The Impact of Influencers on Cigar Promotions: A Content Analysis of Large Cigar and Swisher Sweets Videos on TikTok

Little is known about the content, promotions, and individuals in cigar-related videos on TikTok. TikTok videos with large cigar and Swisher Sweets-related hashtags between July 2016 and September 2020 were analyzed. Follower count was used to identify influencers. We compared content characteristics and demographics of featured individuals between cigar types, and by influencer status. We also examined the association between content characteristics and video engagement. Compared to large cigar videos, Swisher Sweets videos were more likely to feature arts and crafts with cigar packages, cannabis use, and flavored products. In addition, Swisher Sweets videos were also more likely to feature females, Black individuals, and younger individuals. Both Swisher Sweets and large cigar influencers posted more videos of cigar purchasing behaviors than non-influencers, which was associated with more video views. None of the videos disclosed sponsorship with #ad or #sponsored. Videos containing the use of cigar packages for arts and crafts, and flavored products highlight the importance of colorful packaging and flavors in the appeal of Swisher Sweets cigars, lending support for plain packaging requirements and the prohibition of flavors in cigar products to decrease the appeal of cigars. The presence and broad reach of cigar promotions on TikTok requires stricter enforcement of anti-tobacco promotion policies

Critical differences between elective and emergency surgery: Identifying domains for quality improvement in emergency general surgery

Objective: The objective of our study was to characterize providers\u27 impressions of factors contributing to disproportionate rates of morbidity and mortality in emergency general surgery to identify targets for care quality improvement. Background: Emergency general surgery is characterized by a high-cost burden and disproportionate morbidity and mortality. Factors contributing to these observed disparities are not comprehensively understood and targets for quality improvement have not been formally developed. Methods: Using a grounded theory approach, emergency general surgery providers were recruited through purposive-criterion-based sampling to participate in semi-structured interviews and focus groups. Participants were asked to identify contributors to emergency general surgery outcomes, to define effective care for EGS patients, and to describe operating room team structure. Interviews were performed to thematic saturation. Transcripts were iteratively coded and analyzed within and across cases to identify emergent themes. Member checking was performed to establish credibility of the findings. Results: A total of 40 participants from 5 academic hospitals participated in either individual interviews (n = 25 [9 anesthesia, 12 surgery, 4 nursing]) or focus groups (n = 2 [15 nursing]). Emergency general surgery was characterized by an exceptionally high level of variability, which can be subcategorized as patient-variability (acute physiology and comorbidities) and system-variability (operating room resources and workforce). Multidisciplinary communication is identified as a modifier to variability in emergency general surgery; however, nursing is often left out of early communication exchanges. Conclusion: Critical variability in emergency general surgery may impact outcomes. Patient-variability and system-variability, with focus on multidisciplinary communication, represent potential domains for quality improvement in this fiel

E-cigarette use and risk of cardiovascular disease: a longitudinal analysis of the PATH study, 2013-2019.

Research letter: Larger studies with more cardiovascular outcome events and longer follow-up are warranted. Our results suggest that combining smoking with e-cigarette use does not reduce CVD events and that quitting both products is required to ensure a mitigation of risk

Incidence and predictors of opioid prescription at discharge after traumatic injury

Importance: In the current health care environment with increased scrutiny and growing concern regarding opioid use and abuse, there has been a push toward greater regulation over prescriptions of opioids. Trauma patients represent a population that may be affected by this regulation, as the incidence of pain at hospital discharge is greater than 95%, and opioids are considered the first line of treatment for pain management. However, the use of opioid prescriptions in trauma patients at hospital discharge has not been explored. Objective: To study the incidence and predictors of opioid prescription in trauma patients at discharge in a large national cohort. Design, setting, and participants: Analysis of adult (18-64 years), opioid-naive trauma patients who were beneficiaries of Military Health Insurance (military personnel and their dependents) treated at both military health care facilities and civilian trauma centers and hospitals between January 1, 2006, and December 31, 2013, was conducted. Patients with burns, foreign body injury, toxic effects, or late complications of trauma were excluded. Prior diagnosis of trauma within 1 year and in-hospital death were also grounds for exclusion. Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors were considered covariates. The Drug Enforcement Administration\u27s list of scheduled narcotics was used to query opioid use. Unadjusted and adjusted logistic regression models were used to determine the predictors of opioid prescription. Data analysis was performed from June 7 to August 21, 2016. Exposures: Injury mechanism and severity, comorbid conditions, mental health disorders, and demographic factors. Main outcomes and measures: Prescription of opioid analgesics at discharge. Results: Among the 33 762 patients included in the study (26 997 [80.0%] men; mean [SD] age, 32.9 [13.3] years), 18 338 (54.3%) received an opioid prescription at discharge. In risk-adjusted models, older age (45-64 vs 18-24 years: odds ratio [OR], 1.28; 95% CI, 1.13-1.44), marriage (OR, 1.26; 95% CI, 1.20-1.34), and higher Injury Severity Score (≥9 vs \u3c9: \u3eOR, 1.40; 95% CI, 1.32-1.48) were associated with a higher likelihood of opioid prescription at discharge. Male sex (OR, 0.76; 95% CI, 0.69-0.83) and anxiety (OR, 0.82; 95% CI, 0.73-0.93) were associated with a decreased likelihood of opioid prescription at discharge. Conclusions and relevance: The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioid

