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Electronic cigarettes (e-cigarettes) may help cigarette smokers quit smoking, yet they may also facilitate cigarette smoking for never-smokers. We quantify the balance of health benefits and harms associated with e-cigarette use at the population level. Monte Carlo stochastic simulation model. Model parameters were drawn from census counts, national health and tobacco use surveys, and published literature. We calculate the expected years of life gained or lost from the impact of e-cigarette use on smoking cessation among current smokers and transition to long-term cigarette smoking among never smokers for the 2014 US population cohort. The model estimated that 2,070 additional current cigarette smoking adults aged 25-69 (95% CI: -42,900 to 46,200) would quit smoking in 2015 and remain continually abstinent from smoking for ≥7 years through the use of e-cigarettes in 2014. The model also estimated 168,000 additional never-cigarette smoking adolescents aged 12-17 and young adults aged 18-29 (95% CI: 114,000 to 229,000), would initiate cigarette smoking in 2015 and eventually become daily cigarette smokers at age 35-39 through the use of e-cigarettes in 2014. Overall, the model estimated that e-cigarette use in 2014 would lead to 1,510,000 years of life lost (95% CI: 920,000 to 2,160,000), assuming an optimistic 95% relative harm reduction of e-cigarette use compared to cigarette smoking. As the relative harm reduction decreased, the model estimated a greater number of years of life lost. For example, the model estimated-1,550,000 years of life lost (95% CI: -2,200,000 to -980,000) assuming an approximately 75% relative harm reduction and -1,600,000 years of life lost (95% CI: -2,290,000 to -1,030,000) assuming an approximately 50% relative harm reduction. Based on the existing scientific evidence related to e-cigarettes and optimistic assumptions about the relative harm of e-cigarette use compared to cigarette smoking, e-cigarette use currently represents more population-level harm than benefit. Effective national, state, and local efforts are needed to reduce e-cigarette use among youth and young adults if e-cigarettes are to confer a net population-level benefit in the future.

ObjectiveTo assess the extent to which multiple tobacco product use among adolescents and young adults falls outside current Food and Drug Administration (FDA) regulatory authority.MethodsWe conducted a web-based survey of 1596 16–26-year-olds to assess use of 11 types of tobacco products. We ascertained current (past 30 days) tobacco product use among 927 respondents who ever used tobacco. Combustible tobacco products included cigarettes, cigars (little filtered, cigarillos, premium) and hookah; non-combustible tobacco products included chew, dip, dissolvables, e-cigarettes, snuff and snus. We then fitted an ordinal logistic regression model to assess demographic and behavioural associations with higher levels of current tobacco product use (single, dual and multiple product use).ResultsAmong 448 current tobacco users, 54% were single product users, 25% dual users and 21% multiple users. The largest single use category was cigarettes (49%), followed by hookah (23%), little filtered cigars (17%) and e-cigarettes (5%). Most dual and multiple product users smoked cigarettes, along with little filtered cigars, hookah and e-cigarettes. Forty-six per cent of current single, 84% of dual and 85% of multiple tobacco product users consumed a tobacco product outside FDA regulatory authority. In multivariable analysis, the adjusted risk of multiple tobacco use was higher for males, first use of a non-combustible tobacco product, high sensation seeking respondents and declined for each additional year of age that tobacco initiation was delayed.ConclusionsNearly half of current adolescent and young adult tobacco users in this study engaged in dual and multiple tobacco product use; the majority of them used products that fall outside current FDA regulatory authority. This study supports FDA deeming of these products and their incorporation into the national media campaign to address youth tobacco use.

