Background

The coronavirus disease (COVID-19) pandemic, which began in Wuhan, China in December 2019, is rapidly spreading worldwide with over 1.9 million cases as of mid-April 2020. Infoveillance approaches using social media can help characterize disease distribution and public knowledge, attitudes, and behaviors critical to the early stages of an outbreak.

Objective

The aim of this study is to conduct a quantitative and qualitative assessment of Chinese social media posts originating in Wuhan City on the Chinese microblogging platform Weibo during the early stages of the COVID-19 outbreak.

Methods

Chinese-language messages from Wuhan were collected for 39 days between December 23, 2019, and January 30, 2020, on Weibo. For quantitative analysis, the total daily cases of COVID-19 in Wuhan were obtained from the Chinese National Health Commission, and a linear regression model was used to determine if Weibo COVID-19 posts were predictive of the number of cases reported. Qualitative content analysis and an inductive manual coding approach were used to identify parent classifications of news and user-generated COVID-19 topics.

Results

A total of 115,299 Weibo posts were collected during the study time frame consisting of an average of 2956 posts per day (minimum 0, maximum 13,587). Quantitative analysis found a positive correlation between the number of Weibo posts and the number of reported cases from Wuhan, with approximately 10 more COVID-19 cases per 40 social media posts (P<.001). This effect size was also larger than what was observed for the rest of China excluding Hubei Province (where Wuhan is the capital city) and held when comparing the number of Weibo posts to the incidence proportion of cases in Hubei Province. Qualitative analysis of 11,893 posts during the first 21 days of the study period with COVID-19-related posts uncovered four parent classifications including Weibo discussions about the causative agent of the disease, changing epidemiological characteristics of the outbreak, public reaction to outbreak control and response measures, and other topics. Generally, these themes also exhibited public uncertainty and changing knowledge and attitudes about COVID-19, including posts exhibiting both protective and higher-risk behaviors.

Conclusions

The results of this study provide initial insight into the origins of the COVID-19 outbreak based on quantitative and qualitative analysis of Chinese social media data at the initial epicenter in Wuhan City. Future studies should continue to explore the utility of social media data to predict COVID-19 disease severity, measure public reaction and behavior, and evaluate effectiveness of outbreak communication.

Introduction

The state of California has enacted progressive anti-tobacco policies, including Proposition 56 in 2016. In response, the alternative and emerging tobacco product (ATP) industry has increased its political activity. This study explores the association between the proportion of people voting against Proposition 56 and tobacco/ATP retail density.

Methods

We conducted a retrospective analysis using data on licensed California tobacco retailers, which were then cross-referenced for categorization using Yelp. Proportion voting against Proposition 56 was obtained from the Secretary of State's website. A series of linear regression tests were performed between population-normalized retailer density and voting proportion at the county level before and after adjusting for covariates such as age, gender, race/ethnicity and median household income.

Results

The total number of licensed tobacco retailers increased by 29.31% from 2015 to 2019. Association between proportion voting against Proposition 56 and retail density was significant during voting and during periods of policy implementation and post-implementation (2016-2018) for non-specialized tobacco retailers. For specialized/ATP retailers, significance was only detected during the post-implementation period (2018-2019) after normalization. Proportion voting against Proposition 56 was also a significant predictor of increase in total number of non-specific (β=0.48, p=0.008) as well as specialized tobacco and/or ATP retail storefronts (β=0.21, p=0.001) from 2016 to 2018.

Conclusions

This study provides initial evidence of the association between tobacco retail density and voting patterns for anti-tobacco policy. Future research should examine the role of tobacco retail density on variation in local support for state tobacco control initiatives, including tailoring outreach to specific voting census blocks in communities with heavy retail presence.

INTRODUCTION: In 2019, the state of Massachusetts signed into law the first statewide sales restrictions of flavored ENDS/tobacco products for both physical and online shops in response to a previous executive order to curb E-Cigarette, or Vaping Product, Use Associated Lung Injury (EVALI) cases that were surging throughout the nation. METHODOLOGY: This study obtained licensure data from the Massachusetts Department of Revenue, to observe the changes in retail licensure comparing the pre ban (October 2018-August 2019) and post ban periods (October 2020- August 2021). A series of linear regression tests were conducted on both periods using census tract data to explore potential associations with sociodemographic covariates, including median age, median household income, and population proportion by gender, age, and race/ethnicity groups. RESULTS: Analysis of the Massachusetts post-ban period (October 2020-August 2021) found that new tobacco retail licenses issued decreased by 52.9% (n = 968) when compared to the pre-ban period (October 2018-August 2019) of 1831. A significant positive association was discovered between change in new retailer count and proportion male population (2.48 ± 1.05, P = .018) as well as proportion Hispanic population (1.19 ± .25, P < .001) at the census tract level. CONCLUSION/DISCUSSION: Our analysis indicates that, following the temporary MA flavor sales ban, the total number of licenses decreased, though decreases were more pronounced for new licenses when compared to continuing licenses. Higher increases in new tobacco retailer density were significantly associated with concentration of male and Hispanic populations.

