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Racism is embedded in society, and higher education is an important structure for patterning economic and health outcomes. Historically Black Colleges and Universities (HBCUs) were founded on antiracism while predominantly White institutions (PWIs) were often founded on white supremacy. This contrast provides an opportunity to study the association between structural racism and health among Black Americans. We used the National Longitudinal Study of Adolescent to Adult Health (Add Health) to estimate the long-term causal effect of attending an HBCU (vs. PWI) on depressive symptoms among Black students in the United States from 1994–2018. While we found no overall association with attending an HBCU (vs. PWI) on depressive symptoms, we found that this association varied by baseline mental health and region, and across time. For example, among those who attended high school outside of the South, HBCU attendance was protective against depressive symptoms 7 years later, and the association was strongest for those with higher baseline depressive symptoms. We recommend equitable state and federal funding for HBCUs, and that PWIs implement and evaluate antiracist policies to improve mental health of Black students.

Objective In this study, we examine associations between objectively measured weekend night vs. school night sleep patterns, weight status, and weight-related behaviors among adolescents. Design Cross-sectional study. Setting Five Minnesota high schools that started early (7:30 or 7:45 AM) in Spring 2016. Participants Ninth grade students, ages 14.5-16 years (n = 284). Measurements Students completed surveys, had body measurements taken, and wore sleep (wrist) actigraphs for 1 week (n = 284). We examined weekend night-school night differences in sleep duration and sleep timing. We then assessed whether these factors were related to weight status and weight-related behaviors (eating behaviors, food consumption, physical activity, beverage consumption) using generalized linear mixed models. Results On average, students slept 1.5 hours (95% confidence interval 1.3-1.7) more and had a sleep midpoint 1.9 hours (1.8-2.1) later on weekend nights compared to school nights. Female students had larger increases in sleep duration on weekend nights than males but similar timing differences. Sleep duration differences were uncorrelated with sleep timing differences (r = 0.01). Neither duration nor timing differences were associated with overweight, obesity, or any of the eating behaviors we examined. However, sleeping longer on weekend nights than on school nights was associated with lower probability of being active 6-7 days per week (p = .02). Conclusions Adolescents have substantial sleep duration and sleep timing differences on weekend nights vs. school nights. While these differences may not be associated with weight status or weight-related behaviors, they reflect the reality that most adolescents have schedules that restrict their sleep.

Despite a dramatic reduction in the prevalence of commercial cigarette smoking in the United States, children are still commonly exposed to secondhand smoke (SHS), which is a cause of various pediatric health problems. Further, SHS exposure is patterned by race and class, exacting an inequitable toll on children from families with lesser social and economic advantage. In this issue of the Journal, Titus et al. (Am J Epidemiol. 2023;192(1):25–33) use natural experiment evaluation methods (difference-in-differences) to test whether the recently implemented US Department of Housing and Urban Development policy that forbade smoking in and around New York City Housing Authority buildings affected child respiratory health. The results from their work remind us that policies do not always impact outcomes as we might expect. Given that policy is one of the most potent tools for population health promotion, this work underlines the need for epidemiologists to engage in policy evaluation at all stages of the policy life cycle, in order to discover comprehensive approaches to policy development and implementation that prioritize equity and address structural racism.

Cancer survivors are at increased risk of pain due to their either cancer and/or treatments. Substances like alcohol may be used to self-medicate cancer pain; however, these substances pose their own health risks that may be more pronounced for cancer survivors.We used cross-sectional data from the Behavioral Risk Factor Surveillance System (BRFSS) 2012-2019 to quantify the association between cancer pain and alcohol use. We used negative binomial regression, with interaction terms added to examine variations across age, sex, and race. We also examined whether alcohol use relates to cancer pain control status.Cancer survivors with cancer pain were more likely to be younger, female, Black, and to have been diagnosed with breast cancer. Cancer pain was associated with lower alcohol consumption (incidence rate ratio (IRR): 0.88, confidence interval (CI): 0.77, 0.99). This association was primarily among people 65 and older, women, and white and Hispanic people. Cancer pain control status was not related to alcohol use.Lower alcohol use among cancer survivors with pain has many possible explanations, including several alternative pain management strategies or a decrease in social engagement. Our findings of racial and gender disparities in cancer pain are consistent with the broader evidence on disparities in pain.Cancer pain management for marginalized groups should be improved. Healthcare providers should screen cancer survivors for both pain and substance use, to prevent unhealthy self-medication behaviors.

BACKGROUND. Health literacy has yet to be described in a non-clinical, racially diverse, community-based cohort. METHODS. Four questions assessing health literacy were asked during annual phone encounters with Multi-Ethnic Study of Atherosclerosis (MESA) participants between 2016 and 2018 (n=3629). We used prevalence ratios (PRs) with 95% confidence intervals (CIs) to characterize how demographic and acculturation factors related to limited health literacy. Models adjusted for age, sex, and race/ethnicity, and race/ethnicity-stratified models were also examined. RESULTS. Limited health literacy was prevalent in 15.4% of the sample. Participants who were older, female, lower-income, or less acculturated were at greater risk for having limited health literacy. Chinese, Hispanic, and Black participants were more likely than White participants to have limited health literacy. Patterns were similar when stratified by race/ethnicity. DISCUSSION. Within MESA limited health literacy was common, particularly among Chinese and Hispanic participants, with some of the variance explained by differences in acculturation.