National study of triage and access to trauma centers for older adults

Study objective: To identify predictors of undertriage among older injured Medicare beneficiaries, identify any regions in which undertriage is more likely to occur, and examine additional factors associated with undertriage at a national level.Methods: Using 2009 to 2014 Medicare claims data, we identified older adults (≥65 years) receiving a diagnosis of traumatic injury, and linked claims with trauma center designation records from the American Trauma Society. Undertriage was defined as nontrauma centers treatment with an Injury Severity Score greater than or equal to 16, consistent with the American College of Surgeons Committee on Trauma benchmark. We used multivariable logistic regression to estimate odds of undertriage by census region, adjusting for sex, race, age, Injury Severity Score, trauma center proximity, and mode of transportation.Results: Forty-six percent of severely injured patients (n=125,731) were treated at a nontrauma center. Compared with that for patients in the Midwest, adjusted odds of undertriage were 100% higher for patients in Southern states (odds ratio [OR] 2.00; 95% confidence interval [CI] 2.00 to 2.04) and 78% higher in Western states (OR 1.78; 95% CI 1.73 to 1.82). Compared with that for patients aged 65 to 69 years, odds of undertriage gradually increased in all age groups, reaching 57% for patients older than 80 years (OR 1.57; 95% CI 1.52 to 1.61). Distance to a trauma center was associated with increasing odds of undertriage, with 37% higher odds (OR 1.37; 95% CI 1.15 to 1.40) for older adults living more than 30 miles from a trauma center compared with patients living within 15 miles.Conclusion: Nearly half of older adult trauma patients are undertriaged; it increases with age and distance to care and is most common in Southern and Western states. Improvements to field triage and trauma center access for older patients are urgently needed

Qualitative analysis of a cultural dexterity program for surgeons: Feasible, impactful, and necessary

Objectives: Ineffective cross-cultural communication contributes to adverse outcomes for minority patients. To address this, the authors developed a novel curriculum for surgical residents built on the principle of cultural dexterity, emphasizing adaptability to clinical and sociocultural circumstances to tailor care to the needs of the individual patient. This study\u27s objective was to evaluate the feasibility, acceptability, and perception of this program upon conclusion of its first year.Design, setting, and participants: The curriculum was implemented at 3 general surgery programs. The flipped classroom model combined independent study via e-learning modules with interactive role-playing sessions. Sessions took place over 1 academic year. Four focus groups were held, each with 6 to 9 participants, to gain feedback on the curriculum. Focus groups were recorded and transcribed, and the data were analyzed using a grounded theory approach.Results: Five major themes emerged: (1) Role modeling from senior colleagues is integral in developing communication/interpersonal skills and attitudes toward cultural dexterity. (2) Cultural dexterity is relevant to the provision of high-quality surgical care. (3) Barriers to providing culturally dexterous care exist at the system level. (4) Buy-in at all levels of the institution is necessary to implement the principles of cultural dexterity. (5) The shared experience of discussing the challenges and triumphs of caring for a diverse population was engaging and impactful.Conclusion: Early implementation of the curriculum revealed that the tension between surgical residents\u27 desire to improve their cultural dexterity and systemic/practical obstacles can be resolved. Combining surgically relevant didactic materials with experiential learning activities can change the paradigm of cross-cultural training

Prospective association between e-cigarette use frequency patterns and cigarette smoking abstinence among adult cigarette smokers in the United States.

AIMS: To estimate the association of longitudinal patterns of e-cigarette use with cigarette smoking abstinence, after accounting for time-dependent confounding and selection bias. DESIGN: Secondary analysis of longitudinal national cohort data. Using marginal structural models and four waves of the population assessment of tobacco and health (wave 1, 2013-14; wave 2, 2014-15; wave 3, 2015-16; wave 4, 2016-18), we estimated the association of vaping frequency across waves 2 and 3 with 12-month sustained cigarette smoking abstinence at wave 4, adjusting for time-dependent confounders at waves 1 and 2 and selection bias due to drop-out with inverse probability of treatment and censoring weights. PARTICIPANTS/CASES: A total of 5699 adults (18+ years) who smoked cigarettes and did not vape at wave 1. Setting was the United States. MEASUREMENTS: The exposure was vaping frequency at waves 2 and 3 (non-use, non-daily use, daily use), representing nine possible combinations of vaping frequency across two waves. Non-use at both waves was the exposure reference group. The primary outcome was sustained 12-month cigarette smoking abstinence at wave 4. FINDINGS: Among 5699 adults who smoked cigarettes at wave 1, a total of 560 (9.8%) reported smoking abstinence at wave 4. Compared with nonuse at both waves, daily vaping at both waves and non-use at wave 2 followed by daily vaping at wave 3 were positively associated with smoking abstinence; non-daily vaping at both waves was inversely associated with smoking abstinence. Results persisted after accounting for misclassification of e-cigarette use and cigarette smoking abstinence and after restricting to participants with plans to quit smoking. CONCLUSIONS: In a US cohort of adult smokers, longitudinal patterns of vaping frequency appear to predict smoking abstinence, even after accounting for several sources of systematic error. Consistent daily vaping is associated with increased chances of cigarette smoking abstinence, while consistent non-daily vaping is associated with decreased chances of smoking abstinence