Background

In 2016, the "Act on Support for Overseas Expansion of Healthcare System and Attraction of International Patients" was enacted by the South Korean government in an attempt to accelerate growth of its medical tourism industry. However, only a few years after its implementation, the benefits are not well understood, nor have the positive or negative impacts of expanding Korea's medical tourism sector been properly evaluated.

Objective

We aimed to systematically review and summarize existing literature describing South Korea's medical tourism policy and legislative history, while also assessing the impact of this domestic policy approach on the country's public health systems.

Methods

A bilingual systematic literature review was conducted per PRISMA guidelines for all South Korean medical tourism legislative and policy literature using MeSH terms and other related keywords in two academic databases, PubMed and JSTOR. Published studies were included if they directly addressed South Korean medical tourism policy. To supplement results from the peer-review, the grey literature was also searched using Google search engine for relevant policy documents, information from government websites, and national statistics on medical tourism-related data.

Results

This review included 14 peer-reviewed journal articles and 9 websites. The majority of literature focused on the legislative history of South Korea's pro-medical tourism policy, economic considerations associated with industry growth, and the specific experiences of medical tourists. There was a lack of studies, analytical or commentary-based, conducting in-depth analysis of the healthcare impact of these policies or comparing benefits and costs compared to other medical tourism destinations. Proponents of medical tourism continue to advocate the government for increased deregulation and investment in the sector.

Conclusion

This systematic review suggests that policy decisions may prioritize economic growth offered by medical tourism over negative effects on the healthcare workforce, access and equity, and its potential to undermine Universal Health Coverage. South Korea continues to examine ways to further amend the Act and grow this sector, but these actions should be taken with caution by critically examining how other countries have adapted their policymaking based on the real-world costs associated with medical tourism.

Background

Cancer patients often face multiple comorbidities and are at risk for various mental health conditions and substance use disorders. Tobacco/nicotine dependence (TND) is a known risk factor for poor health outcomes and has been associated with psychiatric disorders including substance use disorder. However, the specific relationship between TND and the risk of substance use disorder and mental health conditions among cancer patients remains underexplored. This study aimed to assess the association between TND and the risk of comorbid conditions among cancer patients.

Methods

Data were obtained from a database of electronic health records for patients from the University of California health system. The odds for every condition among cancer patients with TND were calculated and compared with those for cancer patients without TND. ORs were adjusted for gender, ethnicity, and race.

Results

Three thousand seven hundred and ninety-one cancer patients with TND had 252,619 total conditions, and 51,711 cancer patients without TND had 2,310,880 conditions. After adjusting for confounders, the condition for which TND most exacerbated risk was psychoactive substance-induced organic anxiety disorder (OR = 16.3, p < 0.001). This appeared consistent with the second, third, and fifth most-exacerbated conditions: stimulant use disorder (OR = 12.8, p < 0.001), cocaine induced mental disorder (OR = 11.0, p < 0.001), and cocaine use disorder (OR = 11.0, p < 0.001). Different conditions exacerbated by TND include acute alcoholic intoxication (OR = 11.4, p < 0.001), opioid use disorder (OR = 7.6, p < 0.001), schizoaffective disorder (OR = 7.4, p < 0.001), and cannabis use disorder (OR = 6.3, p < 0.001).

Conclusions

Our findings reveal a strong association between TND and an increased risk of substance use disorder and mental health conditions among cancer patients. Specifically, cancer patients with TND were at an elevated risk for psychoactive substance-induced organic anxiety disorder, stimulant use disorder, and cocaine-related disorders. Additionally, TND was associated with an increased risk of acute alcoholic intoxication, opioid use disorder, schizoaffective disorder, and cannabis use disorder. These findings underscore the need for comprehensive screening and interventions to address TND and comorbid conditions among cancer patients.

INTRODUCTION: Previous studies have identified numerous adverse events experienced with the use of ENDS or E-cigarettes. However, much remains unknown about adverse event frequency, duration, and response experienced by users. The purpose of this study was to inductively characterize ENDS-attributed adverse events among young adults. METHODS: Sixteen focus groups were held with 114 young adults (aged 18-29 years) who have reported lifetime ENDS use in April 2021. Discussion topics included current and previous tobacco, nicotine, and cannabis use; specific symptoms and frequency and duration of and response to symptoms of ENDS-attributed adverse events; and the impact of other conditions such as COVID-19 on ENDS use. Data were inductively analyzed using a team-based approach. RESULTS: More than 40 ENDS-attributed adverse events were reported in focus groups among approximately three quarters of all study participants, with headache, coughing, lightheadedness, nausea, dry or sore throat, and dizziness the most common. In general, adverse events were transient, with most resolving in a few hours, although some tended to last for longer. The frequency of adverse events varied most between every time ENDS were used and when someone vaped excessively. Finally, behavioral responses varied by adverse events, with difficulty in breathing, chest pain, and lung discomfort more likely to result in quitting permanently. CONCLUSIONS: Overall, the results of this study show that not only do adverse events vary greatly, but they also vary across multiple dimensions of user experience.

