A pattern of health insurance policy among smokers in the United States Abdulrasak Ejiwumi, Nathan Hale and Melissa White, Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN Previous research has noted that Medicaid expansion has had a positive impact health care access and the quality of healthcare services among individuals with lower incomes. However, only a few studies have been conducted to describe the association between smoking and having any type of healthcare insurance in the United States. Health insurance provides access to important smoking cessation programs that are critical for enabling quit attempts. This study examines the extent to which insurance is associated with smoking cessation. We obtained data from the 2021 nationally representative Behavioral Risk Surveillance System Dataset. A descriptive analysis was conducted on adult smoking status and enrollment in any health insurance policy and variation based on race, gender, income, marital status, and level of education was examined using a Chi-square test. Current smoking status and any health insurance enrollment was also examined using an adjusted logistic regression analysis controlling for age, sex, income, marital status, and race/ethnic group. Among adult smokers in the United States (Sample size 167,079), 85.7% have health insurance while 10.2% do not have any type of health insurance. Approximately 69.5% of individuals with health insurance reported quitting smoking compared to 42.8% of those who do not have health insurance (p=0.001). Adjusting for additional covariates of interest, the odds of quitting smoking was 1.6 times higher for respondents with any type of health insurance compared to uninsured respondents (AOR 1.55, 95% CI=1.49 – 1.61). This study found that the access to health insurance is an important predictor of quitting smoking, even when adjusting for age, race, gender, marital status, levels of education, and income. Insurance remains an important enabling factor that provides the resources and supports necessary to enable smoking cessation programs and ultimately support smoking cessation. Continued efforts to increase access to health insurance are needed.

It is estimated that one third of the world's population is infected with tuberculosis. Though once thought a "dead" disease, tuberculosis is very much alive. The rise of drug resistant strains of tuberculosis, and TB-HIV coinfection have made tuberculosis an even greater worldwide threat. While HIV, poverty, and public health infrastructure are historically assumed to affect the burden of tuberculosis, recent research has been done to implicate smoking in this list. This analysis involves combining data from multiple sources in order determine if smoking is a statistically significant factor in predicting the number of incident tuberculosis cases in a country. Quasi-Poisson generalized linear models and negative binomial regression will be used to analyze the effect of smoking, as well as the other factors, on tuberculosis incidence. This work will enhance tuberculosis control efforts by helping to identify new hypotheses that can be tested in future studies. One of the main hypotheses is whether or not smoking increases the number of tuberculosis cases above and beyond the effects of other factors that are known to influence tuberculosis incidence. These known factors include TB-HIV coinfection, poverty and public health infrastructure represented by treatment outcomes.

The purpose of this paper was to examine how people experience the practice of Cannabis in daily life. The study was based on interviews with five individuals who have experience with cannabis use. They do not represent a bigger population only themselves. We chose these particular individuals because all of them began using cannabis at a young age- everyone before they were twenty. But they have been using cannabis because of different reasons. The results of the interviews were analyzed with the thesis of Howard Becker and the new developed thesis of Hallstone about social control. The thesis explains the pattern of becoming a drug addict and what the steps are. The final results of this study contain answers about how much cannabis they have been using, how often, with whom and with what purpose. We compared these answers to the patterns to see if there was any truth to them and then we explained the function the drug has in their lives. For further explaining we used former researches about cannabis use in different areas of life. In the discussion we try to understand what these answers mean, what the thought behind cannabis use is and if these people really have the control over it.

Fecundity, defined as the biologic capacity for reproduction, is measured operationally as time-to-pregnancy (TTP) among non-contracepting couples. While most couples conceive naturally within six menstrual cycles of trying, 10-24% of couples take longer than six cycles. Fecundity impairments are associated with long-term adverse health consequences including insulin resistance and gynecologic cancers, can cause substantial psychological and economic hardship, and cost over $5 billion annually in the U.S. Therefore, identifying risk factors for subfecundity in order to increase the chances of natural conception among pregnancy planners is an important public health goal. Environmental and psychosocial risk factors are understudied in relation to reproductive health. The goal of this dissertation is to examine the independent associations between exposure to tetrachloroethylene, perceived stress, and cigarette smoking and fecundability, the per cycle probability of conception. In study one, we used data from a retrospective cohort study of Cape Cod women who were exposed to tetrachloroethylene-contaminated drinking water in the 1960s-1980s to examine the relation between tetrachloroethylene exposure and fertility. We found that women with the highest modeled tetrachloroethylene exposure around the time of the pregnancy attempt had increased risk of TTP>12 months compared with unexposed women. Cumulative exposure, however, was not associated with elevated risk of TTP>12 months. Studies two and three used data from Pregnancy Study Online (PRESTO), a preconception cohort study of pregnancy planners from North America. In study two, we found that perceived stress levels in women, but not their male partners, were associated with lower fecundability, with little evidence of mediation by measured behavioral factors. In study three, we found that male current active smoking was associated with lower fecundability. In women, current smoking was only associated with reduced fecundability among women who smoked with high intensity and/or long duration. Passive smoking was not substantially associated with fecundability in either partner, but women exposed in utero to high intensity smoking had lower fecundability than unexposed women. Overall, we observed weak associations between tetrachloroethylene exposure, perceived stress, and active smoking and fertility among pregnancy planners. These findings indicate that environmental and psychosocial factors may play a role in the etiology of infertility. In addition, given that these exposures are common and modifiable, they may be important targets for public health interventions.

