Gina Rae Kruse

Context: States regulate e-cigarettes through tobacco control laws to restrict product accessibility and advance public health objectives. Enforcement of laws results in regulators obtaining e-cigarette products, which are classified as hazardous waste and must be disposed of in accordance with federal standards. As states implement tobacco control laws, they face increasing challenges related to the disposal of e-cigarette products. Objectives: This study provides insights into the challenges states face and the strategies they have developed for managing the disposal of e-cigarette products while implementing tobacco control policies. Design: We conducted semistructured qualitative interviews guided by the Bullock et al policy implementation framework to examine 5 e-cigarette policies: taxation, licensure, flavor restrictions, minimum legal sales age, and clean indoor air. Emergent topics within the framework, including e-cigarette disposal, were analyzed using a second-cycle, team-based inductive approach. Setting: US state government agencies involved in implementing e-cigarette policies. Participants: State key informants (KIs) directly involved in or knowledgeable about e-cigarette policy implementation. Main Outcome Measures: Qualitative themes describing disposal practices for the management of e-cigarette hazardous waste by state KIs. Results: Interviews with state personnel revealed struggles to meet waste management requirements for e-cigarettes. Some KIs reported avoiding or limiting the enforcement of tobacco control laws regulating e-cigarettes because of disposal costs and logistical challenges. KIs proposed solutions that other states could adopt, such as seizure in place and statutory language to recoup costs. Failure to manage e-cigarette disposal undermined public health goals and imposed financial burdens on government agencies. Conclusions: Proper disposal management will require industry accountability, new partnerships, and the development of infrastructure and systems. States need comprehensive model language to guide e-cigarette waste disposal.

Objectives: We aimed to understand tobacco use and treatment patterns among adults starting care in a Chennai HIV clinic. Methods: Cross-sectional survey of adults initiating HIV care with biochemical verification of tobacco exposure. Results: Among 154 adult patients (10/2019-12/2021) initiating HIV care, 37.7% (n = 58) self-reported current tobacco use (13.6% [n = 21] smoking, 17.5% [n = 27] smokeless tobacco [SLT], 6.5% [n = 10] dual use) and 7.8% (n = 12) reported former use (5.8% [n = 9] smoking, 1.3% [n = 2] SLT, 0.6% [n = 1] dual), none reported using cessation medications, two reported counseling. Cotinine levels indicating current use varied by tobacco product (smoking: 66.7% had cotinine ≥ 50ng/ml; SLT: 70.4%; dual: 80.0%, no current tobacco: 44.8%, p = 0.02). Conclusion: Smoking and SLT use are common and underreported and evidence-based cessation treatment use was rare prior to HIV care initiation.

Less than one in five eligible adults has received lung cancer screening (LCS) with low dose computed tomography in the U.S. We aimed to determine factors

Supplementary Table S1: Data collection by phase, quarter, system

Background:Guidelines for management of abnormal cervical cancer screening results have increased in complexity over the past two decades. Little is known about how patient-, clinician-, and organization-level factors influence implementation when guidelines change. Process mapping may offer insights into organizational processes and facilitate visualization for potential intervention opportunities.Methods:We conducted an iterative multimodal qualitative assessment to compare abnormal cervical cancer screening management between two health systems: a safety-net institution and an integrated health system. We interviewed clinicians and staff to generate (phase I, May 2019–March 2021) and validate (phase II, July–Oct 2022) process maps at both systems. We conducted a rapid and thematic content analysis and engaged clinical and nonclinical stakeholders during interpretation.Results:At both health systems, process maps informed by phase I participants (n = 31) identified a gap in care during patients’ transition back to primary care following resolution of abnormal tests by gynecologists. In phase II, participants (n = 21) validated and revised maps, noting guideline updates and quality improvement initiatives. Although each system deployed unique strategies to address gaps in care, strategies in common included creating electronic health record–based clinical decision support tools, enabling gynecologists to provide real-time e-consults to primary care clinicians, and engaging patients via the portal.Conclusions:The complexity of cervical cancer screening management guidelines elevates the importance of identifying system-level tools to support clinician decision-making and coordinate between primary and specialty care teams.Impact:Process maps are valuable in generating cross-system comparisons by documenting clinical workflows, identifying care gaps, and engaging participants in formulating potential interventions.

