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Despite the high prevalence of obesity and associated health risks in the United States adult population, few primary care providers (PCPs) have time and training to provide weight-management counseling to their patients. This study aims to compare the effect of referral to a comprehensive automated digital weight-loss program, with or without provider email feedback, with usual care on weight loss in patients with overweight or obesity.A total of 550 adults (mean [SD], 51.4 [11.2] years, BMI = 35.1 [5.5] kg/mWeight changes (mean [SE]) at 12 months were -0.92 (0.46), -3.68 (0.46), and -3.58 (0.48) kg in the EUC, IWL, and IWL + PCP groups, respectively. Outcomes were significantly different in EUC versus IWL and EUC versus IWL + PCP (p 0.001), but not in IWL versus IWL + PCP.Referral by PCPs to an automated weight-loss program holds promise for patients with obesity. Future research should explore ways to further promote accountability and adherence.

To evaluate the impact of a fruit and vegetable prescription program on diabetes and cardiovascular risk outcomes.Single-arm pre-post study.Primary care clinic in a community-based hospital.Adults with type 2 diabetes (n = 97), aged18 years, with hemoglobin A1c (HbA1c) ≥ 7.0%, and a body mass index (BMI) of ≥ 25 kg/mOver 7 months, participants received monthly group-based diabetes self-management education (DSME) and monthly vouchers ($28-$140/month) redeemable for fruits and vegetables at local markets.Biomarker changes (HbA1c, BMI, and blood pressure) were assessed with paired t tests. Voucher distribution and redemption were tracked, and voucher redemption rates were calculated. Linear mixed-effect regression models tested associations between biomarkers, voucher redemption rates, and participant characteristics.There was a -1.3% (P0.001) postprogram change in HbA1c. Reduced HbA1c was associated with higher voucher redemption rates (P = 0.032) and a change in diabetes medications (P = 0.003). There were no associations with BMI, but blood pressure was positively associated with voucher redemption.Fruit and vegetable prescription programs may improve diabetes outcomes by incentivizing DSME uptake and retention. Future randomized trials are warranted to identify strategies to improve DSME engagement and voucher redemption rates and assess mechanisms through which these programs influence health outcomes.

Cancer survivors experience a worse health-related quality of life (HRQoL) than non-cancer survivors. However, it is not fully understood whether social determinants of health (SDOH) and health behaviors are significantly associated with HRQoL among cancer survivors. The purpose of this study was to investigate the influence of SDOH and health behaviors on HRQoL among cancer survivors.We identified adult (18 years or older) cancer survivors (n = 5784) in the 2017 and 2019 Behavioral Risk Factor Surveillance System. The primary outcome (HRQoL) was defined as whether cancer survivors reported having poor mental or physical health (e.g., 14 or more mentally or physically unhealthy days). Unadjusted and adjusted logistic regression was used to compute the odds ratios and 95% CIs of factors associated with poor HRQoL among the cancer survivors.More than half of the cancer survivors were non-Hispanic White, female, and 65 years or older. In the adjusted multivariable logistic regression models, cancer survivors who were physically active and who did not avoid care because of costs had a lower risk of poor mental and physical health. Current smokers were more likely to report poor physical health. Homeowners were less likely to report poor mental health. Daily fruit and vegetable consumption and healthcare coverage were not associated with poor HRQoL.Some SDOH (healthcare access, economic stability, and the neighborhood and built environment) and health behavior (physical activity) are associated with lower likelihood of experiencing poor mental and/or physical health in the cancer survivors. The study findings can be used to target survivors who experience suboptimal HRQoL and to inform research, public health policies, and/or programs.

Food systems influence environmental sustainability and health. The fact that our current food production and distribution practices neither support nor promote planetary or human health raises ethical concerns. Since health organizations offer food to patients, community members, and employees, they are situated at key intersections among food systems, agricultural policies and practices, and public health. This article considers the nature and scope of health care organizations' local food system leadership responsibilities and describes how health care organizations' food practices can help improve health outcomes and motivate equity.

BACKGROUND Low dietary intake of fruits and vegetables and physical inactivity are 2 modifiable risk factors for cardiovascular disease. Fruit and vegetable gardening can provide access to fresh produce, and many gardening activities are considered moderate physical activity. This makes gardening interventions a potential strategy for cardiovascular disease risk reduction. Previously developed gardening interventions have relied on in-person delivery models, which limit scalability and reach. OBJECTIVE The purpose of this study was to ascertain participant insight on intervention components and topics of interest to inform a digitally delivered, gardening-focused, multiple health behavior change intervention. METHODS A web-based survey was delivered via Amazon Mechanical Turk (MTurk), including quantitative and open-ended questions. Eligible participants were aged ≥20 years, could read and write in English, were US residents, and had at least a 98% MTurk task approval rating. A multilevel screening process was used to identify and exclude respondents with response inattention, poor language fluency, or suspected automated web robots (bots). Participants were asked about their interest in gardening programming, their preferences for intervention delivery modalities (1-hour expert lectures, a series of brief RESULTS A total of 465 participants were included (n=212, 45.6% NG and n=253, 54.4% EG). There was a high level of program interest overall (n=355, 76.3%), though interest was higher in EG (142/212, 67% NG; 213/253, 84.2% EG; PP=.16) over 1-hour lectures (29/212, 13.7% NG; 50/253, 19.8% EG; P=.08) or in-person delivery modes (47/212, 22.2% NG; 57/253, 22.5% EG; P=.93). Intervention functions identified were education and training (performing fundamental gardening and cooking activities), environmental restructuring (eg, social support), enablement (provision of tools or seeds), persuasion (offering encouragement and highlighting the benefits of gardening), and modeling (using content experts and participant testimonials). Content areas identified included the full lifecycle of gardening activities, from the fundamentals of preparing a garden site, planting and maintenance to harvesting and cooking. CONCLUSIONS In a sample of potential web-based learners, participants were interested in a digitally delivered gardening program. They preferred brief videos for content delivery and suggested content topics that encompassed how to garden from planting to harvesting and cooking. The next step in this line of work is to identify target behavior change techniques and pilot test the intervention to assess participant acceptability and preliminary efficacy. CLINICALTRIAL