PurposeTo estimate the effect of Healthy, Hunger-Free Kids Act of 2010 (HHFKA) implementation on dietary quality of all US school-aged children and adolescents, and examine whether those effects differed by demographic group.MethodsWe used survey regression on 2007-2016 National Health and Nutrition Examination Survey (NHANES) data to estimate the proportion of energy intake from school foods and the association between school food intake and dietary quality, before and after HHFKA passage/implementation. To account for demographic changes in the US population over time, inverse probability weighting was employed. The product of the proportion of energy from school foods and the association between school food intake and dietary quality estimated the effect of HHFKA implementation on dietary quality.ResultsSchool food intake quantity remained stable during the study period. HHFKA implementation improved students’ dietary quality by 4.3 Healthy Eating Index-2010 (HEI) points (95% CI: 2.5, 6.1) on days when school foods were eaten, and by 1.3 HEI points (95% CI: 0.73, 1.8) averaged over all days annually.ConclusionsHHFKA implementation improved the total dietary quality of US school students. US students would benefit from eating school meals in the post-HHFKA era, and HHFKA regulations should not be relaxed.

Purpose Few adolescents spend enough time asleep on school nights. This problem could be addressed by delaying high school start times, but does this translate to reduced prevalence of sleep–wake problems like awakening too early or feeling sleepy during the day? Methods The START study (n = 2,414) followed a cohort of students from five Minnesota high schools to evaluate impacts of school start time delays. Participants were enrolled in ninth grade (Baseline) when all schools started early (7:30 or 7:45 a.m. ). At Follow-Up 1 (10th grade) and Follow-Up 2 (11th grade), two schools had delayed their start times by 50 and 65 minutes while three comparison schools started at 7:30 a.m. Six sleep–wake behaviors were assessed at all three time points via survey. Generalized estimating equation models were used to investigate changes in sleep–wake problems between policy change and comparison schools. Results The prevalence of sleep–wake problems at Baseline ranged from 11% for being late to class due to oversleeping to 48% for needing to be told to wake multiple times in the morning. Compared to students from comparison schools, students at policy change schools reported smaller increases in the prevalence of feeling sleepy daily and oversleeping and being late to class between 9th and 11th grade. After implementation of the delayed start, awakening too early was more common among students at policy change schools compared to the comparison schools. Conclusions This longitudinal study provides evidence that delaying high school start times reduces daytime sleepiness and school tardiness.

BACKGROUND: Sleep duration, quality, and timing may influence dietary quality. In adults, poor dietary quality is a risk factor for numerous chronic diseases. It is unclear how these various sleep domains influence adolescents’ diets because prior population-based studies have not effectively manipulated sleep, did not include objective sleep measures, and had short follow-up times. OBJECTIVES: The objectives of this study were to examine 1) how adolescent sleep characteristics relate to dietary quality; and 2) how delay in high school start times (which lengthened sleep duration) affects dietary quality over 2 y. METHODS: In the START study, adolescents (grades 9–11, n = 423) attending 5 high schools in the Minneapolis, Minnesota metropolitan area were annually assessed in 3 waves (2016–2018). At Baseline, all schools started “early” (07:30 or 07:45). From Follow-up 1 through Follow-up 2, 2 “policy change schools” shifted to later start times (to 08:20 and 08:50). Three “comparison schools” maintained their early start throughout. Sleep characteristics were measured with actigraphy. Mixed-effect regression models were used to examine cross-sectional and longitudinal associations of sleep characteristics with dietary quality, and school start time policy change with dietary quality change. RESULTS: Cross-sectionally, later sleep midpoint and onset were associated with dietary quality scores 1.6–1.7 lower (both P

INTRODUCTION: Short sleep duration is exceedingly common among adolescents and has implications for healthy youth development. We sought to document associations between to adolescents’ sleep duration and characteristics of their schedules, behaviors, and wellbeing. METHODS: We used data from the baseline wave (9(th) grade year) of the START study, a cohort of 2,134 students in five Minnesota high schools to assess how self-reported sleep duration was associated with the prevalence of time-use characteristics (i.e. activity schedules, screen use), sleep-wake problems behaviors (i.e. trouble waking in the morning, calling asleep in class, etc.), and risk of depression. RESULTS: Shorter sleep duration was associated with various behaviors including greater computer/screen time and screen use after bed, a lower probability of doing homework, sports, and chores on school nights, and reporting that it takes at least 20 minutes to fall asleep on school days (p < 0.05). Suboptimal sleep duration was also associated with a higher probability of all reported sleep-wake problems as well as high risk of depressive symptoms (p < 0.05). CONCLUSIONS: Given that getting an optimal amount of sleep can protect youth from risk and promote healthy youth development, it is critical that we gain a greater understanding of correlates and consequences of short sleep duration in order to develop a sleep-friendly culture for youth.

Smokers with serious mental illness (SMI) face individual, interpersonal, and healthcare provider barriers to cessation treatment utilization and smoking abstinence. Proactive outreach strategies are designed to address these barriers by promoting heightened contact with smokers and facilitating access to evidence-based treatments. The present study examined the effect of proactive outreach among smokers with SMI (n = 939) who were enrolled in the publicly subsidized Minnesota Health Care Programs (MHCP) and compared this effect to that observed among MHCP smokers without SMI (n = 1382). Relative to usual care, the intervention increased treatment utilization among those with SMI (52.1% vs 40.0%, p = 0.002) and without SMI (39.3% vs 25.4%, p < 0.001). The intervention also increased prolonged smoking abstinence among those with SMI (14.9% vs 9.4%, p = 0.010) and without SMI (17.7% vs 13.6%, p = 0.09). Findings suggest that implementation of proactive outreach within publicly subsidized healthcare systems may alleviate the burden of smoking in this vulnerable population. Trial Registration ClinicalTrials.gov identifier: NCT01123967.

