space producing different health pathways by intersectional position), and Conditional (nominally protective spaces carrying hidden costs for specific positions). We also introduce and validate Intersectional Geographically-Explicit Ecological Momentary Assessment (IGEMA) as the methodology operationalizing SIHF across three data levels. MethodsThe GeoSense study enrolled 32 young sexual and gender minorities of color (ages 18-29) in New York City. IGEMA was implemented across three integrated levels: (1) GPS mobility tracking via participants personal smartphones, linked to census tract structural exposure indices across n=19 participants; (2) ecological momentary assessment of intersectional discrimination with multilevel modeling of mood, stress, and sleep outcomes; and (3) map-guided qualitative interviews with SIHF mechanism coding and intercoder reliability assessment across 92 coded records from 18 participants. This study was conducted as the pilot for NIH R01HL169503. ResultsAll three SIHF mechanisms were empirically detectable. A compound structural gendered racism index outperformed every single-axis alternative in predicting daily mood (b=-0.048, p=.001) and stress (b=0.121, p<.001). The Positional mechanism accounted for 71% of coded harm experiences. Intercoder reliability for mechanism assignment reached kappa=0.824 at Stage 2 reconciliation. Daily intersectional discrimination predicted greater sleep disturbance (b=1.308, p=.004). ConclusionsSIHF and IGEMA together provide an empirically testable framework for specifying how space produces intersectional health inequities. Mechanism specification, not spatial location alone, is the condition for designing research and intervention that reaches the source of harm for multiply marginalized populations.

This study investigated retirement adjustment in retired police officers in the UK (N = 289), examining how time since leaving the service moderates the relationship between perceived organisational support and retirement adjustment while accounting for resilience. Results indicated a developmental trend: organisational support remains stable initially but becomes increasingly influential in later life. Using Johnson-Neyman analysis, a threshold of 32.07 years was identified, after which the association reaches statistical significance. These findings suggest an organisational legacy effect; for the older generation, the retrospective perception of being valued by the service acts as a durable psychological resource. This study offers a novel conceptualisation of long-term organisational influence by identifying a temporally delayed legacy effect that extends beyond existing models of retirement adjustment. The study advocate for lifelong wellbeing strategies that extend, recognising that the organisational relationship continues to shape adjustment outcomes decades after the conclusion of active duty.

Socioeconomic inequalities in health and well-being are a major public health concern, particularly in ageing populations. Education is a key determinant shaping multiple aspects of health outcomes. We used cross-sectional data from wave 9 of the German sample (n=4,148) of the Survey of Health, Ageing and Retirement in Europe (SHARE) to test whether formal education is associated with well-being in later adulthood, with health literacy, self-rated health, and preventive health behaviours as possible mediators. Our results showed that education was positively associated with greater well-being, but only via indirect pathways. Specifically, self-rated health, health literacy, and fruit and vegetable consumption mediated the relationship between education and well-being accounting for 54.7, 24.7, and 12.6 percent of the total effect, respectively. In addition, there were significant positive correlations between education and health literacy, as well as high-intensity physical activity, daily fruit and vegetable consumption, more preventive health check-ups, and less smoking. In contrast, alcohol consumption was more common among those with higher levels of education. All health behaviours and health literacy were correlated directly or indirectly (i.e., mediated by health) with well-being. These findings highlight the importance of examining indirect pathways linking education to well-being in later life. Interventions aimed at improving health literacy and promoting healthy behaviours may help reduce educational inequalities in quality of life among older adults. About the SHARE Working Paper SeriesThe SHARE Working Paper Series started in 2011 and collects pre-publication versions of papers or book chapters, technical and methodological reports as well as policy papers based on SHARE data. The working papers are not reviewed by the publisher (SHARE-ERIC), layout and editing are not standardized. The publisher takes no responsibility for the scientific content of the paper. Working Papers can be updated - a version number is indicated on the front page. Previous versions are available upon request.

Objectives. To test whether the association between household income and tooth retention differs by race/ethnicity and whether this interaction varies by reason for the most recent dental visit among US adults. Methods. We analyzed 13,190 adults in the National Health and Nutrition Examination Survey (2009 to 2018). Survey weighted linear regression estimated interactions between household income and race/ethnicity in models of tooth retention, stratified by reason for last dental visit. Results. Higher income was associated with greater tooth retention across groups, but income related gains were larger for Non-Hispanic White adults than for Non Hispanic Black and Mexican American adults, particularly in problem-focused care settings. In problem focused visits, each higher income category was associated with 0.5 additional teeth among White adults (95% CI 0.4, 0.6) versus 0.2 (95% CI 0.0, 0.4) among Black adults and 0.1 (95% CI 0.1, 0.3) among Mexican American adults. Racial differences were attenuated in routine check-up contexts. Conclusions. Income related gains in tooth retention differed by race/ethnicity and dental care context. Public Health Implications. Expanding access alone may be insufficient to reduce racial inequities in oral health.

