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Routine vaccination is an important public health measure to prevent severe illness from COVID-19. Although the determinants of vaccine hesitancy have been explored in prior research, limited information is available on the varying perceptions of the COVID-19 vaccines among previously vaccinated individuals. This study investigates how individuals previously vaccinated against COVID-19 might develop hesitancy toward future doses, a concept that the authors define as lingering hesitancy. The authors conducted an online cross-sectional survey with 560 vaccinated respondents in 6 urban Chicago community areas (n=440) and Stephenson County, a rural county in Northern Illinois (n=120), between December 2021 and April 2022. The authors explored the role of an individual's sociocultural context (i.e., urban/rural setting, political affiliation, and race/ethnicity) in developing lingering hesitancy. Lingering hesitancy was operationalized using 2 constructs: (1) negative COVID-19 vaccine attitudes and (2) COVID-19 vaccine safety concerns. The authors also investigated whether mistrust in the government and institutions as well as barriers to accessing the COVID-19 vaccines mediate the relationship between context and lingering hesitancy. The authors found significantly higher negative attitudes toward the COVID-19 vaccines and higher safety concerns among conservative versus liberal respondents (b=0.37, p<0.001; b=0.21, p<0.01, respectively) and among urban versus rural residents (b=0.45, p<0.001; b=0.37, p<0.001). Black/African American participants reported higher vaccine safety concerns than White participants (mean=2.6 vs 2.4, p<0.05). A significant portion of lingering hesitancy among conservative and Black/African American respondents was mediated by mistrust in the government and institutions. Barriers partially mediated vaccine safety concerns among Hispanic respondents. Most public health efforts aimed at COVID-19 vaccine outreach and messaging have focused on increasing vaccine uptake, thereby targeting unvaccinated individuals. As the focus shifts toward annual COVID-19 vaccinations, it is essential to consider lingering hesitancy among those who have received previous vaccine doses. This article provides a framework for implementing vaccine-messaging campaigns that increase confidence and build trust in routine vaccinations.

This study aimed to evaluate referral physician' confidence, practices, and barriers in justifying imaging referrals, with specific focus on the impact of training, workload, and guideline accessibility on referral appropriateness. A cross-sectional survey was conducted among 167 referral physicians across various hospitals in the United Arab Emirates. A validated, self-administered questionnaire captured demographic data, referral practices, confidence levels, guideline usage, training participation, and perceived barriers to appropriate imaging justification. Data were analyzed using descriptive statistics and inferential tests, including chi-square, Mann-Whitney U, and Kruskal-Wallis tests. Although 82% of physicians reported high confidence in assessing imaging necessity, over 60% acknowledged frequent issues with referral quality. More than half (51.5%) admitted that imaging referrals were sometimes unnecessary. Training participation was significantly associated with better guideline accessibility (chi-square=50.50, p<0.001), and a small but significant association was found between confidence and experience (U=1,903, p=0.038). Key improvement strategies included enhanced physician-radiologist communication, increased training, and better guideline access. Despite high self-reported confidence, systemic and educational gaps persist in imaging referral justification. Addressing training needs and improving access to guidelines can enhance appropriateness in clinical imaging decisions.

Diet, physical activity, and sleep are behaviors occurring at regular intervals over the 24-hour period. To better understand how they interact and impact the etiology and prevention of chronic diseases, studies are needed that collect data on all 3 behaviors. This scoping review of the authors' portfolio aimed to identify cohort and interventional studies funded by the National Cancer Institute; National Heart, Lung, and Blood Institute; and National Institute of Diabetes and Digestive and Kidney Diseases that collected measures on all 3 behaviors, on 2 behaviors to better understand existing gaps, and on those with data across a 24-hour period (temporal data). Cohorts receiving National Cancer Institute funding; studies identified in the National Heart, Lung, and Blood Institute National Sleep Research Resource and National Institute of Diabetes and Digestive and Kidney Diseases Central Repository; and active National Cancer Institute, National Heart, Lung, and Blood Institute, and National Institute of Diabetes and Digestive and Kidney Diseases intervention grants in Fiscal Years 2021-2022 were reviewed. Data were collected from 2021 to 2022 and analyzed from 2022 to 2023. Twenty-nine cohort and 47 interventional studies collected data on all 3 behaviors, of which 3 cohorts and 20 interventions collected temporal data. Forty-two cohort and 160 interventional studies collected data on 2 behaviors, of which 3 cohorts and 50 interventions collected temporal data; sleep data were most commonly missing. The most common temporal measures were 24-hour dietary recalls and actigraphy. Efforts to promote the collection of temporal data on all 3 behaviors simultaneously can support innovative research questions and analytic approaches focused on their interrelationships across the 24-hour period and health outcomes among various populations. Such efforts can inform tailored interventions and precision health research.