Introduction Concerns about the adverse effects of smoking cessation on alcohol use and mental health are a barrier to cessation for smokers with serious mental illness (SMI). The purpose of this study is to examine how incident smoking cessation affects binge drinking and symptoms of depression and anxiety among smokers with SMI. Methods The present study is a secondary analysis of the OPTIN trial, which demonstrated the effectiveness of proactive outreach for smoking cessation among Minnesota Health Care Programs enrollees. Participants with ICD-9 codes indicating schizophrenia spectrum disorders, psychotic disorders, bipolar disorders, or severe/recurrent major depressive disorder were categorized as having SMI (n = 939); remaining smokers were categorized as non-SMI (n = 1382). Multivariable regressions modeled the association between incident smoking cessation and binge drinking, PHQ-2 depression scores, and PROMIS anxiety scores in the two groups. Results Quitting smoking was not associated with binge drinking among those with SMI, but was associated with less binge drinking among those without SMI (p = 0.033). Quitting smoking was not associated with PHQ-2 depression scores among those with or without SMI. However, quitting smoking was associated with lower mean PROMIS anxiety scores for those with SMI (p = 0.031), but not those without SMI. Conclusion Quitting smoking was not associated with heightened binge drinking or symptoms of depression and anxiety among smokers with SMI. These findings suggest that quitting smoking is not detrimental for these patients, and provide evidential support for facilitating access to cessation resources for patients with serious mental illness who smoke.

E-cigarettes have surged in popularity over the last few years, particularly among youth and young adults. These battery-powered devices aerosolize e-liquids, comprised of propylene glycol and vegetable glycerin, typically with nicotine, flavors, and stabilizers/humectants. Although the use of combustible cigarettes is associated with several adverse health effects including multiple pulmonary and cardiovascular diseases, the effects of e-cigarettes on both short- and long-term health have only begun to be investigated. Given the recent increase in the popularity of e-cigarettes, there is an urgent need for studies to address their potential adverse health effects, particularly as many researchers have suggested that e-cigarettes may pose less of a health risk than traditional combustible cigarettes and should be used as nicotine replacements. This report is prepared for clinicians, researchers, and other health care providers to provide the current state of knowledge on how e-cigarette use might affect cardiopulmonary health, along with research gaps to be addressed in future studies.

Background A steep rise in food insecurity is among the most pressing US public health problems that has resulted from the COVID-19 pandemic. Objective This study aimed to (1) describe how food-insecure emerging adults are adapting their eating and child-feeding behaviors during COVID-19 and (2) identify barriers and opportunities to improve local food access and access to food assistance. Design The COVID-19 Eating and Activity Over Time study collected survey data from emerging adults during April to October 2020 and completed interviews with a diverse subset of food-insecure respondents. Participants/setting A total of 720 emerging adults (mean age: 24.7 ± 2.0 years; 62% female; 90% living in Minnesota) completed an online survey, and a predominately female subsample (n = 33) completed an interview by telephone or videoconference. Main outcome measures Survey measures included the short-form of the US Household Food Security Survey Module and 2 items to assess food insufficiency. Interviews assessed eating and feeding behaviors along with barriers to healthy food access. Analyses performed Descriptive statistics and a hybrid deductive and inductive content analysis. Results Nearly one-third of survey respondents had experienced food insecurity in the past year. Interviews with food-insecure participants identified 6 themes with regard to changes in eating and feeding behavior (eg, more processed food, sporadic eating), 5 themes regarding local food access barriers (eg, limited enforcement of COVID-19 safety practices, experiencing discrimination), and 4 themes regarding barriers to accessing food assistance (eg, lack of eligibility, difficulty in locating pantries). Identified recommendations include (1) expanding the distribution of information about food pantries and meal distribution sites, and (2) increasing fresh fruit and vegetable offerings at these sites. Conclusions Interventions of specific relevance to COVID-19 (eg, stronger implementation of safety practices) and expanded food assistance services are needed to improve the accessibility of healthy food for emerging adults.

Healthcare provider barriers to cessation resources may be undercutting quit rates for smokers with serious mental illness (SMI). The study aim was to examine how providers influence cessation treatment utilization among smokers with SMI. Data were taken from a trial conducted among smokers in Minnesota Health Care Programs. The sample was split into groups of participants with SMI (n = 939) and without SMI (n = 1382). Analyses assessed whether the association between SMI and treatment utilization was mediated by healthcare provider–delivered treatment advice and healthcare provider bias. Results revealed higher rates of treatment utilization among smokers with SMI than those without SMI (45.9% vs 31.7%, p

Population-based smoking-cessation services tend to preferentially benefit high-SES smokers, potentially exacerbating disparities. Interventions that include proactive outreach, telephone counseling, and free or low-cost cessation medications may be more likely to help low-SES smokers quit. This analysis evaluated the role of SES in smokers' response to a population-based proactive smoking-cessation intervention.This study, conducted in 2016 and 2017, was a secondary analysis of the Veterans Victory Over Tobacco Study, a multicenter pragmatic RCT of a proactive smoking-cessation intervention conducted from 2009 to 2011. Logistic regression modeling was used to test the effect of income or education level on 6-month prolonged abstinence at 1-year follow-up.Of the 5,123 eligible, randomized participants, 2,565 (50%) reported their education level and 2,430 (47%) reported their income level. The interactions between education (p=0.07) or income (p=0.74) X treatment arm were not statistically significant at the 0.05 level. The largest effect sizes for the intervention were found among smokers in the lowest education category (≤11th grade), with a quit rate of 17.3% as compared with 5.7% in usual care (OR=3.5, 95% CI=1.4, 8.6) and in the lowest income range ($10,000), with a quit rate of 18.7% as compared with 9.4% in usual care (OR=2.2, 95% CI=1.2, 4.0).In a large, multicenter smoking-cessation trial, proactive outreach was associated with higher rates of prolonged abstinence among smokers at all SES levels. Proactive outreach interventions that integrate telephone-based care and facilitated cessation medication access have the potential to reduce socioeconomic disparities in quitting.This study is registered at www.clinicaltrials.gov NCT00608426.

Indoor smoking bans have often been associated with reductions in smoking prevalence. However, few studies have evaluated their association with within-person changes in smoking behaviors. We linked longitudinal data from 5,105 adults aged 18–30 years at baseline from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985–2011) to state, county, and local policies mandating 100% smoke-free bars and restaurants by census tract. We used fixed-effects models to examine the association of smoking bans with within-person change in current smoking risk, smoking intensity (smoking ≥10 cigarettes/day on average vs.