Abstract Aims To examine which demographic groups nicotine pouch advertisers chose to target on social media, and which groups Meta's algorithms actually delivered the adverts to. Design Cross-sectional analysis of advert-level data from the Meta Ad Library. Setting Meta social media platforms (including Facebook and Instagram) in the UK. Cases A random sample of 741 nicotine pouch adverts shown in the 12 months up to December 2025, and a comparison sample of 1,125 general adverts. Analyses of reach were restricted to adverts eligible for all genders and adult ages (444 pouch adverts; 674 general). Measurements Outcomes were advertiser-set gender and age-group targeting criteria (i.e., groups eligible to be shown each advert) and estimated advert reach to each group (i.e., number of people who saw each advert). Male-to-female reach ratios within age groups, and reach ratios comparing age groups, were calculated per advert and summarised using geometric means. To assess whether patterns were pouch-specific, comparisons with general adverts were made using ratios of reach ratios (RRR). Findings Advertisers of nicotine pouches targeted a broad sample; most adverts (79.1%; 586/741) were eligible to be shown to all genders, the remainder were restricted to men only. All were restricted to adults (minimum age 18 years) and most (95.6%; 708/741) had no upper age limit. Despite this, of pouch adverts eligible to be shown to all adults, adverts were more likely to reach men, particularly among younger men. Among 18-24-year-olds, pouch adverts reached around ten times as many men as women (RR 10.0, 95% CI 8.7-11.5), compared with a slight skew towards women for general adverts (RR 0.81, 95% CI 0.71-0.94), corresponding to an RRR of 12.3 (95% CI 10.0-15.1). Pouch adverts also showed a skew in reach towards younger age groups. Relative to those aged 35-44 years, reach was higher among 18-24-year-olds for nicotine pouch adverts (RR 1.33, 95% CI 1.17-1.51) but much lower for general adverts (RR 0.19, 95% CI 0.17-0.21), corresponding to an RRR of 7.0 (95% CI 6.0-8.2). Conclusions Nicotine pouch adverts on social media are often eligible to be shown broadly to all demographic groups but are disproportionately delivered to young men.

BackgroundOutdoor play and limited screen time are critical for preschoolers physical health and socio-emotional development, yet little is known about how caregiver nativity and acculturation shape these behaviors. MethodsWe analyzed the 2022-2023 National Survey of Childrens Health data for 10,157 U.S. children 3-5 years old. Generalized linear models estimated associations between caregiver nativity and length of U.S. residence and childrens outdoor play and weekday screen time, adjusting for child, caregiver, and household covariates. Models tested interactions with race/ethnicity. ResultsOverall, caregiver length of U.S. residence was not associated with childrens outdoor play. However, screen time differed - children whose caregivers arrived Pre-1997 had lower odds of screen time frequency, whereas those whose caregivers arrived between 1997-2005 had higher odds compared with children of U.S.-born caregivers. Associations for weekday outdoor play and screentime varied significantly by child race/ethnicity. ConclusionsCaregiver length of U.S. residence appears more strongly related to preschoolers screen time than outdoor play, with notable differences across racial/ethnic groups. Culturally tailored strategies may be needed to reduce early childhood screen exposure and support healthy movement behaviors among immigrant families.

Women filmed for pornography report extensive abuse and serious health consequences, yet pathways into pornography remain under-examined. Using an embedded qualitative mixed-methods approach, we explored factors shaping these pathways in Sweden. Twenty-five adults (23 women) who had been filmed for pornography completed questionnaires and participated in teller-focused interviews. Informed by a socio-ecological framework, our reflexive thematic analysis generated the global theme Primed for exploitation, comprising three themes: Imprints of early violence, No one has my back: Relational and institutional betrayals, and Compounding structural vulnerabilities. Our findings reveal how childhood abuse and violence, relational and institutional betrayals, material precarity, and a pornified cultural landscape converge to shape pathways into pornography. To prevent and disrupt these pathways, early identification of sexual abuse, timely access to trauma-informed care that avoids individualizing and pathologizing the consequences of violence, and practical support that addresses material precarity are critical. From a socio-ecological perspective, framing entry into pornography as a simple matter of "choice" is fundamentally flawed: it individualizes deeply social processes and obscures the profound impact of cumulative violence, repeated relational and institutional betrayals, and intersecting structural constraints.