Previous research has shown an inverse relationship between cigarette smoking and educational attainment. However, there is relatively scarce research on the relationship between cannabis use and education level. This article examines whether the inverse relationship between cigarette smoking and educational attainment applies to cannabis use. The 2023 California Health Interview Survey, a representative population-based survey of California adults that assesses health behaviors, was analyzed to examine current cigarette smoking and cannabis use prevalence. Logistic regression was used to examine the association between cigarette smoking/cannabis use and educational attainment among adults aged >26 years (N=20,557), adjusting for age, sex, and race/ethnicity. In 2023, among California adults aged >26 years, current cannabis use prevalence was more than twice as high (13.5%) as current cigarette use prevalence (6.1%). Compared to the odds of being a current cannabis user for those who did not graduate high school, the odds were 2.05 times as high (95% CI=1.35, 3.12) for those who completed high school, 2.57 times as high (95% CI=1.73, 3.80) for those with some college education, and 2.17 times as high (95% CI=1.46, 3.23) for those who completed college. Compared to the odds of being a current cigarette smoker for those who did not graduate high school, the odds were 0.31 times as high (95% CI=0.22, 0.43) for those who completed college. Adults with higher education levels were more likely to be cannabis users than those with less education, which was inverse to the relationship between cigarette smoking and education. Efforts to prevent and reduce cannabis use should have additional focus on those who have completed high school and college.

There are important workplace health lessons to be learned from the pandemic. This study summarizes the relationships between workplace safety practices, fear, resources, and employee engagement during the COVID-19 pandemic through a narrative review on articles published between January 2020 and June 2025 using a primary literature search base. Organizations have had to implement workplace safety management practices aligned with their occupational safety and health management systems in response to COVID-19. Safety management practices include safety initiatives and training as well as employee involvement. Methods to increase employee involvement include fear and anxiety. However, although fear and anxiety promote safety compliance and safe behavior, they also wear down employees and increase their work distraction and turnover intentions. Therefore, social and psychological resources need to be strengthened to overcome this dilemma. These resources can also help safety management practices today as the pandemic begins to wind down. Future research should focus on identifying ways to strengthen employees' social and psychological resources without relying on disasters. To this end, an integration of conservation of resource theory and behavioral theory may be useful.

Globally, COVID-19 has caused widespread morbidity and mortality, with comorbidities and demographic disparities shaping risk of severe illness. Although much focus has been on high-population areas and areas with deep public health responses, relatively few studies have examined the Southwestern U.S., particularly the interborder region with Mexico. This study investigates how the COVID-19 pandemic affected patients with common comorbid conditions and examines and compares outcomes in border counties and selected nonborder counties in southern New Mexico. The data set of COVID-19-positive patients (N=93,586) was collected from the New Mexico Department of Health (June 2020-December 2022). This study examined the associations between demographic characteristics; underlying comorbidities; and COVID-19 outcomes, including hospitalization and death. The patients assessed were more likely to be female (54.8%), Hispanic (48.5%), and border county residents (95.7%). Of all patients, 4,445 (4.8%) were hospitalized, and 1,517 (1.6%) died. Hispanics were associated with higher deaths (OR=1.60; 95% CI=1.28, 1.99), whereas hospitalization did not differ by ethnicity (p=0.072). Nonborder resident status (p<0.001) and pre-existing conditions were significantly associated with increased risk of hospitalization (OR=4.87; 95% CI=3.99, 6.00) and mortality (OR=2.92; 95% CI=1.72, 5.33). All comorbidities except psychiatric conditions were risk factors for severity and all-cause mortality (all p<0.001). This study identified key demographic and clinical factors associated with SARS-CoV-2 outcomes in the New Mexico-Mexico border region. Older age, male adults, residence in nonborder counties, and pre-existing medical conditions were significant predictors of hospitalization and mortality, with several comorbidities showing particularly strong associations. Unlike other studies, in the New Mexico/Mexico region, the greater access to screening and medical services in border zones, given the proximity to 2 larger cities (Las Cruces, NM and El Paso, TX), resulted in improved outcomes than in less well-resourced counties in New Mexico. State departments of health should target state regions with less access to nearby populated areas for their efforts to mitigate these disparities and improve health outcomes.