ObjectiveTo test the associations between sleep indices and eating behaviours in young adults, a group vulnerable to suboptimal sleep.DesignCross-sectional analysis of survey measures of sleep (i.e. time in bed, variability, timing and quality) and dietary patterns (i.e. breakfast skipping, eating at fast-food restaurants, consumption of sports and energy drinks, and sugar-free, sugar-sweetened and caffeinated beverages).SettingMinneapolis/St. Paul metropolitan area of Minnesota (USA).SubjectsA total of 1854 respondents (20–30 years, 55·6 % female) from the 2008–2009 survey conducted for the third wave of the population-based Project EAT (Eating and Activity in Teens and Young Adults) study.ResultsAfter adjustment for demographic and behavioural covariates in linear regression models, those who went to bed after 00.30 hours consumed 0·3 more servings of sugar-sweetened beverages per day, consumed 1·7 times more energy drinks, skipped breakfast 1·8 more times per week and consumed fast food 0·3 more times per week compared with those who went to bed before 22.30 hours. Reported sleep quality in the lowest (Q1)v. highest (Q3) tertile was associated with more intake of energy drinks (Q3v.Q1, prevalence ratio, 95 % CI: 1·79, 1·24, 2·34), sports drinks (1·28, 1·00, 1·55) and breakfast skipping (adjusted mean, 95 % CI: Q1: 4·03, 3·81, 4·26; Q3: 3·43, 3·17, 3·69). Time in bed and sleep variability were associated with few eating behaviours.ConclusionsSome, but not all, sleep indices were related to problematic eating behaviours. Sleep habits may be important to address in interventions and policies that target improvements in eating patterns and health outcomes.

OBJECTIVES: The objectives were 2-fold: (1) to examine how high school start times relate to adolescent sleep duration, and (2) to test associations between sleep duration and mental health– and substance use–related issues and behaviors in teens. DESIGN: This study examines selected questions from survey data collected between 2010 and 2013 high school students. SETTING: Respondents included more than 9000 students in grades 9 to 12 in 8 high schools in 5 school districts across the United States. MEASUREMENTS: The survey instrument is the 97-item Teen Sleep Habits Survey. Logistic regression models were used to calculate adjusted odds ratios and 95% confidence intervals. Because of clustering within schools and the use of repeated measures, generalized estimating equations were used to account for variance inflation. RESULTS: Greater sleep duration was associated with fewer reports of various mental health– and substance use–related issues and behaviors (all P values b.01). For instance, for each additional hour of sleep reported, there was a 28% reduction in the adjusted odds of a participant reporting that he or she felt “unhappy, sad, or depressed.” Later wake-up times were associated with a reduction in risk for some, but not all factors. Later start times were significantly associated with greater sleep duration. CONCLUSIONS: Given that later start times allow for greater sleep duration and that adequate sleep duration is associated with more favorable mental health– and substance use–related issues and behaviors, it is important that school districts prioritize exploring and implementing policies, such as delayed start times, that may increase the amount of sleep of adolescent students, which is needed for their optimal development.

Introduction Smoking denormalization has been paralleled by reduced smoking prevalence, but smoking rates among socioeconomically disadvantaged populations remain high. The social unacceptability of smoking has also led to increased perceptions of smoking-related stigma. By examining how smoking stigma influences cessation intervention effectiveness, we can better tailor interventions to socioeconomically disadvantaged smokers. Aims and methods Data are from a randomized controlled trial evaluating the effectiveness of a proactive cessation intervention on abstinence. Current smokers enrolled in Minnesota Health Care Programs were randomized to proactive outreach (n = 1200) or usual care (n = 1206). The intervention included mailings, telephone outreach, counseling, and access to free cessation treatments. Using baseline measurements, groups with lower (n = 1227) and higher (n = 1093) perceived stigma were formed. Intervention, stigma, and their interaction term were added to a logistic regression modeling abstinence at 12 months. Results Lower perceived smoking-related stigma was associated with less support for quitting, lower rates of physician quitting advice, and less motivation for quitting. A logistic regression modeling abstinence found a significant intervention × stigma interaction. The proactive intervention was more effective among smokers with lower perceived smoking-related stigma (odds ratio 1.94, 95% confidence interval, 1.29 to 2.92) than those with higher perceived smoking-related stigma (odds ratio 1.04, 95% confidence interval, 0.70 to 1.55). Discussion Smokers with lower perceived smoking-related stigma had social environments that were conducive to smoking, received less physician advice to quit, and were less motivated to quit than higher stigma smokers. Despite these barriers, the intervention was more effective for lower stigma smokers, suggesting that proactive outreach is an efficient treatment for these hard-to-reach smokers. Implications Smoking denormalization has led to increased perceptions of smoking-related stigma among many smokers; however, little is known about how this stigma influences the cessation process. In the present study, smokers with lower levels of perceived smoking-related stigma lived in social environments that were more conducive to smoking and were less motivated to quit than higher stigma smokers. Despite these barriers, our proactive outreach cessation intervention was more effective for lower stigma smokers, suggesting that interventions which utilize proactive outreach to stimulate interest in quitting and offer facilitated access to free cessation treatments are an effective treatment approach for these hard-to-reach smokers. These strategies may be particularly effective for motivating smokers enrolled in government-subsidized health insurance programs to take advantage of cessation resources.