Gardening benefits health in older adults, but previous studies have limited generalizability or do not adequately adjust for sociodemographic factors or physical activity (PA).We examined health outcomes, fruits and vegetables (FV) intake, and 10-year mortality risk among gardeners and exercisers compared with nonexercisers.Cross-sectional data of noninstitutionalized US adults in the 2019 Behavioral Risk Factor Surveillance System was collected via landline and cellular phone survey.Adults 65 years and older reporting any PA (n = 146,047) were grouped as gardeners, exercisers, or nonexercisers.Outcomes included cardiovascular disease (CVD) risk factors, mental and physical health, FV intake, and 10-year mortality risk.Summary statistics were calculated and adjusted logistic regression models were conducted to calculate adjusted odds ratios (aORs) and 95% CIs, accounting for the complex survey design.The sample included gardeners (10.2%), exercisers (60.0%), and nonexercisers (30.8%). Gardeners, compared with nonexercisers, had significantly lower odds of reporting all studied health outcomes and higher odds of consuming 5 or more FV per day (CVD: aOR 0.60, 95% CI 0.53 to 0.68; stroke: aOR 0.55, 95% CI 0.47 to 0.64; heart attack: aOR 0.63, 95% CI 0.55 to 0.73, high cholesterol: aOR 0.86, 95% CI 0.79 to 0.93; high blood pressure: aOR 0.74, 95% CI 0.68 to 0.81; diabetes: aOR 0.51, 95% CI 0.46 to 0.56; body mass index ≥25: aOR 0.74, 95% CI 0.68 to 0.80; poor mental health status: aOR 0.50, 95% CI 0.43 to 0.59; poor physical health status: aOR 0.35, 95% CI 0.31 to 0.39; 5 or more FV per day: aOR 1.56, 95% CI 1.40 to 1.57; high 10-year mortality risk: aOR 0.39, 95% CI 0.36 to 0.42). Male and female gardeners had significantly lower odds of reporting diabetes even when compared with exercisers.Among adults 65 years and older, gardening is associated with better CVD health status, including lower odds of diabetes. Future longitudinal or interventional studies are warranted to determine whether promoting gardening activities can be a CVD risk reduction strategy.

BACKGROUNDThe U.S. Food and Drug Administration and the government of New Zealand have proposed a reduction of the nicotine content in cigarettes to very low levels. This study examined the likely effects of this regulation in smokers with affective disorders.METHODSIn a randomized controlled trial conducted at two sites (Penn State Hershey and Massachusetts General Hospital, Boston) 188 adult smokers with a current or lifetime anxiety or unipolar mood disorder, not planning to quit in the next 6 months, were randomly assigned to smoke either Usual Nicotine Content (UNC) (11.6 mg nicotine/cigarette) cigarettes, or Reduced Nicotine Content (RNC) cigarettes where the nicotine content per cigarette was progressively reduced to 0.2 mg in five steps over 18 weeks. Participants were then offered the choice to either receive assistance to quit smoking, receive free research cigarettes, or resume using their own cigarette brand during a 12-week follow-up period. Main outcomes were biomarkers of nicotine and toxicant exposure, smoking behavior and dependence and severity of psychiatric symptoms.RESULTSAfter switching to the lowest nicotine content cigarettes, compared to smokers in the UNC group, the RNC group had significantly lower plasma cotinine (metabolite of nicotine), urine NNAL (metabolite of NNK, a lung carcinogen), exhaled carbon-monoxide, cigarette consumption, and cigarette dependence. There were no significant effects on psychiatric symptoms. At the end of the 12-week treatment choice phase, those randomized to the RNC group were more likely to have quit smoking (18% RNC v 4% UNC, p=0.004).CONCLUSIONReducing nicotine content in cigarettes to very low levels reduces toxicant exposure and cigarette addiction and increases smoking cessation in smokers with mood and/or anxiety disorders, without worsening mental health.Trial registrationTRN: NCT01928758, registered August 21, 2013

Introduction The Food and Drug Administration issued an advanced notice of proposed rulemaking for setting a product standard for nicotine levels in cigarettes, with an emphasis on minimally or non-addicting very low nicotine content (VLNC). Methods A 33 week, two-arm, double-blind randomized trial conducted in Hershey, Pennsylvania, USA and Washington, DC, USA included adult daily cigarette smokers (≥5 cigarettes per day) with less than a college degree, and who had no plans to quit within the next six months. Participants were randomized to either reduced nicotine content (RNC) study cigarettes tapered every three weeks to a final VLNC (0.2 mg/cigarette) for six weeks or to usual nicotine content (UNC) study cigarettes (11.6 mg/cigarette). Outcomes included acceptability of study cigarettes measured by attrition (primary outcome), compliance, reduction in cigarette dependence and tobacco biomarkers, and post-intervention cessation. Results The RNC (n = 122) versus UNC (n = 123) group had higher attrition (adjusted Hazard Ratio 3.4; 95% confidence interval [CI] 1.99 to 5.81). At the end of the intervention, cotinine levels were 50% lower in the RNC group (mean group difference −137 ng/mL; 95% CI −172, −102). The RNC group smoked fewer CPD (−4.1; 95% CI −6.44, −1.75) and had lower carbon monoxide levels (−4.0 ppm; 95% CI −7.7, −0.4). Forty seven percent (29/62) of the RNC group were biochemically-confirmed compliant with smoking VLNC cigarettes (mean cotinine = 8.9 ng/ml). At three month follow-up, only compliant VLNC smokers quit with an assisted quit attempt (N = 6/22, 27%). Conclusions This study supports a VLNC standard in cigarettes. Implications Differential dropout and noncompliance indicate some smokers had difficulty transitioning to cigarettes with reduced nicotine. These smokers will benefit from supplemental nicotine in medicinal or noncombustible tobacco products if a nicotine reduction standard is established. Other smokers successfully transitioned to very low nicotine content cigarettes exclusively and substantially reduced their exposure to nicotine.

Background There is compelling evidence on the impact of diet as preventative medicine, and with rising health care costs healthcare organizations are attempting to identify interventions to improve patient health outcomes. Objectives The purpose of this systematic scoping review was to characterize existing healthcare organization-based interventions to improve access to fruits and vegetables (F&V) for their patient populations. In addition, we aimed to review the impact of identified interventions on dietary intake and health outcomes. Methods Titles and abstracts were searched in PubMed® (MEDLINE®), Embase®, CINAHL®, and the Cochrane Library® from 1 January 1990 to 31 December 2019. To be selected for inclusion, original studies must have included a healthcare organization and have had a programmatic focus on increasing access to or providing fresh F&V to patients in an outpatient, naturalistic setting. The Effective Public Health Practice Project tool was used to assess study quality in 6 domains (selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts). Results A total of 8876 abstracts were screened, yielding 44 manuscripts or abstracts from 27 programs. Six program models were identified: 1) a cash-back rebate program, 2) F&V voucher programs, 3) garden-based programs, 4) subsidized food box programs, 5) home-delivery meal programs, and 6) collaborative food pantry-clinical programs. Only 6 of 27 studies included a control group. The overall quality of the studies was weak due to participant selection bias and incomplete reporting on data collection tools, confounders, and dropouts. Given the heterogeneity of outcomes measured and weak study quality, conclusions regarding dietary and health-related outcomes were limited. Conclusions Healthcare-based initiatives to improve patient access to F&V are novel and have promise. However, future studies will need rigorous study designs and validated data collection tools, particularly related to dietary intake, to better determine the effect of these interventions on health-related outcomes.