Background

TikTok is a microvideo social media platform currently experiencing rapid growth and with 60% of its monthly users between the ages of 16 and 24 years. Increased exposure to e-cigarette content on social media may influence patterns of use, including the risk of overconsumption and possible nicotine poisoning, when users engage in trending challenges online. However, there is limited research assessing the characteristics of nicotine poisoning-related content posted on social media.

Objective

We aimed to assess the characteristics of content on TikTok that is associated with a popular nicotine poisoning-related hashtag.

Methods

We collected TikTok posts associated with the hashtag #nicsick, using a Python programming package (Selenium) and used an inductive coding approach to analyze video content and characteristics of interest. Videos were manually annotated to generate a codebook of the nicotine sickness-related themes. Statistical analysis was used to compare user engagement characteristics and video length in content with and without active nicotine sickness TikTok topics.

Results

A total of 132 TikTok videos associated with the hashtag #nicsick were manually coded, with 52.3% (69/132) identified as discussing firsthand and secondhand reports of suspected nicotine poisoning symptoms and experiences. More than one-third of nicotine poisoning-related content (26/69, 37.68%) portrayed active vaping by users, which included content with vaping behavior such as vaping tricks and overconsumption, and 43% (30/69) of recorded users self-reported experiencing nicotine sickness, poisoning, or adverse events such as vomiting following nicotine consumption. The average follower count of users posting content related to nicotine sickness was significantly higher than that for users posting content unrelated to nicotine sickness (W=2350.5, P=.03).

Conclusions

TikTok users openly discuss experiences, both firsthand and secondhand, with nicotine adverse events via the #nicsick hashtag including reports of overconsumption resulting in sickness. These study results suggest that there is a need to assess the utility of digital surveillance on emerging social media platforms for vaping adverse events, particularly on sites popular among youth and young adults. As vaping product use-patterns continue to evolve, digital adverse event detection likely represents an important tool to supplement traditional methods of public health surveillance (such as poison control center prevalence numbers).

Introduction

Tobacco retailer density may be associated with greater youth initiation and reduced success during quit attempts; however, the extent to which tobacco retailer density has changed overtime across multiple categories of retailers has not been reported.

Methods

Data on licensed tobacco retailers within California from 2015-2019 were obtained from the California Department of Tax and Fee Administration. Store type was categorized by automated cross-referencing with Yelp. Geolocations were aggregated at county level for analyzing longitudinal trends in changes in tobacco retail density including demographic characteristics.

Results

The number of active CA tobacco retailer licenses increased from 19825 in 2015 to 25635 in 2019. The highest percent increase in tobacco retailer licenses (9.1%) was observed in 2017. The number of specialized tobacco stores was highest in Los Angeles, San Diego, and Riverside counties. We observed a significant increase in the number of active licenses for non-specialized and specialized tobacco stores, both overall and after controlling for the size of populations within each region. Time was a statistically significant predictor for the number of active licenses for only non-specialized stores, after adjusting for covariates. Regional volume of retailers was positively associated with higher proportion of women, lower median household income, and higher proportion of Hispanic residents.

Conclusions

Monitoring the changes in tobacco retail density and associated sociodemographic factors over time can help to identify communities at higher risk for tobacco and nicotine product exposure and access, and its associated health disparities.

Introduction

Exposure to pro-tobacco and electronic nicotine delivery system (ENDS) social media content can lead to overconsumption, increasing the likelihood of nicotine poisoning. This study aims to examine trends and characteristics of nicotine sickness content on Twitter between 2018-2020.

Methods

Tweets were collected retrospectively from the Twitter Academic Research Application Programming Interface (API) stream filtered for keywords: 'nic sick', 'nicsick', 'vape sick', 'vapesick' between 2018-2020. Collected tweets were manually annotated to identify suspected user-generated reports of nicotine sickness and related themes using an inductive coding approach. The Augmented Dickey-Fuller (ADF) test was used to assess stationarity in the monthly variation of the volume of tweets between 2018-2020.

Results

A total of 5651 tweets contained nicotine sickness-related keywords and 18.29% (n=1034) tweets reported one or more suspected nicotine sickness symptoms of varied severity. These tweets were also grouped into five related categories including firsthand and secondhand reports of symptoms, intentional overconsumption of nicotine products, users expressing intention to quit after 'nic sick' symptoms, mention of nicotine product type/brand name that they consumed while 'nic sick', and users discussing symptoms associated with nicotine withdrawal following cessation attempts. The volume of tweets reporting suspected nicotine sickness appeared to increase throughout the study period, except between February and April 2020. Stationarity in the volume of 'nicsick' tweets between 2018-2020 was not statistically significant (ADF= -0.32, p=0.98) indicating a change in the volume of tweets.

Conclusions

Results point to the need for alternative forms of adverse event surveillance and reporting, to appropriately capture the growing health burden of vaping. Infoveillance approaches on social media platforms can help to assess the volume and characteristics of user-generated content discussing suspected nicotine poisoning, which may not be reported to poison control centers. Increasing volume of user-reported nicotine sickness and intentional overconsumption of nicotine in twitter posts represent a concerning trend associated with ENDS-related adverse events and poisoning.