Studies have shown that patient portals facilitate cancer screening, but less is known about how. Causal pathway diagrams, which include influencing factors such as mechanisms and moderators, can be used to understand how portals improve screening. The authors conducted a scoping review of influencing factors to inform early causal pathway diagrams of the portal as a strategy to increase cancer screening. The authors searched PubMed for U.S. studies published from 2014 to 2024, including average-risk patients; portal interventions/evaluations; and primary outcomes of breast, cervical, colorectal, or lung cancer screening. Two authors completed manuscript screening and data extraction and synthesized findings to create causal pathway diagrams. Thirty-two studies met inclusion criteria. Studies were often set in large academic health systems (n=13) or utilized survey data from nationally representative cohorts (n=11); 6 were RCTs. Most studies focused on breast (n=10) or colorectal (n=9) cancer screening. Of 21 studies comparing portal use with no use, 18 found that portals were associated with increased screening. Most proposed influencing factors were hypothetical, citing findings from prior literature rather than observed directly. Of the 10 studies that performed statistical analysis, significant moderators included provider recommendation for self-scheduling; significant mechanisms included cancer worry and patient activation for general portal use, cancer fatalism and patient activation for secure messaging with providers, and choice architecture for interventions delivered through secure messaging. Few studies directly tested influencing factors, suggesting a significant research gap. More research is needed to further evaluate proposed mechanisms to understand how portals facilitate cancer screening and optimize implementation. The protocol for this scoping review was registered through Open Science Framework.

Vaccine hesitancy poses a hurdle toward achieving high population-level immunity and reducing disease transmission. One policy response adopted during the COVID-19 vaccination campaign was the implementation of vaccination-differentiated public health and social measures. This paper aims to evaluate the impact of vaccination-differentiated public health and social measures on COVID-19 vaccination rates in Singapore, with a specific focus on vaccine-hesitant persons. An interrupted time series design with segmented linear regression was utilized to assess the impact of the announcement of each vaccination-differentiated public health and social measure on vaccine uptake rates among the vaccine-naive population. Newey-West standard errors with a 7-day lag were applied to address potential autocorrelation in the data. Covariates adjusted for included day of the week, daily numbers of COVID-19-related cases, deaths, hospitalizations, and patients in the intensive care unit. The study found a significant and positive effect of vaccination-differentiated public health and social measure announcements on the daily vaccine uptake rate among the vaccine-naive population, specifically for dining out and patronizing shopping malls. When stratified by age group, the significant and positive effect of the announcement of mall access vaccination-differentiated public health and social measures persisted across all age groups, and it only persisted for individuals aged 13-17, 25-34, and 35-49 years for the announcement of dining vaccination-differentiated public health and social measures. Overall, the findings support the effectiveness of vaccination-differentiated public health and social measures in increasing vaccine uptake rates among vaccine-hesitant persons. However, the compelling evidence for complementary policies should also be considered.