Introduction The extent to which use of electronic nicotine delivery systems (ENDS) for smoking reduction leads to cigarette abstinence in smokers with no plans to quit smoking is unclear. This exploratory analysis examined the effects of ENDS delivering different amounts of nicotine on cigarette abstinence up to 24-week follow-up, in comparison to placebo or a behavioral substitute. Methods This four-arm parallel-group, randomized, placebo-controlled trial took place at two academic medical centers in the United States (Penn State Hershey and Virginia Commonwealth University). Participants were current adult smokers (N = 520) interested in reducing but not planning to quit. They received brief advice and were randomized to one of four 24-week conditions, receiving either an eGo-style ENDS paired with 0, 8, or 36 mg/ml nicotine liquid (double-blind) or a cigarette-shaped tube, as a cigarette substitute (CS). Self-reported daily cigarette consumption and exhaled carbon monoxide (CO) were measured at all study visits. Outcomes included intent-to-treat, self-reported 7-day cigarette abstinence, biochemically confirmed by exhaled CO at 24 weeks after randomization. Results At 24 weeks, significantly more participants in the 36 mg/ml condition (14/130, 10.8%) than in the 0 mg/ml condition (1/130, 0.8%) and the CS condition (4/130, 3.1%) were abstinent (relative risk = 14 [95% CI = 1.9–104.9] and 3.5 [95% CI = 1.2–10.4], respectively). The abstinence rate in the 8 mg/ml condition was 4.6% (6/130). Conclusions When smokers seeking to reduce smoking tried ENDS, few quit smoking in the short term. However, if smokers continued to use an ENDS with cigarette-like nicotine delivery, a greater proportion completely switched to ENDS, as compared with placebo or a cigarette substitute. Implications The extent to which use of electronic nicotine delivery systems (ENDS) for smoking reduction leads to cigarette abstinence in smokers with no plans to quit smoking was unclear. This randomized trial found that ENDS with nicotine delivery approaching that of a cigarette are more effective in helping ambivalent smokers to quit cigarette smoking.

Background: While student-run free clinics (SRFCs) increasingly serve as part of the safety net for the uninsured and underinsured, it is unknown whether SRFCs consistently follow immunization guidelines in patients that smoke. This study characterized the preventative care in our clinic by evaluating the rate of adult immunizations and referrals of patients that smoke to cessation treatment. Methods: We conducted a retrospective chart review of patients seen in 2016 at the LionCare Free Clinic. Data extracted included tobacco smoking status, desire to quit, smoking cessation treatment referrals, influenza and pneumococcal vaccination status, and demographics. Chi-square tests and Fisher Exact analysis were used to examine differences in influenza and pneumococcal vaccination rates in smokers versus non-smokers. We assessed the rate of interested smokers who received a referral to cessation therapy. Results: In 2016, 498 patients were evaluated, of whom 67% were smokers. Among smokers, 21% reported receiving the influenza vaccination compared to 20% of non-smokers (p=0.85). Seven percent of patients who smoke received the pneumococcal vaccine compared to 5% of non-smokers. Of the total patients who were vaccinated, a small percentage received the vaccines in the clinic. Although 66% of smokers reported interest in quitting during the first clinic visit, only 3% were referred to a smoking cessation program. Conclusion: SRFCs face challenges in providing preventative health care for the underserved population. Despite guidelines recommending smokers receive the pneumococcal vaccine before age 65, few patients received it. Quality improvement interventions are needed to improve preventative health services to this vulnerable population.

Introduction Little is known about the effects of long-term e-cigarette use, particularly the risks of relapse to cigarette smoking or increased dependence. Methods In a 2012–2014 baseline online e-cigarette survey, 1,863 respondents consented to participate in future research. A follow-up online survey was conducted in 2017–2018 to assess changes in e-cigarette use behaviors and e-cigarette–related dependence. For both surveys, exclusive e-cigarette use was defined as only using e-cigarettes in the past 7 days, and poly use was defined as using both e-cigarettes and other tobacco or nicotine products in the past 7 days. The Penn State Electronic Cigarette Dependence Index (PSECDI) score was calculated for each study subject and was used to evaluate e-cigarette dependence. Paired t-tests or Pearson correlation coefficients were used to examine changes in e-cigarette use behaviors or PSECDI scores between baseline and follow-up. Baseline and follow-up survey data were analyzed in January 2019. Results A total of 494 subjects provided complete data on both surveys. At baseline, 402 subjects (81.4%) were exclusive e-cigarette users, and 71 subjects (14.4%) were poly users. Among baseline exclusive e-cigarette users, the majority (88.3%) continued using e-cigarettes exclusively, but 37 users (9.2%) became poly users and 1 returned to cigarette smoking at follow-up. Among baseline poly users, 60.6% became exclusive e-cigarette users at follow-up. The mean PSECDI score remained similar over time (8.4 at baseline vs 8.3 at follow-up). Conclusions Findings suggest that the risk of relapse to cigarette smoking is low, and e-cigarette-related dependence remains stable in long-term e-cigarette users.

Background Eleven percent of households in the United States experience food insecurity, which is a lack of access to adequate, desirable food for a healthy lifestyle. Although food insecurity is associated with increased risk of obesity and nonadherence to dietary management of chronic diseases such as diabetes, the correlates of food insecurity have not yet been studied in a bariatric surgery population. Objectives To replicate, in a bariatric sample, previous findings that food insecurity is related to eating pathology and to test the hypothesis that this relationship is mediated by depressive symptoms. Setting University hospital, United States. Methods Two hundred forty bariatric surgery candidates responded to self-report measures of food insecurity and mood, night-eating, and binge-eating symptoms. The sample was 74% female and 71% white, with a mean age of 41.09 (11.84) years. Based on responses to the United States Department of Agriculture Adult Food Security Survey Model, 15.8% were categorized as food insecure and 25.8% as marginally food secure. Multiple regression models with bootstrapping for confidence interval estimates were used to explore mediation hypotheses. Results Food insecurity was positively associated with symptoms of night eating and binge eating, and these relationships were cross-sectionally mediated by depressive symptoms. Conclusions Food insecure bariatric candidates may be at increased risk of poorer postoperative outcomes because of lack of access to needed food and the detrimental mental health impact of this lack of access.