Objectives: The use of flavored electronic cigarettes (e-cigarettes) is common among e-cigarette users, but little is known about the potential harms of flavorings, the extent to which the concurrent use of multiple flavor types occurs, and the correlates of flavor type use. The objective of this study was to assess the types of e-cigarette flavors used by adolescent (aged 12-17), young adult (aged 18-24), and older adult (aged ≥25) e-cigarette users. Methods: We assessed the prevalence of flavored e-cigarette use within the past month by flavor types and concurrent use of multiple flavor types among past-month e-cigarette users sampled during Wave 2 (2014-2015) of the Population Assessment for Tobacco and Health Study among 414 adolescents, 961 young adults, and 1711 older adults. We used weighted logistic regression models for the use of fruit-, candy-, mint/menthol–, tobacco-, or other-flavored e-cigarettes and concurrent use of multiple flavor types. Covariates included demographic characteristics, e-cigarette use frequency, cigarette smoking status, current use of other tobacco products, and reasons for e-cigarette use. Results: The leading e-cigarette flavor types among adolescents were fruit, candy, and other flavors; among young adults were fruit, candy, and mint/menthol; and among older adults were tobacco or other flavors, fruit, and mint/menthol. Compared with older adults, adolescents and young adults were more likely to use fruit-flavored e-cigarettes (adjusted odds ratio [aOR] = 3.35; 95% confidence interval [CI], 2.56-4.38; and aOR = 2.31; 95% CI, 1.77-3.01, respectively) and candy-flavored e-cigarettes (aOR = 3.81; 95% CI, 2.74-5.28; and aOR = 2.95; 95% CI, 2.29-3.80, respectively) and concurrently use multiple flavor types (aOR = 4.58; 95% CI, 3.39-6.17; and aOR = 2.28; 95% CI, 1.78-2.91, respectively). Conclusions: Regulation of sweet e-cigarette flavors (eg, fruit and candy) may help reduce the use of e-cigarettes among young persons without substantially burdening adult e-cigarette users.

The screening of persons at risk for lung cancer may reduce lung-cancer mortality by 20%. Although cost-effectiveness estimates vary widely depending on assumptions, a careful analysis indicates that the cost is $81,000 per quality-adjusted life-year. Lung cancer is the leading cause of cancer-related deaths in the United States 1 ; however, until recently, no method of screening had been shown to reduce mortality from lung cancer. The National Lung Screening Trial (NLST) showed that screening with low-dose helical computed tomography (CT) of the chest in patients at high risk for lung cancer was associated with a 20% reduction in lung-cancer mortality. 2 Several major medical societies have since recommended screening with low-dose CT for patients with a similarly high risk of lung cancer. 3 The U.S. Preventive Services Task Force has released a grade B recommendation for low-dose . . .