The utilization of Extreme Risk Protection Orders (ERPOs) throughout Colorado varies regionally. Given the potential of ERPOs to decrease firearm violence, this study aims to explore community acceptability of ERPOs in Colorado and to compare acceptability among regions. The cross-sectional 2023 Colorado Firearm Injury Prevention Survey was administered to 1,520 Colorado adults across 4 geographic regions. Respondents ranked the appropriateness of ERPOs in 5 high-risk scenarios to assess acceptability. Responses were weighted to represent each region's population, and differences in acceptability were analyzed using logistic regression. More than 70% of Colorado adults across all regions deemed ERPOs at least sometimes appropriate in all 5 scenarios. Although there were minimal regional differences in ERPO acceptability, the West/South region was significantly less likely than other regions to say ERPOs were at least sometimes appropriate in 2 of 5 scenarios (p<0.01). Community support for ERPOs is generally high across culturally diverse Colorado regions, suggesting that the acceptability of ERPOs as a violence prevention intervention might not align with regional disparities in ERPO utilization. Few regional differences in acceptability underscore the need to align ERPO application and educational efforts with this widespread public support. Policymakers and public health professionals should challenge narratives purporting low public support for ERPOs and prioritize the education of community members about how and when ERPOs could be useful.

This study aimed to assess the association between tobacco use patterns and cigarette smoking cessation in a representative cohort of adults who smoked combustible cigarettes in the U.S. Study included current cigarette smoking adults in Wave 4 of the Population Assessment of Health and Tobacco study (N=5,669). Patterns of use were exclusive cigarette smoking, dual cigar and cigarette smoking, dual ENDS use, and multiple product use (poly use). Abstinence status (cessation) was obtained from Population Assessment of Health and Tobacco study Wave 5 and defined as abstinent &#x2265;3 months. Weighted multivariable logistic regression analyses were performed. Analyses were completed in June 2024. Exclusive cigarette smoking was 82.0%, and dual cigar smoking and dual ENDS use constituted 3.7% and 4.4%, respectively. Of adults who smoked cigarettes, 25.7% were abstinent &#x2265;3 months at follow-up. Adults with dual cigar smoking (20.8%) were more likely to be abstinent &#x2265;3 months than those who smoked cigarettes exclusively (10.0%). Adults reporting dual cigar smoking had higher odds of being 3-month abstinent than those reporting exclusive cigarette smoking (OR=2.60, 95% CI=1.60, 4.21). Dual cigar smoking is positively associated with smoking abstinence in adults 1 year later. A deeper understanding of the dynamics and characteristics of dual cigar smoking that rendered cigarette smoking cessation more likely is needed. The data did not offer supporting evidence for dual ENDS use as a cessation aid. The majority of smoking cessation was achieved without the use of assistance.

This study was aimed to evaluate follow-up after benign or low-grade colposcopic findings and identify the factors associated with delayed care. The authors completed a retrospective study to evaluate follow-up for patients with benign or low-grade colposcopy findings over a 4-year period at a single institution. Demographics as well as cotesting and pathology results were abstracted. Descriptive statistics and bivariate associations were completed. Of 393 patients, 20.6% had an on-time follow-up. The majority of patients (50.4%) had delayed follow-up, with a mean time to repeat evaluation of 27.6 months. There were no differences in follow-up cytology and human papillomavirus test results between those patients who followed up within 12 months and those who were evaluated later. Tobacco nonsmoking and initial biopsy with indeterminate findings were associated with on-time follow-up. This study demonstrated significant delays in follow-up after colposcopy, consistent with prior work showing insufficient cervical cancer screening and prevention nationally. Improving follow-up times and rates will likely depend on addressing barriers that impact access to care.

The Framework Convention on Tobacco Control includes tobacco price promotion bans as a part of a comprehensive tobacco control strategy. The authors examined how U.S. adults who use commercial tobacco would react to a hypothetical national ban on tobacco price promotions. Data were from a cross-sectional survey of a nationally representative sample of U.S. adults (aged &#x2265;21 years) between March and May 2024. Participants who used discount coupons and price promotions during the 12 months prior to the survey and were currently using commercial tobacco (N=608) reported whether they would engage in a list of behaviors more frequently to save money on tobacco (e.g., buying a cheaper brand, quitting tobacco and E-cigarette use) in the case of a national ban on tobacco discount coupons and price promotions. Weighted prevalence of these behaviors and predicted marginal probabilities by demographics were estimated. Among U.S. adults who used tobacco discount coupons and promotions, 33.1% reported that they would quit using tobacco and E-cigarettes in response to a nationwide ban on tobacco price promotions. However, 95.9% reported that they would engage in tobacco expenditure minimizing strategies more frequently (e.g., finding less expensive places to buy cigarettes or E-cigarettes=73.0%, purchasing by bulk=58.7%, using a cheaper form of tobacco=38.7%). The probabilities of engaging in these strategies varied somewhat by demographics. Although a national ban on tobacco price promotions may promote tobacco use cessation, most adults who used tobacco price promotions would increase tobacco expenditure minimizing strategies use to continue commercial tobacco use, highlighting the importance of simultaneously addressing shifts in tobacco expenditure minimizing strategies use.