OBJECTIVES: Health advocates have been working to educate the public about the harms of smoking for more than 50 years. Recently, smoking rates have reduced more slowly among people with low incomes. The purpose of this study was to evaluate what low-income smokers may have learned from a lifetime of exposure to public health education and how this knowledge may have translated into smoking-related behaviors. METHODS: We used narrative inquiry and elicitation interview techniques. Interviews were recorded, transcribed verbatim, coded, and organized into themes using the constant comparative method. RESULTS: All the participants were aware of smoking-related harms to health but negative experiences with quitting, cessation medications, and healthcare professionals contributed to avoiding or rejecting educational messages. Participants’ perceptions of hypocritical societal tobacco control policies also led some to believe that the harms of tobacco use were exaggerated, or were being used to control or manipulate them. This contributed to a distrust of the government, public health advocates, and healthcare providers. CONCLUSIONS: Low-income smokers were aware of the harms of smoking and that quitting would improve their health. Public health advocates should consider developing messages that attempt to foster trust in healthcare professionals and are consistent with low-income adult smokers’ quitting experiences.

OBJECTIVES: Cigarettes vary in rod length but are generally thought of as a constant unit. In this study, we evaluated whether the rod length of participants’ usual brand cigarettes affected their perceptions and smoking habits when switching to SPECTRUMs. METHODS: Data were analyzed for 341 participants smoking their own brand cigarettes for one week and after switching to normal nicotine content (11.6 mg) SPECTRUMs for 2 weeks. Changes in perceptions of cigarette attributes and biomarkers of smoke exposure were evaluated using linear mixed models among 3 groups: usual length short (ULS, 72 mm); medium/king (ULM, ~84 mm); and long (ULL ≥ 100 mm). RESULTS: Among the 3 cigarette length groups, only ULL smokers’ rated SPECTRUMs significantly less strong, harder to draw, lower in taste, and lower in enjoyment (p < .03) compared to usual brand. Among all groups, satisfaction was significantly lower for SPECTRUMs (p < .02). Cigarettes per day (CPD) increased significantly more for ULL (+4.75 CPD) as compared to ULM (+1.38 CPD) (p < .001). When switching to SPECTRUMs, cotinine-per-cigarette decreased among all groups, and exhaled carbon monoxide increased significantly in ULL and ULM smokers (p < .001). CONCLUSION: People who smoked long cigarettes had the largest changes in perceptions and use when switching to SPECTRUM research cigarettes.

Summary Background Electronic nicotine delivery systems (ENDSs) are used by some smokers to reduce cigarette consumption, but their effectiveness is uncertain. We aimed to examine the extent to which ENDSs or a non-nicotine cigarette substitute influence tobacco-related toxicant exposure and cigarette consumption in smokers interested in smoking reduction. Methods We did a four-arm, parallel-group, randomised controlled trial at two sites in the USA (Penn State University, Hershey, PA, and Virginia Commonwealth University, Richmond, VA). We enrolled adults aged 21–65 years who smoked more than nine cigarettes per day (for at least the past year), with exhaled CO of more than 9 parts per million at screening, who were not currently using an ENDS, and who were interested in reducing smoking but not quitting. Participants were randomised (site-specific with allocation concealment; 1:1:1:1) to receive either a cartomiser-based, pen-style ENDS (eGo-style) paired with 0, 8, or 36 mg/mL liquid nicotine (participants and researchers masked to concentration) or a non-ENDS cigarette-shaped plastic tube that delivered no nicotine or aerosol (cigarette substitute; unmasked) for 24 weeks. Conditions were chosen to reflect a range of nicotine delivery including none (cigarette substitute and 0 mg/mL ENDS), low (8 mg/mL), and cigarette-like (36 mg/mL), and all conditions were paired with smoking reduction instructions. The primary outcome was concentration of the tobacco-specific carcinogen metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL; urinary total) collected at randomisation and at 4, 12, and 24 weeks. Multiple imputation with and without covariate adjustment was used in addition to sensitivity analyses. This trial is registered with ClinicalTrials.gov, NCT02342795. Findings Between July 22, 2015, and Nov 16, 2017, 684 individuals were screened and 520 (76%) were enrolled and randomised. 188 (36%) of 520 participants were lost to follow-up by week 24; attrition did not differ by study group (39 [30%] of 130 in the cigarette substitute group, 56 [43%] of 130 in the ENDS with 0 mg/mL nicotine group, 49 [38%] of 130 in the ENDS 8 mg/mL group, and 44 [34%] of 130 in the ENDS 36 mg/mL group). Urinary total NNAL at 24 weeks in the ENDS with 36 mg/mL nicotine group was 210·80 pg/mg creatinine (95% CI 163·03–274·42) compared with 346·09 pg/mg creatinine (265·00–455·32) in the cigarette substitute group (p=0·0061). No other significant differences between groups were observed for any time point for urinary total NNAL. Serious adverse event frequency was similar across groups (12 events in 12 participants [9%] in the ENDS with 36 mg/mL nicotine group, seven events in six participants [5%] in the 8 mg/mL group, 11 events in ten participants [8%] in the 0 mg/mL group, and 13 events in 13 participants [10%] in the cigarette substitute group), and all of these were deemed unrelated or unlikely to be related to study product use. There was one death between randomisation and 24 weeks (suicide; in the ENDS with 0 mg/mL nicotine group). Interpretation Use of an ENDS with cigarette-like nicotine delivery can reduce exposure to a major pulmonary carcinogen, NNAL, even with concurrent smoking. Future ENDS trials should involve products with well characterised nicotine delivery, including those with nicotine delivery approaching that of a cigarette. Funding National Institutes of Health, US Food and Drug Administration.

Background Studies regarding whether light to moderate alcohol consumption is associated with a lower risk of cardiovascular diseases (CVD) have generated mixed results. Further, few studies have examined the potential impact of alcohol consumption on diverse disease outcomes simultaneously. We aimed to prospectively study the dose-response association between alcohol consumption and risk of CVD, cancer, and mortality. Methods This study included 83,732 adult Chinese participants, free of CVD and cancer at baseline. Participants were categorized into 6 groups based on self-report alcohol consumption: 0, 1–25, 26–150, 151–350, 351–750, and > 750 g alcohol/wk. Incident cases of CVD, cancers, and mortality were confirmed by medical records. Hazard ratios (HRs) for the composite risk of these three outcomes, and each individual outcome, were calculated using Cox proportional hazard model. Results During a median follow-up of 10.0 years, there were 6411 incident cases of CVD, 2947 cancers and 6646 deaths. We observed a J-shaped relation between alcohol intake and risk of CVD, cancer, and mortality, with the lowest risk at 25 g/wk., which is equivalent to ~ 2 servings/wk. Compared to consuming 1–25 g/wk., the adjusted HR for composite outcomes was 1.38 (95% confidence interval (CI):1.29–1.49) for non-drinker, 1.15 (95% CI: 1.04–1.27) for 26–150 g/wk., 1.22 (95% CI: 1.10–1.34) for 151–350 g/wk., 1.33 (95% CI: 1.21–1.46) for 351–750 g/wk., and 1.57 (95% CI: 1.30–1.90) for > 750 g/wk., after adjusting for age, sex, lifestyle, social economic status, and medication use. Conclusions Light alcohol consumption at ~ 25 g/wk was associated with lower risk of CVD, cancer, and mortality than none or higher consumption in Chinese adults.