Factors associated with long-term outcomes after injury: Results of the functional outcomes and recovery after trauma emergencies (FORTE) multicenter cohort study

Objective: The aim of this study was to determine factors associated with patient-reported outcomes, 6 to 12 months after moderate to severe injury. Summary of background data: Due to limitations of trauma registries, we have an incomplete understanding of factors that impact long-term patient-reported outcomes after injury. As 96% of patients survive their injuries, several entities including the National Academies of Science, Engineering and Medicine have called for a mechanism to routinely follow trauma patients and determine factors associated with survival, patient-reported outcomes, and reintegration into society after trauma. Methods: Over 30 months, major trauma patients [Injury Severity Score (ISS) ≥9] admitted to 3 Level-I trauma centers in Boston were assessed via telephone between 6 and 12 months after injury. Outcome measures evaluated long-term functional, physical, and mental-health outcomes. Multiple regression models were utilized to identify patient and injury factors associated with outcomes. Results: We successfully followed 1736 patients (65% of patients contacted). More than half (62%) reported current physical limitations, 37% needed help for at least 1 activity of daily living, 20% screened positive for posttraumatic stress disorder (PTSD), all SF-12 physical health subdomain scores were significantly below US norms, and 41% of patients who were working previously were unable to return to work. Age, sex, and education were associated with long-term outcomes, while almost none of the traditional measures of injury severity were. Conclusion: The long-term sequelae of trauma are more significant than previously expected. Collection of postdischarge outcomes identified patient factors, such as female sex and low education, associated with worse recovery. This suggests that social support systems are potentially at the core of recovery rather than traditional measures of injury severit

Adolescent use of flavored non-tobacco oral nicotine products.

BACKGROUND AND OBJECTIVES: Flavored non-tobacco oral nicotine products (eg, nicotine pouches and nontherapeutic nicotine gum, lozenges, tablets, gummies), are increasingly marketed in the United States. Prevalence of non-tobacco oral nicotine product use among adolescents is unknown. METHODS: We calculated prevalence of ever and past 6-month use of nicotine pouches, other non-tobacco oral nicotine products (ie, gum, lozenges, tablets, and/or gummies), e-cigarettes, cigarettes, hookah or waterpipe, cigars, cigarillos, and snus among high school students in Southern California between September and December 2021. Generalized linear mixed models tested associations of sociodemographic factors and tobacco-product use with use of any non-tobacco oral nicotine product. RESULTS: Among the sample (n = 3516), prevalence was highest for e-cigarettes (ever: 9.6%, past 6-month: 5.5%), followed by non-tobacco oral nicotine products (ever: 3.4%, past 6-month: 1.7%), and <1% for other products. Ever users of combustible tobacco and ever users of noncombustible tobacco had higher odds of ever using non-tobacco oral nicotine products, compared to never users of combustible and noncombustible tobacco. Use of any non-tobacco oral nicotine product was greater for Hispanic (versus all other races/ethnicities except Asian), sexual minority (versus heterosexual), gender minority (versus male), and female (versus male) participants. CONCLUSIONS: Non-tobacco oral nicotine products were the second most prevalent nicotine product used by adolescents. They were disproportionately used by certain racial or ethnic, sexual, or gender minority groups, and those with a history of nicotine use. Adolescent non-tobacco oral nicotine product use surveillance should be a public health priority

Association of cigarette and electronic cigarette use patterns with levels of inflammatory and oxidative stress biomarkers among US adults: Population Assessment of Tobacco and Health study.

Research letter: The cardiovascular toxicity of electronic cigarettes (e-cigarettes) is not well understood, and population data assessing the cardiovascular effects of e-cigarette use are sparse. In the present study, we used nationally represen-tative data to examine the association of cigarette and e-cigarette use behaviors with biomarkers of inflammation and oxidative stress. Inflammation and oxidative stress are key contributors of smoking-induced cardiovascular disease, and related biomarkers have been studied as predictive factors for cardiovascular events. In this nationally representative population study of adults, we observed no difference in inflammatory and oxidative stress biomarkers between exclusive e-ciga-rette users and nonusers (no cigarettes or vaping), and levels were lower in exclusive e-cigarette users relative to exclusive smokers. These findings are consistent with recent population studies of inflammatory biomarker and toxicant exposure in users of e-cigarettes and ciga-rettes and highlight the importance of completely re-placing cigarette smoking with e-cigarettes or quitting the use of both products for cigarette smokers to derive potential health benefits