People who smoke nondaily represent nearly one third of U.S. adults who smoke and experience significant smoking-related morbidity and mortality, yet they are rarely considered when evaluating the efficacy of graphic cigarette warnings. In October 2019, U.S. adults who smoked nondaily (n=59) and daily (n=183) evaluated 13 Food and Drug Administration-proposed graphic warnings and 13 equivalent text-only warnings on the extent to which they elicited understanding, perceived new knowledge, worry about smoking, and discouragement to smoke and were believable. Repeated-measures ANOVA and planned comparisons tested for between-subjects (smoking status) and within-subjects (warning type) effects. The strength of within-subjects effects were characterized using Cohen's dp and Common Language Effect Size. Finally, repeated-measures ANCOVAs evaluated whether demographic characteristics (e.g., race/ethnicity) that differed between adults smoking nondaily and daily were associated with within-subject evaluations of graphic versus text-only warnings. Adults who smoked nondaily (versus daily) were younger (p<0.001); more educated (p<0.001); and less likely to be non-Hispanic White (p=0.04), to be female (p=0.04), or to intend to quit within 6 months (p<0.001). Adults smoking nondaily (versus daily) rated graphic warnings as eliciting more discouragement to smoke (p=0.045). Graphic (versus text) warning evaluations were stronger for all outcomes in both groups (p<0.001). The effect sizes for graphic warnings were substantially larger among adults smoking nondaily for discouragement and believability (dp difference >0.10). Race/ethnicity moderated evaluations of discouragement (p=0.03) and believability (p=0.01) among adults smoking nondaily and daily. The capacity of graphic warnings to elicit responses associated with motivation to quit smoking may be particularly robust for adults smoking nondaily. That graphic warnings discourage smoking is promising for this underserved group of people who smoke.

The prevalence of chronic kidney disease among persons with diabetes in the U.S. appears to be decreasing. Understanding the reasons for this decrease is an important health policy issue. Data on 7,320 adults with diabetes from National Health and Nutrition Examination Survey (1999-2018) were examined to estimate the prevalence of chronic kidney disease in 4-year cohorts. Chronic kidney disease was defined by an estimated glomerular filtration rate <60 ml/min/1.73m2 or urine albumin-to-creatinine ratio &#x2265;30 mg/g. Diabetes and hypertension were defined by combination of self-report, medication, or laboratory detection. Weighted logistic regression models adjusting for demographics, comorbidities, angiotensin-converting enzyme inhibitor/angiotensin-2 receptor blocker medication, smoking, diet, and physical activity were used to assess change in chronic kidney disease prevalence over time. The prevalence of chronic kidney disease among individuals with diabetes decreased from 40.5% to 35.4% over 20 years (p=0.02) with a decline of &#x223c;5% during each 4-year period (OR=0.95, 95% CI=0.90, 0.99) and &#x223c;7% per 4-year period (OR=0.93, 95% CI=0.88, 0.98) for albuminuria. The reduction in chronic kidney disease prevalence was greater after adjusting for demographics (OR=0.92, 95% CI=0.88, 0.97). After adjusting for glucose; blood pressure; medication use; and health behaviors, including smoking, diet, and physical activity, the decreasing trend became nonstatistically significant (OR=0.95, 95% CI=0.90, 1.00), suggesting that these factors may have played a role in the lower chronic kidney disease prevalence over time. No decrease in chronic kidney disease was seen among individuals with hypertension. The prevalence of chronic kidney disease among participants with diabetes has decreased steadily in the U.S. over the past 20 years, mostly from reductions in the prevalence of albuminuria. Improvements in medical management may explain part of the decrease. Individuals adopting healthy lifestyle behaviors may further explain the decrease.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) supports low-income mothers and children aged <5 years in the U.S. with nutrition and healthcare resources; however, not all eligible individuals participate. This scoping review aimed to synthesize evidence on factors associated with WIC participation from the perspective of WIC program implementers; WIC participants; and WIC-eligible nonparticipants. Qualitative, quantitative, and mixed-methods studies published between March 2019 and December 2024 in peer-reviewed journals were included. Eligible studies were U.S. based, were published in English, and included at least 12 participants. Systematic searches were conducted across the following databases: MEDLINE, PsycINFO, Cochrane Library, Web of Science, and Scopus. Screening and data extraction were completed in Covidence, and the study quality was assessed using the Mixed Methods Appraisal Tool. Among 33 studies included, 15 were qualitative (45.4%), 13 were quantitative (39.3%), and 5 were mixed methods (15.1%). On average, studies met 85.1% of the quality criteria. Overall, the most commonly assessed barriers and enablers were at the organizational level-particularly program logistics and staff interactions. For individual factors, the most assessed concepts were knowledge, awareness, perceptions, and feelings about Special Supplemental Nutrition Program for Women, Infants, and Children. Fewer studies examined interpersonal (n=6) or community/cultural (n=5) factors, although participants frequently reported a lack of culturally relevant food options and mixed experiences with staff interactions. In summary, there are multiple factors at the individual, interpersonal, organizational, and structural levels that are associated with WIC participation. Barriers and enablers at the individual and organizational levels were most common in the published literature from 2019 to 2024. Although the overall study quality was moderate to high, findings across levels were mixed.