OBJECTIVES: Gestational diabetes (GDM), glucose intolerance with onset during pregnancy, is associated with increased risk of maternal and fetal complications. Prevention and management are critical, with diet and exercise as mainstays. Diets rich in fruits and vegetables are beneficial for glucose control. Despite receiving nutrition counseling by dietitians, patients often have difficulty successfully implementing lifestyle changes. Prevention Produce is a student-run program previously shown to benefit patients with hypertension. This pilot study was conducted to determine feasibility of implementing Prevention Produce with a tailored nutrition curriculum for women with newly diagnosed GDM. Secondary aims included measurement of change in nutrition knowledge, fruits and vegetable intake, glucose control, and incidence of related pregnancy complications. METHODS: Women newly diagnosed with GDM through routine obstetric care at Penn State were screened and consented. Baseline data was obtained, including a nutrition knowledge questionnaire, validated food intake survey, and fruit and vegetable preferences. Nutrition, public health and medical students collaborated to provide patients with four sessions each including nutrition lessons and vouchers for produce at a market. After completion of the program, participants repeated the questionnaires which were compared to baseline. RESULTS: To date, 6 out of 9 patients enrolled have completed the program. Of those who completed the program, 83% rated the program as excellent, felt it improved their health overall, and reported eating more fruits and vegetables. Additionally, 100% felt it helped manage their GDM. Nutrition knowledge improved in 83% of patients by an average of 14% in questionnaire scores. The majority of patients increased servings of vegetables compared to baseline, with increased preferences for peppers, tomatoes, and cucumbers predominating. CONCLUSIONS: Preliminary results demonstrate that patients with newly diagnosed GDM find Prevention Produce helpful for improving produce intake and health overall. Participants will be monitored for the remainder of pregnancy, with a more in-depth evaluation of glucose control and rates of related complications. FUNDING SOURCES: Community Start Up Grant, Penn State Hershey Public Health Sciences.

Background The United States Food and Drug Administration has prioritized understanding the dependence potential of electronic cigarettes (e-cigs). Dependence is often estimated in part by examining frequency of use; however measures of e-cig use are not well developed because of varying product types. This study used an e-cig automatic puff counter to evaluate the value of self-reported e-cig use measures in predicting actual use (puffs). Methods Data were collected from a two-site randomized placebo-controlled trial evaluating the effects of e-cigs on toxicant exposure in smokers attempting to reduce their cigarette consumption. Participants randomized to an e-cig condition self-reported their e-cig frequency of use (times per day—one “time” consists of around 15 puffs or lasts around 10 minutes) on the Penn State Electronic Cigarette Dependence Index (PSECDI) and kept daily diary records of the number of puffs per day from the e-cig automatic puff counter. A linear mixed-effects model was used to determine the predictive value of the times per day measure. Correlations were used to further investigate the relationship. Results A total of 259 participants with 1165 observations of e-cig use were analyzed. Self-reported e-cig use in times per day was a significant predictor of e-cig puffs per day (p < .01). The Spearman correlation between measures was r equal to .58. Examination of individual participant responses revealed some potential difficulties reporting and interpreting times per day because of the difference in use patterns between cigarettes and e-cigs. Conclusion This study provides evidence that the self-reported PSECDI measure of times per day is a significant predictor of actual frequency of e-cig puffs taken. Implications Self-reported measures of e-cig frequency of use are predictive of actual use, but quantifying e-cig use in patterns similar to cigarettes is problematic.

Investigational tobacco products, specifically variable nicotine content research cigarettes (SPECTRUM), are available through the National Institute of Drug Abuse Drug Supply Program. Randomized controlled trials using research cigarettes are intended to support tobacco regulatory science research. The current paper provides an in-depth look into managing research cigarettes for two multi-site clinical trials and the design of a computer-based Cigarette Management System (CMS). The paper provides guidance intended for any investigator using similar products on the operating procedures under Good Clinical Practice standards and describes features of the CMS. The CMS and procedures described have been field tested for the past three years and have dispensed over 160,000 cigarette packs to participants. The CMS can accommodate a range of practical issues with real-world study implementation making it a robust application that is scalable to any study.

Introduction‘Stealth vaping’ is the practice of vaping discreetly in places where electronic cigarette (e-cigarette) use is prohibited. While anecdotal evidence suggests that stealth vaping is common, there have been no formal studies of the behaviour. The purpose of this study is to examine stealth vaping behaviour among experienced e-cigarette users.MethodsData were collected from the follow-up survey of a large longitudinal cohort study of adult experienced e-cigarette users conducted in January 2017. To measure stealth vaping behaviour, participants were asked ‘Have you ever ‘stealth vaped’, that is to say, used an e-cig in a public place where it was not approved and attempted to conceal your e-cig use? (yes/no)’. Participants indicating yes completed additional questions about the frequency of stealth vaping and were asked to select all the locations where they commonly stealth vape. Frequencies were used to examine the overall prevalence, frequency and common locations for stealth vaping. A logistic regression model was run to predict stealth vaping.ResultsApproximately two-thirds (64.3%, n=297/462) of the sample reported ever stealth vaping, of which 52.5% (n=156/297) reported stealth vaping in the past week. Among stealth vapers (n=297), 31% reported owning a smaller device solely for stealth vaping. The most common places to stealth vape included at work (46.8%), followed by bars/nightclubs (42.1%), restaurants (37.7%), at the movies (35.4%) and in airports/on airplanes (11.7%). Predictors of stealth vaping were greater dependence and owning a smaller device solely for stealth vaping.ConclusionsStealth vaping is a common behaviour for many experienced e-cigarette users. More research is needed to understand the reasons for stealth vaping and its potential health and safety implications. This information could help researchers and regulators to design interventions to minimise the public health impact of stealth vaping.

IntroductionAbout half of smokers relight their cigarette, a habit that is a risk factor for chronic bronchitis and possibly lung cancer. Little is known about the characteristics of smokers who relight and their dependence on nicotine. It is unknown whether relighting affects exposure to tobacco smoke constituents. This study examined the characteristics of relighters of usual brand cigarettes and whether relighting affects exposure to selected tobacco smoke constituents.MethodsWe explored relighting status and frequency, using baseline data from 248 adult smokers participating in studies of reduced nicotine cigarettes in relation to demographic and cigarette characteristics, smoking behaviors, nicotine dependence, biomarkers of exposure (exhaled carbon monoxide, blood cotinine), and biomarkers of oxidative stress (ratio of oxidized/reduced glutathione).Results69.4% (n = 172) of subjects reported relighting, and they relit an average of five cigarettes out of 20. Both relighters and non-relighters smoked a mean of 20 cigarettes per day (p = .6). Relighting was significantly associated with higher nicotine dependence, use of longer rod cigarettes, older age, lower income, and unemployment. There were no significant associations between relighting and blood cotinine, exhaled carbon monoxide or measures of oxidized/reduced blood glutathione.ConclusionsThe majority of subjects were relighters, who had higher levels of nicotine dependence than non-relighters. Relighters had similar levels of plasma cotinine and exhaled carbon monoxide to non-relighters.ImplicationsNo study has compared the cigarette characteristics and biomarkers of exposure of adult cigarette smokers who relight with those who do not. Relighting behavior was common in our sample and was associated with low income, not currently working, higher nicotine dependence, cigarette rod length, daily cigarette use years, and a lifetime history of depressed mood.