The majority of current smokers in the United States want to quit smoking; however, long-term abstinence rates do not improve beyond 30%, despite the availability of effective pharmaco-behavioral treatments and increased outreach of awareness programs on quitting benefits. One of the reasons is non-adherence to pharmacological treatment. Pharmacological treatments are developed to alleviate withdrawal symptoms experienced during a quit attempt. However, without continued treatment adherence, especially in the first few weeks of a quit attempt (when withdrawal symptoms fluctuate the most), the chances of relapse peak. Thus, adherence to pharmacological treatments must be improved to sustain long-term smoking abstinence. Moreover, smoking cessation is a complex and time-varying process. Therefore, the time-varying causal structure of adherence and smoking cessation must be studied carefully.The time-varying mechanisms underlying the smoking cessation process can be captured efficiently through intensive longitudinal data and quantified through appropriate methods. Mediation analysis is an efficient tool for studying such mechanisms. However, despite the time-varying nature of the data, existing approaches for assessing mediation provide overall average (in)direct effects over time and omit describing the temporal characteristic of the dynamic effect. This dissertation research aims to develop a new approach to estimating time-varying causal (in)direct effects of pharmacological treatments on daily smoking cessation outcome(s) mediated via daily treatment adherence. Additionally, it is hypothesized that adherence is influenced by daily stress events related to social contextual factors, not treatment-induced. The purpose of this research is to derive time-varying causal (in)direct effects. A local polynomial regression-based approach integrated with the mediational g-formula was proposed as a possible solution. Furthermore, since no other studies have studied time-specific mediation effects using a potential outcomes framework-based method, the performance of the proposed method was tested using two simulation studies. Finally, the optimum analytical approach (based on the findings from the simulation studies) was applied to answer the substantive research questions on smoking cessation using empirical data from a smoking cessation clinical trial. This dissertation is divided into six chapters. A brief overview of the chapters is as follows: Chapter 1 provides a comprehensive background and rationale for the methodological and substantive research that motivated this work. The chapter concludes with the three specific aims addressed in this research and a summary of the next steps. In Chapter 2, the longitudinal causal frameworks and the assumptions required to interpret the estimated time-varying (in)direct effects as causal are described in detail. These frameworks were further used in Chapters 3 and 4 for the two simulation studies that evaluated the performance of the proposed new approach. The simulation study in Chapter 3 evaluates the time-varying (in)direct effects in a longitudinal study in the absence of exposure-induced time-varying confounding of a mediator-outcome pathway. Four outcome scenarios with a binary exposure, a binary mediator, and a time-varying binary confounder of the mediator-outcome pathway were examined: 1) continuous outcome, 2) rare binary outcome, 3) common binary outcome, and 4) count outcome that is not zero-inflated. Two types of path-specific causal estimands are identifiable for these scenarios. The findings suggest good performance of the proposed analytical approach in producing accurate effect estimates (reduced bias and reasonable coverage) of these estimands for all the outcome scenarios. The simulation study in Chapter 4 evaluates the time-varying (in)direct effects in a longitudinal study in the presence of exposure-induced time-varying confounding of a mediator-outcome pathway. A zero-inflated count outcome scenario with a binary exposure, a binary mediator, and a time-varying binary confounder of the mediator-outcome pathway was examined. Four types of path-specific causal estimands are identifiable for this scenario, and the findings suggest good performance of the proposed analytical approach in producing accurate effect estimates. Chapter 5 uses the Wisconsin Smokers Health Study II data to assess the mechanisms via which pharmacological smoking cessation treatments affect the cessation-related outcome(s) in the presence of time-varying confounding that is not exposure induced. We found that individuals randomized to Nicotine Patch only group have better smoking cessation outcome(s) compared to individuals on Varenicline or combination Nicotine Replacement Therapy. This is due to better adherence among Nicotine Patch-only users. Finally, Chapter 6 presents the concluding remarks, including key findings from the three studies, limitations, and recommendations for future research. / Epidemiology

Although there has been progress in trying to decrease the use of cigarette smoking, a new method of smoking has evolved which is rapidly increasing, namely vaping. Adolescents who participate in smoking are more likely to increase smoking frequency if they believed that it is self-defining (“I smoke cigarettes” versus “I am a smoker”). While there has been evidence to support the claim that internal motives for smoking are correlated with smoker identity development, there has been none, to our knowledge, found for vaping identity. Due to the similarities of smoking and vaping, it is important to discover whether those who vape also have an identity similar to those who smoke. In other words, with vaping being a new technology, do users identify themselves as “I am a vaper” or “I vape e-cigarettes”? The way in which users identify themselves may have important implications for intervention efforts. Further, smoking is a type of substance abuse, and substance abuse, primarily alcohol, has been linked to identity status, identity distress, and psychopathology. Smoking has been linked to alcohol use and abuse, but it is unclear if smoking is related to similar identity and adjustment variables, particularly internalizing symptoms, in the same way as alcohol use. Thus, the purpose of this study was to explore the associations between smoking, vaping, identity, and psychopathology. Using college student participants (N = 303) who completed anonymous online surveys for course credit, four hypotheses were tested, but none was confirmed. Possible reasons for the lack of significant findings are discussed. Despite the lack of findings in regard to the relationship among the study variables, the new concept and measure of vaping identity proposed in this thesis appear to be a potentially valid and useful avenue for future research.

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