Cognition is influenced by the neighborhood social and built environment, but the underlying mechanisms through which neighborhood environments affect cognition are unclear and may differ by race/ethnicity. The authors tested the hypothesis that sleep mediates the association between environmental characteristics and cognition. The authors also explored environment-sleep-cognition interrelationships separately for non-Hispanic White, non-Hispanic Black, and Hispanic older adults in the U.S. Analyses included older adults from Round 2 of the National Social Life, Health, and Aging Project (N=3,111). The social environment latent variable was constructed using indicators for social cohesion, social ties, and perceived neighborhood danger. The built environment was operationalized using indicators for litter, noise, traffic, pollution, and building conditions. Gross cognitive ability was characterized using the Chicago Cognitive Function Measure as an estimate of Montreal Cognitive Assessment scores. Actigraphic sleep characteristics included sleep fragmentation, time spent awake after sleep onset, and sleep percentage. Participants with better cognition lived in supportive social environments and less hazardous, disruptive (e.g., noisy, polluted) built environments. The sleep mediation hypothesis was partially supported in the full sample: time spent awake after sleep onset mediated the social environment-cognition relationship, but sleep characteristics did not mediate the built environment-cognition relationship. However, in exploratory subgroup analyses, sleep mediated the social environment-cognition relationship among White older adults and mediated the built environment-cognition relationship among Black older adults. Sleep did not mediate any environment-cognition relationships among Hispanic older adults. These results demonstrate that although the social and built environment influence cognition directly and indirectly through sleep, the mediational pathways may vary by specific racial/ethnic subgroups.

Skin cancer remains a major public health concern, and White individuals carry the highest lifetime risk and mortality. Ultraviolet exposure and sunburn are well-established skin cancer risk factors, yet regular sunscreen use remains low among U.S. adults. Few studies have assessed barriers to sunscreen use in the U.S., and prior studies are often geographically or demographically limited, restricting comparability among subgroups. A cross-sectional online panel survey of White U.S. adults (N=739) was developed and administered. Participants selected all personally relevant barriers, followed by their top barrier. Descriptive statistics summarized perceived barriers to sunscreen use. Separate multivariable logistic regression models explored the associations between demographic characteristics and barrier endorsement. Overall, 20.3% of participants reported no barriers. The most commonly endorsed barriers were forgetting to bring or apply sunscreen (52.1%), disliking the feel or smell (24.2%), cost (21.7%), inconvenience (20.3%), preference for being tanned (14.1%), and difficulty in selecting an appropriate sunscreen (12.6%). Younger cohorts had greater odds of reporting at least 1 barrier than baby boomers. Generational differences were observed for forgetfulness, inconvenience, product selection, and tanning preference. Men had lower odds of endorsing a preference for being tanned than women. Skin phototype was associated with differences in cost, tanning preference, forgetfulness, and product selection. Differences in barriers were also observed for marital status, education, and income. Findings support audience-segmented approaches to improve sunscreen use by gender, generation, skin phototype, and socioeconomic factors. Individual-level strategies include integrating sunscreen into daily routines and using cues to action to support bringing, applying, and reapplying sunscreen. Multilevel approaches that shift tanning norms, improve product acceptability, strengthen product selection guidance, and reduce cost may further reduce barriers and support sustained use.