Table 1 Participant characteristics and weighted prevalence of past 30-day use JUUL, Vuse, and Suorin by characteristics of youth and young adults Youth (N=1000) Young adult (N=1000) Participant characteristics N (%) or mean (SD) JUUL use (%) Suorin use (%) Vuse use (%) N (%) or mean (SD) JUUL use (%) Suorin use (%) Vuse use (%) Age 16.3 (0.7) – – – 20.9 (2.0) – – –  Gender        Male 397 (39.7) 13.3 4.6 1.9 436 (43.6) 23.3§ 9.3§ 9.2§  Female 544 (54.4) 13.2 4.3 1.8 540 (54.0) 12.8§ 4.2§ 3.3§  Transgender or other gender identities 57 (5.7) 8.2 4.1 5.8 24 (2.4) 19.2§ 3.6§ 1.9§  Missing 2 (0.2) – – – 0 (0.0) – – – Sexual orientation*        Heterosexual – – – – 795 (79.5) 17.4 7.2 6.6  Lesbian or gay – – – – 40 (4.0) 20.9 4.7 2.1  Bisexual – – – – 133 (13.3) 24.7 4.0 2.6  Something else – – – – 14 (1.4) 10.7 0.0 0.0  Missing – – – – 18 (1.8) – – – Race/ethnicity        Non-Hispanic white 448 (44.8) 16.1§ 5.6 1.6 490 (49.0) 19.8 7.2 5.6  Non-Hispanic black 179 (17.9) 6.3§ 2.9 2.2 184 (18.4) 11.7 7.1 7.2  Hispanic 215 (21.5) 12.1§ 2.3 3.4 219 (21.9) 19.9 4.7 6.8  Non-Hispanic other races 158 (15.8) 7.1§ 4.5 1.8 107 (10.7) 14.8 7.9 6.3 Highest grade of school completion        9th grade or below 191 (19.1) 9.5 2.2§ 1.1 24 (2.4) 16.4 9.1 4.7  10th grade 286 (28.6) 13.4 3.2§ 1.7 18 (1.8) 0.0 0.0 12.7  11th grade 331 (33.1) 13.2 7.0§ 2.4 34 (3.4) 10.1 5.9 2.3  12th grade/high school degree/General Education Development (GED) 169 (16.9) 17.2 6.3§ 4.6 377 (37.7) 17.9 8.4 7.3  Some college, but no degree 0 (0.0) – – – 303 (30.3) 21.4 7.3 5.5  Associate degree 0 (0.0) – – – 94 (9.4) 15.2 6.3 6.3  Bachelor's degree and above 0 (0.0) – – – 141 (14.1) 20.9 2.0 4.6  Missing 23 (2.3) – – – 9 (0.9) – – – Cigarette smoking status        Never Smoker 500 (50.0) 6.7§ 1.9§ 1.0§ 292 (29.2) 7.8§ 5.1§ 5.1  Ever but not past 30-day Smoker 379 (37.9) 28.8§ 9.7§ 4.8§ 159 (15.9) 27.0§ 5.1§ 4.8  Past 30-day Smoker† 121 (12.1) 50.3§ 22.0§ 9.0§ 549 (54.9) 30.0§ 12.5§ 10.2 Ever tried other tobacco products‡        No 644 (64.4) 8.3§ 3.1§ 1.4§ 363 (36.3) 10.9§ 4.9§ 2.0§  Yes 343 (34.3) 40.6§ 12.4§ 6.2§ 628 (62.8) 32.6§ 10.3§ 14.4§  Missing 13 (1.3) – – – 9 (0.9) – – – *Youth participants were not asked the sexual orientation question. †This category included all participants who smoked in the past 30 days, including those who may not have smoked 100 lifetime cigarettes. ‡Other tobacco products include hookah or waterpipe, cigars, cigarillos, or little cigars, smokeless (chew, snuff, or dip), roll-your-own, pipe, snus, dissolvables, and bidi. §χ2 tests significant at p<0.05. Discussion The findings of higher rates of awareness and current use of JUUL compared with Suorin and Vuse e-cigarettes are aligned with JUUL as the market leader,1 being the most popular device among high-school youth who ever used e-cigarettes,10 increased media and news coverage, promotion on social media platforms,1 online engagement about JUUL,11 12 and sharing about JUUL via word-of-mouth in recent years.13 The worrisome trend of social normalisation of e-cigarette use among young people could potentially renormalise combustible cigarette use due to a fourfold increased odds of initiating smoking among e-cigarette users.14 The high nicotine content of newer pod-based vaping devices may further increase the risks of nicotine addiction and initiating smoking.15 Efforts to restrict access of pod-based devices, ban flavours that appeal to young people, and counter-marketing campaigns on the addictiveness of vaping are needed to stem this growing trend. Funding Data collection for this study was supported by the National Institute on Drug Abuse and Food and Drug Administration Center for Tobacco Products (K01DA037903-S1). Funding sources did not have any role in the study design; collection, analysis and interpretation of data; writing the report; the decision to submit the report for publication.