Purpose: The aims of this analysis were to explore how self-reported barriers to quitting vary by socioeconomic status (SES) among young-adult smokers and to assess their relationship to quitting. Design: This analysis uses 2 waves of telephone-survey data from the Minnesota Adolescent Community Cohort study. Setting: Midwestern United States. Participants: Participants (n = 419) were smokers aged 17 to 24 years. Measures: Socioeconomic status was estimated using the highest level of education completed by the participants’ parents. Demographics, smoking behavior, and perceived barriers to quitting were collected via survey questions. Analysis: Differences in barriers by SES were assessed using prevalence ratios (PRs). Relative risks were calculated to assess the association between barriers and quitting status 1 year later, testing for effect modification by SES. Results: Compared to the high SES group (n = 314), the low SES group (n = 105) was more likely to report several barriers to quitting; however, only the risk of gaining weight was significantly more common (PR: 1.38 [1.05-1.83]). There were no significant associations between barriers and quitting status 1 year later, but the number of cigarettes per day was consistently related to the likelihood of quitting 1 year later, regardless of SES. Conclusion: Despite the limited generalizability to racially diverse populations and different geographic locations, the results suggest perceived barriers may not differ by SES or predict quitting among young adults; however, nicotine dependence may play an important role.

IntroductionProximal environments could facilitate smoking cessation among low-income smokers by making cessation appealing to strive for and tenable.AimsWe sought to examine how home smoking rules and proximal environmental factors such as other household members' and peers' smoking behaviors and attitudes related to low-income smokers' past quit attempts, readiness, and self-efficacy to quit.MethodsThis analysis used data from Offering Proactive Treatment Intervention (OPT-IN) (randomized control trial of proactive tobacco cessation outreach) baseline survey, which was completed by 2,406 participants in 2011/12. We tested the associations between predictors (home smoking rules and proximal environmental factors) and outcomes (past-year quit attempts, readiness to quit, and quitting self-efficacy).ResultsSmokers who lived in homes with more restrictive household smoking rules, and/or reported having ‘important others’ who would be supportive of their quitting, were more likely to report having made a quit attempt in the past year, had greater readiness to quit, and greater self-efficacy related to quitting.ConclusionsAdjustments to proximal environments, including strengthening household smoking rules, might encourage cessation even if other household members are smokers.

Background: Insufficient sleep is widespread among adolescents and has consequences that extend far beyond hampering day-to-day functioning. It may influence eating and physical activity patterns and be an important determinant of adolescent overweight/obesity status. Methods: We assessed how self-reported sleep duration on school nights was associated with weight-related behaviors (eating, diet, and physical activity) and overweight/obesity at the baseline wave (ninth grade year) of the START study (n = 2134). Results: Fifteen percent of our sample reported optimal sleep duration (8.5–10.0 hours); nonwhites, participants of lower socioeconomic status, and girls were at greater risk for insufficient sleep. Suboptimal sleep was associated with various poor weight-related behaviors such as increased sugar-sweetened beverage consumption, decreased vegetable consumption, and decreased breakfast eating (p

Introduction: In 2018 the American Heart Association released a Scientific Statement on the importance of health literacy to cardiovascular disease (CVD) primary and secondary prevention. Health literacy has been defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” However, most studies exploring the prevalence of health literacy have been conducted in populations that were demographically relatively homogeneous. Hypothesis: Using cross-sectional data from the race-ethnically diverse, sex-balanced and community-based Multi-Ethnic Study of Atherosclerosis (MESA), we tested the hypotheses that low health literacy was associated with older age, lower income and less acculturation. Methods: Four standard questions assessing health literacy were asked during annual phone follow up encounters which took place from August 2016 through August 2018. The questions assessed: 1) ability to read materials received from a doctor, 2) problems learning about health conditions, 3) confidence in filling out medical forms, and 4) understanding of medical statistics. Consistent with prior literature, responses to the 4 questions were combined into a composite score, and then a dichotomous variable was created to classify health literacy as low or adequate. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated, adjusted for age, sex, and race/ethnicity. Race/ethnicity-stratified associations were also explored. Results: Our sample consisted of 3,638 adults ages 53-94 years (median, 69), including 1,513 White, 445 Chinese, 936 Black, and 734 Hispanic participants. A total of 15.4% had low health literacy, which was more common among elderly [PR (95% CI) for ≥70 years vs. Conclusions: Within a diverse population low health literacy was more common among individuals who were older, female, had lower income, and were less acculturated. Since patients with low health literacy may need additional support to optimize their cardiovascular health, our results illustrate possible priority populations for health education intervention.

Background: New pediatric hypertension (HTN) definitions were recently introduced in a clinical practice guideline (CPG). We evaluated the impact of the CPG (compared to the previous guideline, the “Fourth Report”) on the prevalence of pediatric HTN and associations with HTN in adulthood. Methods: Data from the International Childhood Cardiovascular Cohort (i3C), a consortium comprising seven large, long-standing study cohorts from the United States, Finland, and Australia, were used. The mean of 2-6 BP measurements using an auscultatory technique were obtained. BP was categorized as normal, elevated, and hypertensive (stage 1 and 2) using the Fourth Report and CPG. For those with multiple BP assessments within an age category, a random assessment was selected for analysis. Childhood participants were contacted in adulthood and data on self-reported HTN was recorded. Results: There were 34,014 youth (mean age 10.4 ± 3.1 years, 49.4% male) with 92,751 BP assessments available for analysis. Use of the CPG increased hypertension prevalence from 7.6% to 13.5% (stage 1) and 1.3% to 2.5% (stage 2, p Conclusion: The CPG resulted in a significantly increased prevalence of HTN in children and adolescents due to significant re-classification to higher BP categories. While the observed increases were not consistent across age groups, the results suggest increased sensitivity regarding the development of HTN in adulthood.