Resting state functional brain connectivity (rsFC) may be an important neuromarker of smoking behavior. Prior research has shown, among cigarette smokers, that nicotine administration alters rsFC within frontal and parietal cortices involved in executive control, as well as striatal regions that drive reward processing. These changes in rsFC have been associated with reductions in withdrawal symptom severity. We currently have a limited understanding of how rsFC is affected by the use of electronic cigarettes (ecigs), an increasingly popular class of products, the members of which deliver nicotine with varying effectiveness. The current study used fMRI to determine the effects of ecig use on rsFC and withdrawal symptoms. Independent component, dual regression, and permutation analyses were conducted on rsFC collected from ecig users before and after an ecig use episode (n=9) that occurred after 14 hours of nicotine abstinence. Similar to the known effects of nicotine administration, ecig use decreased rsFC of two clusters in the right frontal pole and frontal medial cortex with an attentional control salience network, and decreased rsFC of five clusters in the left thalamus, insula, and brain stem with a reward network encompassing the striatum. Ecig use increased inverse coupling between the prefrontal reward network and the right frontoparietal executive control network. Reductions in craving and difficulty with concentration were correlated with decreases in coupling strength between reward and executive control networks. These preliminary results suggest that the effects of ecig use on rsFC are similar to those seen with nicotine administration in other forms. In order to gain insight into the addictive potential of ecigs, further research is needed to understand the neural influence of ecigs across the range of nicotine delivery within this class of products.

Varenicline is a safe and effective aid to smoking cessation but most trials have involved frequent visits or intensive behavioral support unlike that typically provided in primary care. The current study examined if motivational text messages, sent via cellphone, would increase quit rates in smokers being treated with varenicline and 3 brief sessions in a family practice setting.This study was a randomized controlled, parallel-group smoking cessation trial. Intervention group participants (n = 74) received daily motivational text messages, additional texted tips in response to keywords, and weekly study questions while control group participants (n = 76) received only weekly study questions. Both groups received individualized counseling. Self-reported non-smoking and exhaled breath CO10ppm were used to validate smoking abstinence at 3 weeks and 12 weeks.Overall, 30.7% (46/150) of participants were abstinent at the 12 week follow-up and the abstinence rate did not differ between groups (INT 31.1% v. CON 30.3%, p = .91). The only predictor of abstinence at 12 weeks was use of varenicline during a previous quit attempt (p = .01). Intervention group participants were more likely to rate the text messaging program as good or excellent (p .01), to recommend a similar program to family or friends (p .01), and to complete positive smoking cessation activities (p = .04), when compared with the control group.Although there were no differences in quit rates between the intervention and control group, intervention group participants rated the text messaging system more favorably, were more likely to recommend the program to others, and were more likely to complete positive smoking cessation activities.

Background The Family Smoking Prevention and Tobacco Control Act gave the Food and Drug Administration jurisdiction over the regulation of all tobacco products, including their nicotine content. Under this act, a major strategy to reduce harm from cigarette tobacco is lowering the nicotine content without causing unintended adverse consequences. Initial research on reduced nicotine content (RNC) cigarettes has shown that smokers of these cigarettes gradually decrease their smoking frequency and biomarkers of exposure. The effectiveness of this strategy needs to be demonstrated in different populations whose response to RNC cigarettes might be substantially mediated by personal or environmental factors, such as low socioeconomic status (SES) populations. This study aims to evaluate the response to a reduced nicotine intervention in low SES smokers, as defined here as those with less than 16 years of education, by switching smokers from high nicotine commercial cigarettes to RNC cigarettes. Methods/design Adults (N = 280) who have smoked five cigarettes or more per day for the past year, have not made a quit attempt in the prior month, are not planning to quit, and have less than 16 years of education are recruited into a two-arm, double-blinded randomized controlled trial. First, participants smoke their usual brand of cigarettes for 1 week and SPECTRUM research cigarettes containing a usual amount of nicotine for 2 weeks. During the experimental phase, participants are randomized to continue smoking SPECTRUM research cigarettes that contain either (1) usual nicotine content (UNC) (11.6 mg/cigarette) or (2) RNC (11.6 to 0.2 mg/cigarette) over 18 weeks. During the final phase of the study, all participants are offered the choice to quit smoking with nicotine replacement therapy, continue smoking the research cigarettes, or return to their usual brand of cigarettes. The primary outcomes of the study include retention rates and compliance with using only research cigarettes and no use of other nicotine-containing products. Secondary outcomes are tobacco smoke biomarkers, nicotine dependence measures, smoking topography, stress levels, and adverse health consequences. Discussion Results from this study will provide information on whether low SES smokers can maintain a course of progressive nicotine reduction without increases in incidence of adverse effects. Trial registration ClinicalTrials.gov, NCT01928719. Registered on 21 August 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2038-9) contains supplementary material, which is available to authorized users.

