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Purpose This paper aims to apply the Product Life Cycle (PLC) and Product Evolutionary Cycle (PEC) frameworks to the nicotine and tobacco market to predict the impact of television commercials for electronic cigarettes (e-cigarettes) on youth. Design/methodology/approach Surveys were administered over a three-year period to 417 alternative high school students from Southern California who had never used e-cigarettes, cigarettes or cigars at the baseline. Covariate-adjusted logistic regression causal mediation models were used to test competing hypotheses from the PLC and PEC frameworks. Findings Results support a refined version of the PEC framework where e-cigarette commercials increase the odds of e-cigarette use, which leads to subsequent use of competing products including cigarettes and cigars. Practical implications This investigation demonstrates the utility of frameworks that conceptualize youth-oriented marketing as a two-part process in which potential customers are first convinced to adopt a behavior and then enticed to use a specific product to enact the behavior. Social implications Rising rates of nicotine and tobacco product use among youth may be partially attributable to e-cigarette commercials. Originality/value Regulations in the USA that permit television commercials for e-cigarettes but restrict the promotion of cigarettes and cigars have created an opportunity to study product adoption among youth consumers when one product has a strategic marketing advantage.

Stroke severity is the most important predictor of post-stroke outcome. Most longitudinal cohort studies do not include direct and validated measures of stroke severity, yet these indicators may provide valuable information about post-stroke outcomes, as well as risk factor associations. In the Atherosclerosis Risk in Communities (ARIC) study, stroke severity data were retrospectively collected, and this paper outlines the procedures used and shares them as a model for assessment of stroke severity in other large epidemiologic studies. Trained physician abstractors, who were blinded to other clinical events, reviewed hospital charts of all definite/probable stroke events occurring in ARIC. In this analysis we included 1,198 ischemic stroke events occurring from ARIC baseline (1987–1989) through December 31, 2009. Stroke severity was categorized according to the National Institutes of Health Stroke Scale (NIHSS) score and classified into 5 levels: NIHSS ≤ 5 (minor), NIHSS 6–10 (mild), NIHSS 11–15 (moderate), NIHSS 16–20 (severe), and NIHSS > 20 (very severe). We assessed interrater reliability in a subgroup of 180 stroke events, reviewed independently by the lead abstraction physician and one of the four secondary physician abstractors. Interrater correlation coefficients for continuous NIHSS score as well as percentage of absolute agreement and Cohen Kappa Statistic for NIHSS categories were presented. Determination of stroke severity by the NIHSS, based on data abstracted from hospital charts, was possible for 97% of all ischemic stroke events. Median (25%-75%) NIHSS score was 5 (2–8). The distribution of NIHSS category was NIHSS ≤ 5 = 58.3%, NIHSS 6–10 = 24.5%, NIHSS 11–15 = 8.9%, NIHSS 16–20 = 4.7%, NIHSS > 20 = 3.6%. Overall agreement in the classification of severity by NIHSS category was present in 145/180 events (80.56%). Cohen’s simple Kappa statistic (95% CI) was 0.64 (0.55–0.74) and weighted Kappa was 0.79 (0.72–0.86). Mean (SD) NIHSS score was 5.84 (5.88), with a median score of 4 and range 0–31 for the lead reviewer (rater 1) and mean (SD) 6.16 (6.10), median 4.5 and range 0–36 in the second independent assessment (rater 2). There was a very high correlation between the scores reported in both assessments (Pearson r = 0.90). Based on our findings, we conclude that hospital chart-based retrospective assessment of stroke severity using the NIHSS is feasible and reliable.