Background: Smoking is known to cause clinical cardiovascular disease. We report the natural history of smoking from childhood until average age 47 years in the large cohort followed in the International Childhood Cardiovascular Cohort (i3C) Consortium, which consists of seven long-standing cohorts in the US, Finland and Australia. Methods: Data on childhood smoking status were obtained from questionnaires answered during age 6-19 during the 1980s. Childhood smoking status was categorized as never smoker, tried smoking only a few times, tried more extensively (including quitters), and regular smoker. The i3C participants had follow-up visits until 2015-18 (Finland 2010-12), when they reported whether they were smokers during their 20s and/or 40s. Results: Of the 9977 participants, prevalence of regular smoking decreased from 35.5% in their 20s, to 20.5% in their 40s; cessation was unrelated to childhood smoking status. As shown in the Figure, among 1816 participants queried at age 18/19, prevalence of regular smoking in their 20s was 4.1% (36/886) in those who never smoked even during adolescence, 12% (22/183) in those who tried only a few times, 21.5% (40/186) in those who tried more extensively, and 76.5% (429/561) in those who were regular smokers during childhood. The pattern was similar among 860 whose last childhood smoking status was queried at age 16/17 (some probably experimented more during the remainder of childhood), but smoking in their 20s was more common for all smoking experimentation groups than in 18/19 year olds. Conclusions: These long-term follow-up data suggest that prevalence of adult smoking was significantly related to level of smoking experimentation during adolescence. However, cessation during adulthood does not depend on childhood smoking status. Policy change (such as taxes and restrictions on smoking indoors) has proven to be one of the most powerful tobacco control tools. These data support an emerging new policy strategy, namely raising the legal cigarette purchase age to 21 years

Background: Cigarette smoking is one of the strongest modifiable risk factors for peripheral artery disease (PAD), a disease which affects over 200 million people worldwide. Though cigarette use has decreased across time, use of cigars, pipes and smokeless tobacco remains unchanged or slightly increased. The association of PAD and non-cigarette tobacco use is not well described. Thus, we tested the hypothesis that the use of cigars, pipes or smokeless tobacco is associated with incident PAD even after adjustment for cigarette use. Methods: A total of 14,395 Atherosclerosis Risk in Communities (ARIC) Study participants with no history of prevalent PAD were followed from 1987 to 2015 for PAD events (hospitalizations with PAD diagnosis or leg revascularization). Baseline pipe, cigar smoking and smokeless tobacco use was self-reported. Multivariable-adjusted Cox proportional hazards regression was used. Results: At enrollment the 14,395 participants included in the study were on average (SD) 54 (6) years old, 55% female and 27% African American; 489 (3.4%) were current users of smokeless tobacco and 481 (3.3%) current users of cigars or pipes. A total of 1,289 incident PAD events occurred during a median of 25.9 years of follow-up. After adjustment for demographics and cigarette smoking status, risk of incident PAD was higher among current (versus never) users of smokeless tobacco [HR (95% CI): 1.66 (1.29-2.12)], though this association was attenuated with adjustment for CVD risk factors (Table). Cigar and pipe use were not associated with PAD incidence, regardless of degree of adjustment (Table). Conclusion: Active use of smokeless tobacco was associated with increased risk for incident PAD compared to non-use, independent of cigarette smoking, although this relationship was not statistically significant after adjustment for cardiovascular risk factors. No association was observed with use of pipes or cigars. Use of smokeless tobacco may increase PAD risk and could be a potential target for intervention.

Training sessions that offer feedback and coaching to trainees are effective in helping participants retain motivational interviewing skills for tobacco cessation counseling.

Sleep disturbance and insufficiency are associated with physical and mental health problems in school-aged adolescent children. Early start times (before 8:30 a.m.) restrict sleep for adolescents at over 80% of US middle and high schools. Delaying school start times could be an effective population-level strategy to promote adolescent health and well-being. We review the evidence for the effect of school start time on adolescent sleep, academic achievement and truancy, and mental and physical health. Consistent evidence shows that adolescents at later-starting schools sleep longer than those at earlier-starting schools. Limited evidence suggests that students at later-starting schools may learn more, attend school more regularly, have fewer mental health problems, and are less prone to unintentional injury. We conclude by discussing the trade-offs school districts weigh when considering scheduling changes, and the need for school start time research to improve study design and expand the scope of outcomes.

Importance Sleep is a resource that has been associated with health and well-being; however, sleep insufficiency is common among adolescents. Objective To examine how delaying school start time is associated with objectively assessed sleep duration, timing, and quality in a cohort of adolescents. Design, Setting, and Participants This observational cohort study took advantage of district-initiated modifications in the starting times of 5 public high schools in the metropolitan area of Minneapolis and St Paul, Minnesota. A total of 455 students were followed up from grade 9 (May 3 to June 3, 2016) through grade 11 (March 15 to May 21, 2018). Data were analyzed from February 1 to July 24, 2019. Exposures All 5 participating schools started early (7:30amor 7:45am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), 2 schools delayed their start times by 50 and 65 minutes, whereas 3 comparison schools started at 7:30amthroughout the observation period. Main Outcomes and Measures Wrist actigraphy was used to derive indices of sleep duration, timing, and quality. With a difference-in-difference design, linear mixed-effects models were used to estimate differences in changes in sleep time between delayed-start and comparison schools. Results A total of 455 students were included in the analysis (among those identifying sex, 225 girls [49.5%] and 219 boys [48.1%]; mean [SD] age at baseline, 15.2 [0.3] years). Relative to the change observed in the comparison schools, students who attended delayed-start schools had an additional mean 41 (95% CI, 25-57) objectively measured minutes of night sleep at follow-up 1 and 43 (95% CI, 25-61) at follow-up 2. Delayed start times were not associated with falling asleep later on school nights at follow-ups, and students attending these schools had a mean difference-in-differences change in weekend night sleep of −24 (95% CI, −51 to 2) minutes from baseline to follow-up 1 and −34 (95% CI, −65 to −3) minutes from baseline to follow-up 2, relative to comparison school participants. Differences in differences for school night sleep onset, weekend sleep onset latency, sleep midpoints, sleep efficiency, and the sleep fragmentation index between the 2 conditions were minimal. Conclusions and Relevance This study found that delaying high school start times could extend adolescent school night sleep duration and lessen their need for catch-up sleep on weekends. These findings suggest that later start times could be a durable strategy for addressing population-wide adolescent sleep deficits.