Since their introduction in the United States in 2007, electronic cigarettes (e-cigs) have risen in popularity. A nationally representative sample of adults showed that between 2010 and 2013, ever use of e-cigs increased from 1.8% to 13% (McMillen, Gottlieb, Shaefer, Winickoff, & Klein, 2015). While use is significantly higher in those who are current or former smokers (Delnevo et al., 2015), there is concern that e-cigs may appeal to never cigarette smokers and cause them to become nicotine dependent (Cobb, Hendricks, & Eissenberg, 2015). Based on 2014 data from the U.S. National Health Interview Survey, 2.8% of never cigarette smoking adults had tried e-cigs, and 0.4% were currently using them some days or every day (Delnevo et al., 2015). Although many cigarette smokers report using e-cigs as a smoking cessation or reduction tool (Foulds, Veldheer, & Berg, 2011), it is unclear why never cigarette smokers are using e-cigs. Never cigarette smoking e-cig users are important to understand as they have the potential to develop nicotine addiction through a new mode of delivery that has similarities to a cigarette (McMillen et al., 2015). While it is certainly possible that never tobacco users are initiating nicotine use with e-cigs, the majority of the literature focuses primarily on youth populations. Some studies have found evidence of e-cig uptake among never cigarette smoking adolescents, although rates of e-cig use are still higher in adolescent cigarette smokers (Bunnell et al., 2015; Camenga et al., 2014). They have also found there may be differences in risk factors for tobacco product use among adolescents using e-cigs vs. combustible cigarettes and those at intermediate levels of risk may engage in e-cig use when they would not have otherwise been susceptible to tobacco product use (Wills, Knight, Williams, Pagano, & Sargent, 2015). While these studies assume that adolescents are initiating nicotine use with e-cigs, a recent study has shown that a significant proportion of adolescent e-cig users are using e-cigs that do not contain nicotine (Miech, Patrick, O'Malley, & Johnston, 2016). Adults may differ from adolescents in their reasons for use and use patterns but there have been few studies that have examined e-cig use among adult never cigarette smokers. A comprehensive survey study conducted by Farsalinos et al. included an analysis of the use patterns of e-cig users who were never cigarette smokers, but it did not account for traditional tobacco product use aside from cigarettes (e.g. cigars, hookah, pipes, and chew) (Farsalinos, Romagna, Tsiapras, Kyrzopoulos, & Voudris, 2014). If the never cigarette smokers are current or past traditional tobacco product users taking up e-cigs as an alternative to traditional tobacco, it is not the case that they have initiated their nicotine addiction with e-cigs. For instance, Berg conducted a quantitative survey of young adult e-cig users including a full tobacco use history and found that more than 75% of never cigarette smokers had used at least one other tobacco product in their lifetime. Berg noted the need for qualitative research to more fully understand the reasoning behind e-cig use in this population (Berg, 2016). Because quantitative methods are most commonly used when studying e-cigs, it is useful to present quantitative data for comparability across studies. However, qualitative research is also useful when a phenomenon is not well understood because these methodologies allow for the illumination of contextual factors and details from the participant that would not otherwise be captured when using quantitative methods alone. Due to the limited data available on e-cig users who were never cigarette smokers, combining these methodologies using a mixed methods approach allows for strengthening of the quantitative results through the support of qualitative responses. Therefore, this study aims to utilize a mixed methods approach in order to gain a more comprehensive understanding of adult e-cig users who were never cigarette smokers with regard to their traditional tobacco product use, reasons for e-cig use and e-cig use patterns as well as to identify topics for future research within this population.

We evaluated the feasibility of a mentored gardening intervention for adolescent and young adult (AYA) cancer survivors in a hospital-based community garden as a way to improve diet and physical activity, using qualitative data to assess the challenges, facilitators, and areas for future programmatic improvement and replication. Over the course of growing season 2018, AYA cancer survivors tended a garden plot in a community garden under the mentorship of an experienced (master) gardener. AYA cancer survivors were successful in planting and harvesting vegetables from the garden in partnership with their mentors. Qualitative results and future directions for the project are discussed.

OBJECTIVES: Barriers regarding affordability of and access to fresh vegetables and fruit pose low-income families at increased risk of diet-related diseases. Small farms can play a key role in providing local communities with fresh produce, through farmers’ markets, Community Supported Agriculture (CSA), and other direct marketing strategies. Nevertheless, these farms face specific challenges related to payment terms and conditions and delivery when aiming to connect with low-income communities. Rodale Institute's Agriculture Supported Communities (ASC) program aims to connect small-scale fruit and vegetable farms with low-income communities. This farm-share program sells weekly food boxes with organic fruits and vegetables in cities with major food insecurity problems in Pennsylvania (Allentown and Reading). ASC allows members to pay week-to-week, rather than upfront as in a traditional CSA. ASC shareholders can use federal SNAP dollars to pay for discounted shares or apply for subsidized shares. ASC pick-up sites are located in the targeted communities. Our objective is to evaluate the ASC program and its ability to reach the intended low-income communities. METHODS: In 2016 and 2017, surveys were distributed among ASC shareholders to collect socio-economic data and program satisfaction. In addition, we evaluated how many participants used SNAP to pay for the shares. RESULTS: ASC had 150 shareholders in 2016 and 151 in 2017. In 2016, 89 shareholders (59%) were living in low-income areas in Allentown or Reading, in 2017 this was 76 (50%). In 2016, 43% of the shareholders reported an income

OBJECTIVES: Bariatric surgery is an effective treatment for patients with severe obesity (e.g., BMI > 35). To prevent complications, postoperative patients must comply with dietary requirements and nutritional supplementation. A potential barrier to adherence to dietary requirements is food insecurity (FI). In 2017, the national prevalence of FI was 11.8% and a recent study of a pre-bariatric sample found 18% were FI and 27% were marginally FI. Despite this high prevalence, the characteristics associated with FI in preoperative bariatric patients is not known. The purpose of this study was to identify characteristics associated with FI in a sample of patients presenting to an academic medical center for preoperative bariatric surgery assessment. METHODS: 238 participants aged 17–70 with a BMI > 35 were included in the study. Height and weight were measured by clinical staff. Participants completed questionnaires including demographics, the 10-item USDA Adult FI Survey Module (score range 0–10, 0 = food secure, 1–2 = marginal FI, and >3 = FI), the Beck Depression Inventory-II (BDI, range 0–68), the Binge Eating Scale (BES, range 0–48), and the Night Eating Questionnaire (NEQ, range 0–52). An ordinal logistic generalized linear model (GLM) was used with FI as the dependent variable (ordinal, 3 levels) and all variables above as independent variables. RESULTS: The overall sample had a mean age of 41.1 years and a mean BMI of 48.3. It was predominantly female (75%, n = 180), white (71.3%, n = 171), and had less than a college education (77.1%, n = 185). The overall mean FI, BDI, BES, and NEQ scores were 1.1, 9.0, 13.7, 15.2, respectively. The prevalence of marginal FI was 26% (n = 62) and FI was 15.8% (n = 38). In the GLM, FI was significantly associated with having less than a college education (OR 2.08, P = .04), being non-white (OR 2.12, P = .01), younger age (OR 1.05, P = .002), higher depression scores (1.05, P = .03) and higher night eating scores (1.06, P = .04). CONCLUSIONS: In our sample, the proportion of patients reporting FI was similar to previously reported bariatric samples, and higher than national estimates. Bariatric programs should consider screening for FI as part of routine preoperative evaluations. Further studies are needed to understand the impact of FI on postoperative outcomes. FUNDING SOURCES: None.