This study was aimed to examine the bidirectional relationships and patterns of concurrent smokeless tobacco and alcohol use among U.S. high-school students, investigating whether demographic characteristics and behavioral factors differentially predict concurrent versus single substance use of smokeless tobacco or alcohol (referred to as either-alone use in the remaining parts of this paper). Analysis of nationally representative Youth Risk Behavior Survey data was perfomed, combining 3 cross-sectional surveys (2019, 2021, 2023) from 39,164 students in Grades 9-12. Logistic regression examined the bidirectional smokeless tobacco-alcohol associations, whereas multinomial models compared the characteristics of concurrent users, users of smokeless tobacco or alcohol alone, and nonusers. The authors found a strong bidirectional relationship: smokeless tobacco users had 3.8 times higher odds of alcohol use than non-users, and similarly, alcohol users had 4.5 times higher odds of smokeless tobacco use than non-users, adjusting for covariates. This relationship was asymmetric: 84.5% of smokeless tobacco users reported alcohol use, whereas only 7.8% of alcohol users reported smokeless tobacco use. Males had lower odds of either-alone use but 2.2 times greater odds of concurrent use (relative to neither use) than females. Past-year sports participation was associated with smokeless tobacco use and alcohol use as well as concurrent use, with athletes showing 2.2 times higher odds of concurrent use relative to neither use and 1.4 times higher odds of concurrent use relative to either-alone use than nonathletes. Furthermore, combustible tobacco users and E-cigarette users were more likely to be concurrent smokeless tobacco and alcohol users. The strong yet asymmetric relationship suggests that smokeless tobacco users may be a crucial target for alcohol prevention. The distinct risk patterns for concurrent use-particularly among males and other tobacco users-indicate that prevention strategies should likely differ between concurrent and either-alone use. Results also suggest reconsidering how substance use prevention is approached in sports contexts, particularly given the strong association between athletic participation and concurrent smokeless tobacco and alcohol use.

Firearms account for more than half of U.S. suicide deaths and nearly two thirds of all firearm-related deaths; although men are more likely to use a firearm than other lethal means, firearms account for approximately a third of suicide deaths for women. Suicide deaths involving firearms tend to be higher in states with fewer state firearm restrictions, with fewer suicide deaths involving firearms in states with more restrictive firearm laws. Critically, firearm storage practices are associated with an increased risk of both intentional and unintentional injury. The purpose of this study was to explore the experiences, attitudes, and practices of women firearm owners in New Jersey and Ohio to inform firearm-specific suicide prevention recommendations. The authors conducted semistructured qualitative interviews with 40-women firearm owners from New Jersey and Ohio between January and July of 2023. Transcripts were analyzed through thematic analysis using an inductive approach. Nearly half of all participants (47.5%) reported at least 1 loaded firearm, with 50% reporting at least 1 unlocked firearm, and 11 (27.5%) reported at least 1 firearm that was both loaded and unlocked. Slightly fewer women reported storing firearms securely in New Jersey than in Ohio. The authors identified 5 common motivators in the storage practices of women, which included safety, upbringing and education, household composition, accessibility versus security, personal experiences of violence and victimization. Future research should explore unique opportunities to improve firearm risk communication and lethal means safety counseling among women and other underrepresented firearm owners to prevent intentional and unintentional firearm injury.