PURPOSE OF REVIEW: Later school start times are associated with a number of benefits for adolescents. The purpose of the current review is to summarize the literature regarding the effects of delaying school start times on adolescent psychological health. RECENT FINDINGS: We identified eight observational studies that examined the relationship between schools’ starting times and psychological outcomes. Of these, three were longitudinal studies that reported measures of adolescent mental health improved following a start time delay. Two cross-sectional studies showed that mental health scores were higher in schools with later compared to earlier start times. Three studies found no relationship between start time and mental health. SUMMARY: In the majority of studies reviewed, later school start times were associated with greater adolescent psychological health. However, inherent design drawbacks in the studies prevent us from concluding that these associations are causal. There are a wide range of potential benefits, beyond mental health, that later high school start times offer. This encouraging, emergent literature on delayed start times has led many school districts to consider changes to their start times.

Background: Smoke-free legislation has been associated with lower rates of cardiovascular disease hospital admissions in ecological studies. However, prior studies lacked detailed information on individual-level factors (eg, sociodemographic and clinical characteristics) that could potentially confound associations. Our objective was to estimate associations of smoke-free policies with incident cardiovascular disease in a longitudinal cohort after controlling for sociodemographics, cardiovascular disease risk factors, and policy covariates. Methods: Longitudinal data from 3783 black and white adults in the CARDIA study (Coronary Artery Risk Development in Young Adults; 1995–2015) were linked to state, county, and local 100% smoke-free policies in bars, restaurants, and nonhospitality workplaces by Census tract. Extended Cox regression estimated hazard ratios (HRs) of incident cardiovascular disease associated with time-dependent smoke-free policy exposures. Models were adjusted for sociodemographic characteristics, cardiovascular disease risk factors, state cigarette tax, participant-reported presence of a smoking ban at their workplace, field center, and metropolitan statistical area poverty. Results: During a median follow-up of 20 years (68 332 total person-years), 172 participants had an incident cardiovascular disease event (2.5 per 1000 person-years). Over the follow-up period, 80% of participants lived in areas with smoke-free policies in restaurants, 67% in bars, and 65% in nonhospitality workplaces. In fully adjusted models, participants living in an area with a restaurant, bar, or workplace smoke-free policy had a lower risk of incident cardiovascular disease compared with those in areas without smoke-free policies (HR, 0.75, 95% confidence interval, 0.49–1.15; HR, 0.76, 95% confidence interval, 0.47–1.24; HR, 0.54, 95% confidence interval, 0.34–0.86, respectively; HR, 0.58, 95% confidence interval, 0.33–1.00 for living in an area with all 3 types of policies compared with none). The estimated preventive fraction was 25% for restaurant policies, 24% for bar policies, and 46% for workplace policies. Conclusions: Consistent with prior ecological studies, these individual-based data add to the evidence that 100% smoke-free policies are associated with lower risk of cardiovascular disease among middle-aged adults.

OBJECTIVE: Given the growing concern about research reproducibility, we conceptually replicated a previous analysis of the relationships between adolescent sleep and mental well-being, using a new dataset. METHODS: We conceptually reproduced an earlier analysis (Sleep Health, June 2017) using baseline data from the START Study. START is a longitudinal research study designed to evaluate a natural experiment in delaying high school start times, examining the impact of sleep duration on weight change in adolescents. In both START and the previous study, school day bedtime, wake up time, and answers to a six-item depression subscale were self-reported using a survey administered during the school day. Logistic regression models were used to compute the association and 95% confidence intervals (CI) between the sleep variables (sleep duration, wake-up time and bed time) and a range of outcomes. RESULTS: In both analyses, greater sleep duration was associated with lower odds (P < 0.0001) of all six indicators of depressive mood. Five of the six sleep duration point estimates from the START Study, and four of the six wake-up time point estimates, fell within the 95% confidence intervals from the previous analysis. However, the associations between wake-up time and outcomes differed between the two studies’ analyses. CONCLUSION: Our findings add strength to the evidence supporting an association between short sleep duration and depression. This issue deserves attention from school districts, given the current epidemic of short sleep duration among youth and the potential impact school scheduling can have on teen sleep.

Introduction: Laws banning smoking in indoor public places have been associated with reductions in second-hand smoke exposure and cardiovascular disease among non-smokers. Second-hand smoke exposure has been associated with hypertension in prior studies. However, it is unknown whether smoke-free policies are associated with changes in blood pressure. Hypothesis: We tested the hypothesis that living in an area with a smoke-free policy banning smoking in restaurants, bars, and/or other workplaces is associated with reductions in systolic and diastolic blood pressure among non-smokers. Methods: Longitudinal data from 2,896 non-smoking participants of the Coronary Artery Risk Development in Young Adults (CARDIA) Study (aged 18-30 at enrollment, 1985-2011, 14,193 person-exam-years) were linked to state, county, and local 100% smoke-free policies in bars, restaurants, and/or non-hospitality workplaces based on participants’ census tract of residence at each exam. Fixed-effects linear regression estimated associations of each type of smoke-free policy (restaurant, bar, workplace) with within-person changes in systolic and diastolic blood pressure (SBP and DBP). Models adjusted for time-varying covariates: exam year (categorical), socio-demographic (education, income, marital status), health-related (body mass index, total physical activity, alcohol use), and policy (state cigarette tax, self-reported ban on smoking in their workplace) covariates, and interactions of baseline covariates (age, sex, race, field center) with exam year to account for differences in blood pressure patterns that were associated with these characteristics (p Results: At baseline, mean SBP was 110.5 mmHg and mean DBP was 69.3 mmHg. By year 25, a majority of participants were exposed to smoke-free policies in restaurants (1,759 of 2,264, 78%), bars (1,536 of 2,264, 68%), and other workplaces (1,518 of 2,264, 67%). Smoke-free policies were associated with within-person reductions in SBP and DBP in fully adjusted models (expressed as average change between exams in mmHg). Mean reductions in SBP were -0.77 (95% CI: -1.51, -0.02) for restaurant policies, -0.73 (95% CI: -1.54, 0.08) for bar policies, and -0.79 (95% CI: -1.51, -0.08) for workplace policies. Mean reductions in DBP were -0.67 (95% CI: -1.27, -0.06) for restaurant policies, -0.54 (95% CI: -1.20, 0.11) for bar policies, and -0.86 (95% CI: -1.44, -0.28) for workplace policies. Conclusions: Smoke-free policies in restaurants and other workplace are associated with within-person reductions in systolic and diastolic blood pressure among non-smokers. These results suggest an additional health benefit of these policies beyond those previously described in the literature.