Ecological momentary assessments (EMAs) and digital wearables (DW) are commonly used remote monitoring technologies that capture real-time data in people's natural environments. Real-time data are core to personalized medical care and intensively adaptive health interventions. The utility of such personalized care is contingent on user uptake and continued use of EMA and DW. Consequently, it is critical to understand user preferences that may increase the uptake of EMA and DW. The study aims to quantify users' preferences of EMA and DW, examine variations in users' preferences across demographic and behavioral subgroups, and assess the association between users' preferences and intentions to use EMA and DW. We will administer 2 discrete choice experiments (DCEs) paired with self-report surveys on the internet to a total of 3260 US adults through Qualtrics. The first DCE will assess participants' EMA preferences using a choice-based conjoint design that will ask participants to compare the relative importance of prompt frequency, number of questions per prompt, prompt type, health topic, and assessment duration. The second DCE will measure participants' DW preferences using a maximum difference scaling design that will quantify the relative importance of device characteristics, effort expectancy, social influence, and facilitating technical, health care, and market factors. Hierarchical Bayesian multinomial logistic regression models will be used to generate subject-specific preference utilities. Preference utilities will be compared across demographic (ie, sex, age, race, and ethnicity) and behavioral (ie, substance use, physical activity, dietary behavior, and sleep duration) subgroups. Regression models will determine whether specific utilities are associated with attitudes toward or intentions to use EMA and DW. Mixture models will determine the associations of attitudes toward and intentions to use EMA and DW with latent profiles of user preferences. The institutional review board approved the study on December 19, 2022. Data collection started on January 20, 2023, and concluded on May 4, 2023. Data analysis is currently underway. The study will provide evidence on users' preferences of EMA and DW features that can improve initial uptake and potentially continued use of these remote monitoring tools. The sample size and composition allow for subgroup analysis by demographics and health behaviors and will provide evidence on associations between users' preferences and intentions to uptake EMA and DW. Limitations include the cross-sectional nature of the study, which limits our ability to measure direct behavior. Rather, we capture behavioral intentions for EMA and DW uptake. The nonprobability sample limits the generalizability of the results and introduces self-selection bias related to the demographic and behavioral characteristics of participants who belong to web-based survey panels. DERR1-10.2196/47567.

Importance Early-life socioeconomic adversity may be associated with poor cognitive health over the life course. Objective To examine the association of childhood and midlife neighborhood socioeconomic position (nSEP) with cognitive decline. Design, Setting, and Participants This cohort study included 5711 men and women enrolled in the community-based Atherosclerosis Risk in Communities (ARIC) Study with repeated cognitive data measured over a median 27.0 years (IQR, 26.0-27.9 years) (1990-2019). Statistical analysis was performed from December 2022 through March 2023. Exposure Residence addresses for ARIC Study cohort participants were obtained at midlife (1990-1993) and as recalled addresses at 10 years of age (childhood). A composite nSEPzscore was created as a sum ofzscores for US Census–based measures of median household income; median value of owner-occupied housing units; percentage of households receiving interest, dividend, or net rental income; percentage of adults with a high school degree; percentage of adults with a college degree; and percentage of adults in professional, managerial, or executive occupations. Childhood nSEP and midlife nSEP were modeled as continuous measures and discretized into tertiles. Main Outcomes and Measures A factor score for global cognition was derived from a battery of cognitive tests administered at 5 in-person visits from baseline to 2019. The rate of cognitive decline from 50 to 90 years of age was calculated by fitting mixed-effects linear regression models with age as the time scale and adjusted for race, sex, birth decade, educational level, and presence of the apolipoprotein E ε4 allele. Results Among 5711 ARIC Study participants (mean [SD] baseline age, 55.1 [4.7] years; 3372 women [59.0%]; and 1313 Black participants [23.0%]), the median rate of cognitive decline was −0.33 SDs (IQR, −0.49 to −0.20 SDs) per decade. In adjusted analyses, each 1-SD-higher childhood nSEP score was associated with a slower (β, −9.2%; 95% CI, −12.1% to −6.4%) rate of cognitive decline relative to the sample median. A comparable association was observed when comparing the highest tertile with the lowest tertile of childhood nSEP (β, −17.7%; 95% CI, −24.1% to −11.3%). Midlife nSEP was not associated with the rate of cognitive decline. Conclusions and Relevance In this cohort study of contextual factors associated with cognitive decline, childhood nSEP was inversely associated with trajectories of cognitive function throughout adulthood.

INTRODUCTION Hearing loss is highly prevalent among older adults and independently associated with cognitive decline. The Aging and Cognitive Health Evaluation in Elders (ACHIEVE) study is a multicenter randomized control trial (partially nested within the infrastructure of an observational cohort study, the Atherosclerosis Risk in Communities [ARIC] study) to determine the efficacy of best‐practice hearing treatment to reduce cognitive decline over 3 years. The goal of this paper is to describe the recruitment process and baseline results. METHODS Multiple strategies were used to recruit community‐dwelling 70–84‐year‐old participants with adult‐onset hearing loss who were free of substantial cognitive impairment from the parent ARIC study and de novo from the surrounding communities into the trial. Participants completed telephone screening, an in‐person hearing, vision, and cognitive screening, and a comprehensive hearing assessment to determine eligibility. RESULTS Over a 24‐month period, 3004 telephone screenings resulted in 2344 in‐person hearing, vision, and cognition screenings and 1294 comprehensive hearing screenings. Among 1102 eligible, 977 were randomized into the trial (median age = 76.4 years; 53.5% female; 87.8% White; 53.3% held a Bachelor's degree or higher). Participants recruited through the ARIC study were recruited much earlier and were less likely to report hearing loss interfered with their quality of life relative to participants recruited de novo from the community. Minor differences in baseline hearing or health characteristics were found by recruitment route (i.e., ARIC study or de novo) and by study site. DISCUSSION The ACHIEVE study successfully completed enrollment over 2 years that met originally projected rates of recruitment. Substantial operational and scientific efficiencies during study startup were achieved through embedding this trial within the infrastructure of a longstanding and well‐established observational study. Highlights The ACHIEVE study tests the effect of hearing intervention on cognitive decline. The study is partially nested within an existing cohort study. Over 2 years, 977 participants recruited and enrolled. Eligibility assessed by telephone and in‐person for hearing, vision, and cognitive screening. The ACHIEVE study findings will have significant public health implications.