Objectives SPECTRUM research cigarettes (SPECTRUMs) are being used in trials evaluating the effects of switching to reduced nicotine content (RNC) cigarettes. Because smokers have a high brand affinity, we evaluated if they were willing to switch and continue smoking normal nicotine content (NNC) SPECTRUMs. Methods We asked smokers (N = 341) to rate their own brand of cigarettes and NNC SPECTRUMs (after 2 weeks of use) using subjective measures including satisfaction, reward, taste, and craving reduction. We measured plasma cotinine, exhaled carbon monoxide (CO), and cigarettes per day (CPD), and recorded reasons for dropping out. Results After 2 weeks, 95% of participants chose to continue using SPECTRUMs for an additional 18 weeks. Moreover, 67% said SPECTRUMs were as good as or better than their own brand, and 65% said they would consider purchasing them. Ratings of satisfaction, reward, and craving reduction were 10%-15% lower on SPECTRUMs than on their own brand (p < .01). There were no differences in these ratings between menthol and non-menthol smokers. Conclusions Menthol and non-menthol SPECTRUMs are acceptable to smokers. Lower SPECTRUM ratings were likely due to brand switching and did not hinder study retention.

OBJECTIVES: Gardeners consume more fruits and vegetables (F&V) and have lower body mass indexes (BMI) than non-gardeners, making gardening a potential public health intervention. Little is known about information needed to teach gardening skills to novice gardeners. This study investigated what never gardeners (NG) and experienced gardeners (EG) perceived as necessary information to teach gardening. METHODS: Amazon Mechanical Turk (MTurk) workers responded to demographic and gardening questions via an online survey. After reviewing responses for completeness, 415 participants were included in the analysis. Participants were characterized by gardening experience level based on the total years they had gardened (0 years = NG, 1 + years = EG). In open ended questions, NG were asked: “What, if anything, would encourage you to start vegetable gardening?” and “What information do you think you would need to start a vegetable garden?” Experienced gardeners were asked “What information would be most important to teach someone who is new to vegetable gardening?” Qualitative responses were coded and the most frequent responses are presented. RESULTS: The overall sample had a mean age of 40 years, was 47% female, 80% white, and 68% with a college degree. There were 203 NG (48.9%) and 241 EG (51.1%). For reasons that would motivate NG to start a garden, the two most frequently indicated were, 1) having the space needed to start a garden (n = 33, 16%) or 2) if it would be a way to save money (20, 9.7%). For NGs the most frequently mentioned response to what information they would need to start vegetable gardening on their own was information regarding maintenance, such as sunlight, water, weeding, and spacing (n = 30, 14.8%). For EGs the most frequent response to what information would be most important to teach someone new to vegetable gardening, was also information related to maintenance such as, such as sunlight, water, weeding, and spacing (n = 41, 17%). CONCLUSIONS: Gardening is a potential public health intervention that can influence health. Understanding space needs, costs of starting a garden, and knowing when to plant are key learning topics needed when developing these interventions for new gardeners. Future analyses will investigate the preferences and characteristics of those who would like to participate in an online versus an in-person gardening intervention. FUNDING SOURCES: None.

OBJECTIVES: Gardeners may have better health outcomes, and consume more fruits and vegetables (F&V), than non-gardeners. However, this evidence is mainly based on small, non-representative samples. The purpose of this study was to understand differences in dietary and health outcomes between gardeners and non-gardeners using physical activity data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS). METHODS: Adults (age 18+) with complete self-reported physical activity (PA) data were included. Participants were grouped as those who: (1) did not engage in any PA (non-exercisers), (2) reported gardening as their first or second PA (gardeners), or (3) reported any PA other than gardening (exercisers). Logistic and linear regression models identified associations between cardiovascular disease risk factors (self-reported, yes/no for body mass index (BMI)≥ 25 kg/m(2), high cholesterol, or hypertension) or F&V intake (times/day, continuous) and group after controlling for age, race, sex, and education level. RESULTS: The sample (n = 396,261) was 55% women, majority white (81%), with more than a high school education (66%), and a mean age of 51 years. It was 7.6% gardeners, 65.2% other exercisers, and 27.2% non-exercisers. Gardeners were significantly more likely than exercisers or non-exercisers to be women (60.7% v. 49.3% and 53.4%, P

OBJECTIVES: There is compelling evidence that diet can prevent chronic disease, and with rising health care costs, healthcare organizations are attempting to identify new clinical interventions that can improve the diets of their patients. The purpose of this systematic scoping review was to understand what clinical strategies healthcare organizations are using to increase access to fruits and vegetables (F&V) for their patient populations. In addition, we aimed to review the impact on health outcomes. METHODS: Titles and abstracts were searched in PubMed® (MEDLINE®), Embase®, CINAHL®, and the Cochrane Library® from January 1, 1990 to December 31, 2019. Original studies must have included a healthcare organization and had a programmatic focus on increasing access to or providing fresh F&V to patients in an outpatient, naturalistic setting. The Effective Public Health Project tool was used to assess study quality in 6 domains (selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts). Two reviewers independently verified included studies, study quality, and data extraction. RESULTS: A total of 8877 abstracts were screened which yielded 46 manuscripts from 30 studies. There were 6 program models identified including: 1) cash-back rebate programs, 2) prescription voucher programs, 3) garden-based programs, 4) subsidized food boxes/community supported agriculture (CSA) programs, 5) home-delivery meal programs, and 6) collaborative food pantry-clinical programs. Only 6/30 studies included a control group. The overall quality of the studies was weak due to study participant selection bias, and incomplete reporting on tools used for data collection, confounders, and dropouts. Generally, studies that measured dietary intake found some improvements after these interventions. Other objective health markers such as blood pressure and body mass index had mixed results. CONCLUSIONS: Healthcare-based models currently being tested that provide patients with access to F&V are novel and appear to have promise. However, future studies will need to use rigorous study designs, validated data collection tools and more sophisticated data analysis methodologies to better determine the effect of these interventions on health outcomes. FUNDING SOURCES: This study was funded with internal fund to RW and SV.

Background There is limited evidence about the effects of dual electronic cigarette (e-cig) and combustible cigarette use on lung health or other health outcomes. Studies that have evaluated these outcomes have not included estimates of e-cig or cigarette exposure in the analyses. Materials and methods Data analyzed were from 263 smokers participating in a randomized controlled trial designed to encourage participants to reduce their combustible cigarette use by substituting with an e-cig or a non-electronic cigarette substitute (cig-sub). t-tests were used to evaluate changes from baseline at 1 month and 3 months in lung function, blood pressure, pulse, exhaled carbon monoxide, and weight. Linear mixed effects models were used to test associations between health outcomes and study product group, including exposure to the study products (e-cig and cig-sub times used and days used in the past 7 days) and cigarettes per day (CPD). Results There were few significant differences between the groups for lung function indices at any time point in the unadjusted analyses. There were significant reductions in diastolic blood pressure and pulse at 1 month in the unadjusted analyses for those in the e-cig group compared to the cig-sub group. CPD decreased significantly more for the e-cig group than for the cig-sub group at both time points. There were no significant associations between any measured health outcomes and group in the linear mixed effects models. Conclusion E-cig use did not contribute to significant changes in health outcome markers as compared with use of a non-electronic cig-sub.