Although the built environment has been identified as a risk factor for depressive symptoms, it is unclear whether these associations are driven by specific environmental features and whether they remain stable over time. In 10,310 ALSPAC women living in Bristol city, we conducted preregistered network analyses to investigate cross-sectional and longitudinal associations between built environment features (e.g., population density, green space and walkability) and depressive symptoms (at ages 28, 32 and 48 years). Contrary to our hypotheses, associations between individual built environment variables and depressive symptoms were consistently weak. Exploratory factor analyses indicated a built environment factor associated with depressive symptoms at baseline ({beta} = 0.148, p < .001) and 4-year follow-up ({beta} = 0.114, p = .011), but not at 18-year follow-up ({beta} = -0.005, p = .950). These findings suggest the combined influence of built environment features may explain depressive outcomes better than individual built environment measures alone.

Background and Objectives: Arts and cultural engagement may contribute to well-being in later life. However, evidence from longitudinal studies from Asia, including Japan, remains limited. This study examined the association of arts and cultural engagement with subsequent multidimensional well-being among older adults in Japan, one of the fastest-aging countries. Research Design and Methods: This longitudinal study used panel data from 354 individuals aged 60 and older (mean age 74.0 years; 78.6% women) who completed self-administered questionnaires by mail between 2022 and 2024. The PERMA-Profiler was used to assess five multifaceted aspects of psychological well-being: positive emotion, engagement, relationships, meaning, and accomplishment. Frequencies of arts and cultural engagement at baseline were measured for active (e.g., activities by individuals and participation in groups, such as music and painting) and receptive (e.g., visiting museums, galleries, and theaters) forms. Results: Multivariable linear regression analysis, adjusted for the covariates including baseline PERMA scores, showed that higher frequencies of active engagement were positively associated with higher PERMA scores for all domains. Higher frequencies of receptive engagement were associated with the domains of positive emotion, meaning, and accomplishment, but not clearly associated with engagement and relationships. Restricted cubic spline analyses suggested clearer positive frequency-response patterns for active engagement than for receptive engagement. Discussion and Implications: Arts and cultural engagement, both active and receptive forms, was associated with subsequent multiple aspects of well-being in later life. These findings suggest the importance of ensuring access to arts and cultural opportunities for older adults to create, participate, and connect.

Background Meat processing plants in Alberta, Canada experienced among North America's largest COVID-19 outbreaks. We examined health impacts among workers by occupational hierarchy and equity-relevant characteristics. Methods This exploratory sequential mixed-methods study was guided by community-based participatory research and the PROGRESS-Plus framework. Multilingual qualitative interviews and surveys using validated instruments were conducted among meat plant workers who experienced outbreaks. Interviews were analysed using inductive-deductive thematic analysis. Multivariable logistic regression and linear regression estimated associations between occupational group, racialization, facility, and self-reported COVID-19 diagnosis, physical and mental health, and mean Everyday Discrimination Scale score. We integrated findings using joint displays. Findings Qualitative and integrated analysis of thirty-six interviews described occupational hierarchy shaping unequal protection, limited communication, constrained agency, and psychosocial harms, amplified by income insecurity and family separation. Among 187 survey respondents, compared with general labour, skilled labour (aOR 0.38; 95% CI 0.15-0.89) and management (aOR 0.13; 95% CI 0.01-0.75) had lower odds of reported COVID-19 diagnosis. Compared with Black workers, other racialized workers had lower odds of reporting fair or poor mental (aOR 0.24; 95% CI 0.09-0.58) and physical health (aOR 0.20; 95% CI 0.06-0.54). Compared with workers from the primary facility, others reported lower mean everyday discrimination scores ({beta} = -0.54; 95% CI -0.96 to -0.12). Interpretation COVID-19 harms followed workplace social hierarchies. Pandemic preparedness should combine infection-control measures with paid sick leave and income protection, multilingual communication, enforceable anti-discrimination standards, and independent reporting mechanisms. Funding Canadian Institutes for Health Research (CIHR Application no. 469206). Keywords COVID-19, immigrant workers, migrants, essential workers, health equity, occupational health, PROGRESS Plus

Objective: To verify the association between perceived social & emotional support and self-reported food insecurity in the United States Design: Cross-sectional secondary data analysis Setting: Behavioral Risk Factor Surveillance System (BRFSS) data from 2024, collected via a nationwide telephone survey. Food insecurity was defined as responding always, usually, or sometimes to "During the past 12 months how often did the food that you bought not last, and you didn't have money to buy more?" Social support was measured using a BRFSS item assessing the frequency with which respondents received the social and emotional support they needed. Adjusted logistic regression models were used to assess the relationship between these variables while controlling for a wide variety of demographic, socioeconomic, and health status factors. Participants: Adults (n = 190,577) aged 18-80 years old (72.3% non-Hispanic White) Results: Individuals who reported only "sometimes" receiving the social and emotional support they need were more likely to report food insecurity as compared to those who "always" receive such support (aOR = 1.75; 95% CI 1.56, 1.96). Conclusions: These findings indicate that decreased social support may put individuals at higher risk of food insecurity. Future work should seek to understand the mechanisms of this association to inform targeted policy and other interventional programs.