Supplementary Table S2: Standards for Reporting Qualitative Research (SRQR)

Background: Alcohol withdrawal hospitalizations present unmet opportunities to initiate medications for alcohol use disorder (MAUD). Objective: To examine patient and hospital factors associated with MAUD initiation during hospitalizations. Methods: We conducted a retrospective cohort study of alcohol withdrawal hospitalizations in a large health system using electronic health record and pharmacy data from 2022 to 2024. The outcome was MAUD initiation defined as inpatient administration of injectable naltrexone or prescriptions for outpatient oral naltrexone, acamprosate, disulfiram, topiramate, or baclofen. We excluded patients who filled MAUD in the prior 90 days. We used a multivariable linear model with socioeconomic, clinical, and hospitalization factors as fixed effects and individual patients and hospital sites as random effects to account for clustering. Results: Among 5993 alcohol withdrawal hospitalizations across 12 hospitals, 19.8% (range: 5.1%– 43.2%) initiated MAUD. Oral naltrexone was the most common MAUD initiated, while topiramate was the least common (66.9% and 1.2% of MAUD initiated, respectively). Patients less likely to initiate MAUD were age ≥ 65 years (absolute adjusted difference −6.89 percentage points [pp] vs. age 18–29; 95% confidence interval [CI] −12.20, −1.58) and those without cirrhosis and liver enzymes >200 U/L (−3.46 pp vs. liver enzymes ≤ 200 U/L; 95% CI: −6.87, −0.01). Four hospitals initiated MAUD at significantly lower rates, and two at higher rates including the only hospital with an addiction consult service. Conclusion: MAUD initiation during alcohol withdrawal hospitalizations was low and varied by patient factors and hospital sites. Factors driving this variation can inform interventions to address MAUD underutilization.

Introduction: All 50 states have e-cigarette minimum legal sales age (MLSA) policies. In 2019, national tobacco control organizations released a model MLSA policy providing guidance on how tobacco policies should be structured to effectively prevent underage sales. We explored state e-cigarette MLSA implementation in relation to the model policy. Methods: Key informant (KI) interviews were conducted with state personnel involved in MLSA implementation from a purposive sample of states. Informants were asked about policy components, implementation facilitators, challenges, and processes, based on Bullock’s determinants of policy implementation framework. Interviews were coded by framework domains and analyzed for themes related to implementing model policy components. Key components included product definitions, age restrictions, licensure, funding, education, preemption, ID verification, signage, enforcement agency and protocols, compliance checks, penalties, and prosecution. Results: Between April 2023 and July 2024, 24 MLSA interviews were conducted with 32 KIs from 23 states, yielding 4589 coded passages. KIs reported engaging with model policy components during the implementation process, though states varied in their alignment with the model’s recommendations, with areas of more common deviation including penalty structures, whether clerks or retailers were penalized, and required compliance checks. Several implementation factors absent from the model also emerged as important, including online sales, license transfer, “decoy buy” products, complaint-driven compliance checks, and product disposal. Conclusion: States’ e-cigarette MLSA policy implementation experiences in relation to model policy recommendations identified areas where states could improve (eg, penalties) and novel issues (eg, online sales) whose implementation is worthy of ongoing attention. Implications: Insights from the state MLSA implementation experiences should inform advocates, bureaucrats, and elected officials about potential solutions to implementation barriers for e-cigarette MLSA. Findings highlight implementation facilitators and identify existing model policy components that may be improved in future guidance. Key elements for revising state policies and/or the model include shifting penalties from clerks to retailers, setting a minimum number of compliance checks, coordinating compliance programs, reconsidering criminal penalty structures, regulating online sales, preventing illegitimate license transfers, establishing complaint-driven enforcement, and requiring the inclusion of e-cigarette products in a minimum percentage of decoy buys.