Despite increasing rates of cancer, biospecimen donations for cancer research remains low among Pacific Islanders (PIs). To address this disparity, researchers partnered with PI community organizations to develop and test a theory-based culturally tailored educational intervention designed to raise awareness about the issues surrounding biospecimen research. A total of 219 self-identified PI adults in Southern California were recruited to participate in a one-group pre-post design study. Participants completed questionnaires that assessed their knowledge and attitude regarding biospecimen research before and after viewing an educational video and receiving print materials. Results showed that participants’ overall knowledge and attitude increased significantly from pre-test to post-test (p < .0001). Over 98% of participants also reported that they would be willing to donate at least one type of biospecimen sample. Efforts such as these that utilize culturally tailored education interventions may be instrumental in improving biospecimen donation rates in the PI community as well as other minority populations.

Recent prevalence data indicates that Pacific Islanders living in the United States have disproportionately high smoking rates when compared to the general populace. However, little is known about the factors contributing to tobacco use in this at-risk population. Moreover, few studies have attempted to determine these factors utilizing technology-based assessment techniques. The objective was to develop a customized Internet-based Ecological Momentary Assessment (EMA) system capable of measuring cigarette use among Pacific Islanders in Southern California. This system integrated the ubiquity of text messaging, the ease of use associated with mobile phone apps, the enhanced functionality offered by Internet-based Cell phone-optimized Assessment Techniques (ICAT), and the high survey completion rates exhibited by EMA studies that used electronic diaries. These features were tested in a feasibility study designed to assess whether Pacific Islanders would respond to this method of measurement and whether the data gathered would lead to novel insights regarding the intrapersonal, social, and ecological factors associated with cigarette use. 20 young adult smokers in Southern California who self-identified as Pacific Islanders were recruited by 5 community-based organizations to take part in a 7-day EMA study. Participants selected six consecutive two-hour time blocks per day during which they would be willing to receive a text message linking them to an online survey formatted for Web-enabled mobile phones. Both automated reminders and community coaches were used to facilitate survey completion. 720 surveys were completed from 840 survey time blocks, representing a completion rate of 86%. After adjusting for gender, age, and nicotine dependence, feeling happy (P=<.001) or wanting a cigarette while drinking alcohol (P=<.001) were positively associated with cigarette use. Being at home (P=.02) or being around people who are not smoking (P=.01) were negatively associated with cigarette use. The results of the feasibility study indicate that customized systems can be used to conduct technology-based assessments of tobacco use among Pacific Islanders. Such systems can foster high levels of survey completion and may lead to novel insights for future research and interventions.

Background Hearing loss is an established risk factor for Alzheimer's disease and related dementias (ADRD) but the mechanism is unknown. We investigated the cross‐sectional association of hearing loss with plasma AD/ADRD biomarkers, hypothesizing that hearing loss is associated with biomarkers reflective of broader neurodegeneration (e.g., neurofilament light chain [NfL]) but not with AD‐specific markers (e.g., amyloid‐b, phosphorylated tau). Methods We used data from the observational cohort, the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC‐NCS). Pure tone air conduction hearing thresholds (frequencies 0.5‐4 kHz) were obtained at Visit 6 (2016‐17) and averaged, with better‐ear hearing loss modeled continuously. The Quanterix SiMoA platform measured ADRD plasma biomarkers from stored specimens at the nearest visit – Visit 5 (2011‐13), Visit 6 (2016‐17) or Visit 7 (2018‐19) – including amyloid‐β 42 /amyloid‐β 40 ratio (Ab42/40), phosphorylated tau at threonine 181 (p‐tau 181), NfL, and glial fibrillary acidic protein (GFAP). Multivariable‐adjusted linear regression was used to estimate differences in biomarker levels, adjusting for time between audiology assessment and plasma collection, age, sex, race, center, education, APOE e4 genotype, BMI, estimated glomerular filtration rate, cigarette use, total cholesterol, high‐density lipoprotein cholesterol, hypertension, diabetes, coronary heart disease and hearing aid use. Global cognition (a composite cognitive score created from 10 cognitive tests) was modeled as a positive control. Results Participant ages ranged from 67‐94 years, 60% were female and 36% identified as Black race (Table 1). As expected, audiometric hearing was not correlated with AD‐specific biomarkers (Ab42/40 ratio, p‐tau181). However, weak correlations were observed for markers more reflective of general neurodegeneration (NfL and GFAP) (Figure) and hearing loss was positively associated with NfL in adjusted linear regression models, with each 10 dB increase (worse hearing) associated with 0.079 (95% confidence interval [CI] 0.007, 0.150) higher log NfL (Table 2). Conclusions Poorer audiometric hearing in older adults is associated with plasma biomarkers of neurodegeneration, specifically NfL, but is not associated with AD‐specific markers (amyloid and tau), suggesting that pathways linking hearing and ADRD are independent of these pathognomonic Alzheimer's‐related brain changes.