Achieving universal health coverage (UHC) requires health financing systems that provide prepaid pooled resources for key health services without placing undue financial stress on households. Understanding current and future trajectories of health financing is vital for progress towards UHC. We used historical health financing data for 188 countries from 1995 to 2015 to estimate future scenarios of health spending and pooled health spending through to 2040. We extracted historical data on gross domestic product (GDP) and health spending for 188 countries from 1995 to 2015, and projected annual GDP, development assistance for health, and government, out-of-pocket, and prepaid private health spending from 2015 through to 2040 as a reference scenario. These estimates were generated using an ensemble of models that varied key demographic and socioeconomic determinants. We generated better and worse alternative future scenarios based on the global distribution of historic health spending growth rates. Last, we used stochastic frontier analysis to investigate the association between pooled health resources and UHC index, a measure of a country's UHC service coverage. Finally, we estimated future UHC performance and the number of people covered under the three future scenarios. In the reference scenario, global health spending was projected to increase from US$10 trillion (95% uncertainty interval 10 trillion to 10 trillion) in 2015 to $20 trillion (18 trillion to 22 trillion) in 2040. Per capita health spending was projected to increase fastest in upper-middle-income countries, at 4·2% (3·4–5·1) per year, followed by lower-middle-income countries (4·0%, 3·6–4·5) and low-income countries (2·2%, 1·7–2·8). Despite global growth, per capita health spending was projected to range from only $40 (24–65) to $413 (263–668) in 2040 in low-income countries, and from $140 (90–200) to $1699 (711–3423) in lower-middle-income countries. Globally, the share of health spending covered by pooled resources would range widely, from 19·8% (10·3–38·6) in Nigeria to 97·9% (96·4–98·5) in Seychelles. Historical performance on the UHC index was significantly associated with pooled resources per capita. Across the alternative scenarios, we estimate UHC reaching between 5·1 billion (4·9 billion to 5·3 billion) and 5·6 billion (5·3 billion to 5·8 billion) lives in 2030. We chart future scenarios for health spending and its relationship with UHC. Ensuring that all countries have sustainable pooled health resources is crucial to the achievement of UHC. The Bill & Melinda Gates Foundation.

More smokers report using e-cigarettes to help them quit than FDA-approved pharmacotherapy. To assess the association of e-cigarettes with future abstinence from cigarette and tobacco use. Cohort study of US sample, with annual follow-up. US adult (ages 18+) daily cigarette smokers identified at Wave 1 (W1; 2013-14) of the PATH Study, who reported a quit attempt before W2 and completed W3 (n = 2443). Use of e-cigarettes, pharmacotherapy (including nicotine replacement therapy), or no product for last quit attempt (LQA), and current daily e-cigarette use at W2. Propensity score matching (PSM) of groups using different methods to quit. 12+ months abstinence at W3 from cigarettes and from all tobacco (including e-cigarettes). 30+ days abstinence at W3 was a secondary outcome. Among daily smokers with an LQA, 23.5% used e-cigarettes, 19.3% used pharmacotherapy only (including NRT) and 57.2% used no product. Cigarette abstinence for 12+ months at W3 was ~10% in each group. Half of the cigarette abstainers in the e-cigarette group were using e-cigarettes at W3. Different methods to help quitting had statistically comparable 12+ month cigarette abstinence at W3 (e-cigarettes vs no product: Risk Difference (RD) = 0.01, 95% CI: -0.04 to 0.06; e-cigarettes vs pharmacotherapy: RD = 0.02, 95% CI:-0.04 to 0.09). Likewise, daily e-cigarette users at W2 did not show a cessation benefit over comparable no-e-cigarette users and this finding was robust to sensitivity analyses. Abstinence for 30+ days at W3 was also similar across products. The frequency of e-cigarette use during the LQA was not assessed, nor was it possible to assess continuous abstinence from the LQA. Among US daily smokers who quit cigarettes in 2014-15, use of e-cigarettes in that attempt compared to approved cessation aids or no products showed similar abstinence rates 1-2 years later.