Objective: In 2010 nearly 60% of American Indian (AI) adults in Minnesota reported they currently used cigarettes, a prevalence 3.5 times greater than the general population in that region. Here, we aim to describe the prevalence of secondhand smoke exposure and its correlates among Upper Midwest AIs in their homes and at work. Methods: Between 2010 and 2012 the American Indian Community Tobacco Project (AICTP) administered the Adult Tobacco Survey in collaboration with seven reservations and three urban communities in Minnesota. Eligible participants (n=2926) answered questions regarding exposure to secondhand smoke. Results: A third [33% (347 of 1059), 95% CI (30-36%)] of AIs reported being exposed to smoke in their workplace (compared to the 9% of the general Minnesota population). Half of males [50% (155 of 365), 95% CI (42-58%)] were exposed to secondhand smoke in the workplace, whereas only 27% [188 of 686, 95% CI (26-33%)] of females were exposed to secondhand smoke in the work environment. Of those who work on the reservation, 42% [237 of 570, 95% CI (36-48%)] of AI’s were exposed to secondhand smoke at their workplace. Within AI’s who have never smoked 25% [34 of 134, 95% CI (21-41%)] were still exposed to secondhand smoke within the workplace. Among AI’s who reported smoking policies in the workplace 30% [205 of 671, 95% CI (26-38%)] were exposed to secondhand smoke within the workplace, and 27% [158 of 578, 95% CI (20-30%)] of AI’s who stated their workplace was always enforced were still exposed to secondhand smoke in the workplace. A third [37% (120 of 321), 95% CI (35-54%)] of those who reported not having a workplace policy were exposed to secondhand smoke, demonstrating the need for policy development regarding smoking in the workplace. Conclusions: In conclusion, although strong policy protects most Minnesotans from secondhand smoke in workplaces, these policies do not seem to be benefitting AIs in the state. Discovery of who is at greatest risk for secondhand smoke exposure can inform future interventions and inform future policy optimization and protection.

Introduction Few studies have used longitudinal cohort data to examine associations of cigarette prices with smoking cessation or whether price sensitivity varies by income or education. This study examines these associations in a multicenter US cohort and explores whether associations vary by education and income. Methods Longitudinal data from baseline daily cigarette smokers aged 18-30 years in the Coronary Artery Risk Development in Young Adults study were linked to inflation-adjusted cigarette carton prices from the Council for Community and Economic Research Cost of Living Index based on residential address at baseline and in years 7, 10, and 15 (1985-2001). Multivariable Cox models estimated hazard ratios (HRs) of first (any) smoking cessation and sustained smoking cessation (no relapse) associated with each $1 increase in time-dependent cigarette price over 15 years of follow-up. Models were adjusted for sociodemographic, health-related, and policy covariates. We assessed effect modification by education and household income. Results Among 1489 participants, a $1.00 higher cigarette carton price was associated with a 16% higher likelihood of first smoking cessation (HR = 1.16, 95% CI = 1.11 to 1.21) and an 8% higher likelihood of sustained smoking cessation (HR = 1.08, 95% CI = 1.02 to 1.14). Associations were strongest among participants with lower income for first cessation, and among those with higher income for sustained cessation. Associations were strongest for participants with less than a high school degree for both outcomes. Conclusions Results suggest higher cigarette prices promote smoking cessation among young to middle-aged adults, and that price sensitivity may differ by socioeconomic status. Implications Few studies have examined longitudinal associations of cigarette prices with smoking cessation, and findings are mixed on whether price sensitivity varies by education or income. In a cohort of US adult daily smokers, cigarette prices were associated with greater likelihood of both a first cessation and sustained cessation. Price associations with first cessation were stronger among low-income smokers, but associations with sustained cessation were stronger among high-income smokers. Results suggest that although higher cigarette prices may promote short-term smoking cessation among smokers at all income levels, additional supports may be needed to facilitate sustained smoking cessation among low-income smokers.

We characterized socioeconomic disparities in short sleep duration, which is linked to multiple adverse health outcomes, in a population-based sample of veterans of the US wars in Iraq and Afghanistan who had interacted with the Minneapolis VA Health Care System. Lower reported household assets, lower food security, greater reported discrimination, and lower subjective social status were significantly (P

Objective Many American households struggle to bring in sufficient income to meet basic needs related to nutrition, housing, and healthcare. Nicotine addiction and consequent expenditures on cigarettes may impose extra financial strain on low-income households. We examine how cigarette use behaviors relate to self-reported financial stress/strain among low-income smokers. Methods At baseline in 2011/12, OPT-IN recruited adult smokers age 18–64 from the administrative databases of the state-subsidized Minnesota Health Care Programs (N = 2406). We tested whether nicotine dependency, type of cigarettes used, and smoking intensity were associated with self-reported difficulty affording food, healthcare, housing, and living within one’s income. All regression models were adjusted for race, education, income, age, and gender. Results Difficulty living on one’s income (77.4%), paying for healthcare (33.6%), paying for housing (38.4%), and paying for food (40.8%) were common conditions in this population. Time to first cigarette and cigarettes smoked per day predicted financial stress related to affording food, housing, and living within one’s income (all p, Highlights • Many struggle to meet needs related to nutrition, housing, and healthcare. • Smoking may contribute to difficulties faced paying for necessities. • Heavier and more nicotine-dependent smokers reported more financial stress. • Type of cigarette used was not associated with financial stress.