Background Early life exposure to adverse experiences correlates with poor health outcomes in adulthood. We therefore examined the association of childhood neighborhood socioeconomic position (nSEP) with midlife and late life levels of plasma‐based biomarkers of Alzheimer's disease (AD) pathology and neurodegeneration. Methods The study population included 1362 Atherosclerosis Risk in Communities (ARIC) cohort participants (mean [SD] midlife age: 58.1 [4.8] years; 60.2% female; 26.4% Black) with amyloid‐β 42/40 (Aβ42/40), pTau‐181, neurofilament light chain (NfL), and glial fibrillary acidic protein (GFAP) ascertained at midlife (Visit 3; 1996‐1982) and older adulthood (Visit 5; 2011‐2013) using Quanterix Simoa assays. We used residential addresses at age 10 years to create a childhood composite of six, z‐scored U.S. Census‐based measures of nSEP: median household income; median value of owner‐occupied housing units; percent households receiving interest, dividend, or net rental income; percent adults with a high school degree; percent adults with a college degree; and percent adults in professional, managerial, or executive occupations. We used weighted, mixed‐effects models to estimate standardized log 2 transformed biomarker concentrations across tertiles of childhood nSEP adjusted for midlife age, race‐study center, sex, education, and presence of the APOE ε4 allele. Results At midlife, participants who were in the lowest versus highest tertile of childhood nSEP had higher mean (SD) concentrations of pTau181(1.58 [0.94] vs. 1.53 [1.0], pg/ml), NfL (13.1 [7.4] vs. 12.1 [6.4], pg/ml), and GFAP (108.5 [64.9] vs. 103.9 [50.8], pg/ml.) Differences in biomarker concentrations between low and high childhood nSEP were attenuated in late life. The AB42/40 ratio at midlife and late life was comparable across the childhood nSEP tertiles. After covariate adjustment, midlife pTau181, NfL and GFAP concentrations were inversely associated with childhood nSEP (Figure 1). The association was marginally statistically significant for NfL (p‐trend=0.05). No associations were observed between childhood nSEP and levels of selected biomarkers ascertained in late life (Figure 2). Conclusion Observed trend in the association of low childhood socioeconomic position with an adverse midlife, but not late life, profile of plasma‐based biomarkers of AD pathology and neurodegeneration warrants further study.

INTRODUCTION We examined midlife (1990–1992, mean age 57) and late‐life (2011–2013, mean age 75) nonalcoholic fatty liver disease (NAFLD) and aminotransferase with incident dementia risk through 2019 in the Atherosclerosis Risk in Communities (ARIC) Study. METHODS We characterized NAFLD using the fatty liver index and fibrosis‐4, and we categorized aminotransferase using the optimal equal‐hazard ratio (HR) approach. We estimated HRs for incident dementia ascertained from multiple data sources. RESULTS Adjusted for demographics, alcohol consumption, and kidney function, individuals with low, intermediate, and high liver fibrosis in midlife (HRs: 1.45, 1.40, and 2.25, respectively), but not at older age, had higher dementia risks than individuals without fatty liver. A U‐shaped association was observed for alanine aminotransferase with dementia risk, which was more pronounced in late‐life assessment. DISCUSSION Our findings highlight dementia burden in high‐prevalent NAFLD and the important feature of late‐life aminotransaminase as a surrogate biomarker linking liver hypometabolism to dementia. Highlights Although evidence of liver involvement in dementia development has been documented in animal studies, the evidence in humans is limited. Midlife NAFLD raised dementia risk proportionate to severity. Late‐life NAFLD was not associated with a high risk of dementia. Low alanine aminotransferase was associated with an elevated dementia risk, especially when measured in late life.