As of 31 January 2021, 63.9 million cases and 1.4 million deaths had been reported in Europe and North America, which accounted for 62.5% and 62.4% of the global total, respectively. Comparing the level of mortality across countries has proven difficult because of inherent limitations in the most commonly cited measures (e.g., case-fatality rates). We collected the cumulative number of confirmed deaths from COVID-19 by age in 2020 from the L’Institut National d’études Démographiques (INED) database and Statistics Canada for 15 European and North American countries. We calculated age-specific death rates and age-standardized death rates (ASDR) for each country over a 1-year period from 6 February 2020 (date of first COVID-19 death in Europe and North America) to 5 February 2021 using established demographic methods. We estimated that COVID-19 was the second leading cause of death behind cancer in England and Wales and France and the third leading cause of death behind cancer and heart disease in nine countries including the US. Countries with higher all-cause mortality prior to the COVID-19 experienced higher COVID-19 mortality than countries with lower all-cause mortality prior to the pandemic. The COVID-19 ASDR varied substantially within country (e.g., a 5-fold difference among the highest and lowest mortality states in Germany). Consistently strong public health measures may have lessened the level of mortality for some European and North American countries. In contrast, many of the largest countries and economies in these regions may continue to experience a high mortality level because of poor implementation and adherence to such measures.

Given JUUL e-cigarettes' potential for smoking cessation and its drastically increased sales in the U.S., more evidence is needed to understand the antecedents of JUUL use among adult cigarette smokers. This study assessed the relationships between awareness sources, perceptions about using JUUL, and JUUL use behavior. In an online study with adult smokers who were aware of JUUL e-cigarettes (n = 341), respondents reported their sources for learning about JUUL, perceptions of using JUUL versus Vuse (a competitor brand), and ever and past-30-day (current) JUUL use. Multivariable logistic regressions were used to examine the associations between awareness sources, perceptions, and JUUL use, adjusting for covariates. Learning about JUUL through internet ads was associated with positive perceptions about JUUL compared to Vuse, including JUUL was more fun to use (AOR = 2.04, 95% CI = 1.21, 3.42) and tastier (AOR = 1.96, 95% CI = 1.19, 3.22). Perceiving JUUL as being tastier (AOR = 2.07, 95% CI = 1.23, 3.49), more helpful for quitting smoking (AOR = 2.07, 95% CI = 1.22, 3.53), and cooler (AOR = 2.07, 95% CI = 1.21, 3.56) than Vuse was associated with ever using JUUL. Only perceiving JUUL as being tastier (AOR = 1.98, 95% CI = 1.10, 3.59) than Vuse was associated with current use of JUUL. Adult smokers may be more likely to focus on the sensory and social experience of using JUUL rather than JUUL's smoking cessation benefits. These positive perceptions are likely to be influenced by internet ads in general instead of JUUL's official marketing outlets. They are also more likely to sustain JUUL use than JUUL's perceived smoking cessation benefits.

PurposeTo estimate the potential near-term population impact of alternative second opinion breast biopsy pathology interpretation strategies.MethodsDecision analysis examining 12-month outcomes of breast biopsy for nine breast pathology interpretation strategies in the U.S. health system. Diagnoses of 115 practicing pathologists in the Breast Pathology Study were compared to reference-standard-consensus diagnoses with and without second opinions. Interpretation strategies were defined by whether a second opinion was sought universally or selectively (e.g., 2nd opinion if invasive). Main outcomes were the expected proportion of concordant breast biopsy diagnoses, the proportion involving over- or under-interpretation, and cost of care in U.S. dollars within one-year of biopsy.ResultsWithout a second opinion, 92.2% of biopsies received a concordant diagnosis. Concordance rates increased under all second opinion strategies, and the rate was highest (95.1%) and under-treatment lowest (2.6%) when all biopsies had second opinions. However, over-treatment was lowest when second opinions were sought selectively for initial diagnoses of invasive cancer, DCIS, or atypia (1.8 vs. 4.7% with no 2nd opinions). This strategy also had the lowest projected 12-month care costs ($5.907 billion vs. $6.049 billion with no 2nd opinions).ConclusionsSecond opinion strategies could lower overall care costs while reducing both over- and under-treatment. The most accurate cost-saving strategy required second opinions for initial diagnoses of invasive cancer, DCIS, or atypia.