A greater presence of marijuana co-marketing in neighborhoods with a higher proportion of school-age youth and lower median household income raises concerns about how industry marketing tactics may contribute to disparities in LCC use. The study results also suggest that $1 buys significantly more cigarillos in California school neighborhoods with lower median household income. Policies to establish minimum pack sizes and prices could reduce the widespread availability of cheap cigar products and address disparities in disadvantaged areas. After Boston’s 2012 cigar regulation, the mean price for a grape-flavored cigar was $1.35 higher than in comparison communities. The industry circumvented sales restrictions in some cities by marketing even larger packs of cigarillos at the same low price, and the industry’s tipping point on supersized cigarillo packs for less than $1 is not yet known. The retail availability of 5- and 6-packs of LCCs for less than $1 observed near California schools underscores policy recommendations to establish minimum prices for multi-packs .A novel measure of marijuana co-marketing and a representative sample of retailers near schools are strengths of the current study. A limitation is that the study assessed the presence of marijuana co-marketing, but not the quantity. The protocol likely underestimates the prevalence of marijuana co-marketing near schools because we lacked a comprehensive list of LCC brands and flavor varieties. Indeed, state and local tobacco control policy research and enforcement would be greatly enhanced by access to a comprehensive list of tobacco products from the US Food and Drug Administration, including product name, category, identification number and flavor. Both a routinely updated list and product repository would be useful for tobacco control research,bud drying rack particularly for further identifying how packaging and product design reference marijuana use.
This first assessment of marijuana co-marketing focused on brand and flavor names because of their appeal to youth. However, the narrow focus is a limitation that also likely underestimates the prevalence of marijuana co-marketing. Other elements of packaging and product design should be considered in future assessments. Examples are pack imagery that refers to blunt making, such as the zipper on Splitarillos, as well as re-sealable packaging for cigarillos and blunt wraps, which is convenient for tobacco users who want to store marijuana. Coding for brands that are perforated to facilitate blunt making and marketing that refers to “EZ roll” should also be considered. Future research could assess marijuana co-marketing across a larger scope of tobacco/nicotine products. The same devices can be used for vaping both nicotine and marijuana. Advertising for vaping products also features compatibility with “herbs” and otherwise associates nicotine with words or images that refer to marijuana . Conducted before California legalized recreational marijuana use, the current study represents a baseline for understanding how retail marketing responds to a policy environment where restrictions on marijuana and tobacco are changing, albeit in opposite directions.20 The prevalence of marijuana co-marketing near schools makes it imperative to understand how tobacco marketing capitalizes on the appeal of marijuana to youth and other priority populations. How marijuana co-marketing contributes to dual and concurrent use of marijuana and tobacco warrants study, particularly for youth and young adults. In previous research, the prevalence of adult marijuana use in 50 California cities was positively correlated with the retail availability of blunts.
Whether this is correlated with blunt use by adolescents is not yet known. Consumer perception studies are necessary to assess whether marijuana co-marketing increases the appeal of cigar smoking or contributes to false beliefs about product ingredients. Research is also needed to understand how the tobacco industry exploits opportunities for marijuana co-marketing in response to policies that restrict sales of flavored tobacco products and to policies that legalize recreational marijuana use. Such assessments are essential to understand young people’s use patterns and to inform current policy concerns about how expanding retail environments for recreational marijuana will impact tobacco marketing and use.Patients with obstructive sleep apnea experience apneic and hypopneic events that, when untreated, have detrimental cardiovascular and neurocognitive consequences. Under normal conditions, blood pressure and heart rate decrease during non–rapid eye movement sleep and increase commensurately upon waking. This is attributed to a decrease in sympathetic nervous system activation and a subsequent increase in cardiac vagal tone during sleep . The transient episodes of hypoxemia and hypercapnia caused by apneas or hypopneas, as well as arousals, result in an increase in cardiac output and heart rate that leads to sympathetically induced peripheral vasoconstriction that causes a marked increase in blood pressure. The result of this chronic sympathetic excitation and inflammation does not resolve upon waking, and over time, together with the loss of the normal nocturnal blood pressure dip, it can lead to pathophysiologic changes such as impaired vascular function and stiffness . This impairment in the untreated patient with moderate to severe OSA has been found to increase the risk of both acute coronary syndrome and sudden cardiac death . The increased sympathetic nervous activity, inflammation, and oxidative stress seen in OSA can lead to hypertension.
The prevalence of hypertension in moderate to severe OSA ranges between 13% and 60%, and OSA is considered the most common cause of secondary hypertension . Arrhythmias can be common in patients with OSA, and the prevalence of atrial fibrillation is higher in these patients than in patients without OSA. In fact, severe sleep disordered breathing is associated with twofold to fourfold higher odds of having complex arrhythmias. In addition, untreated OSA has been associated with higher rates of failure to maintain sinus rhythm after cardioversion or ablation therapy . Inflammation, atrial fibrillation, and atherosclerosis are all associated with OSA and overlap with risk factors for cerebrovascular disease. OSA may be frequently diagnosed after stroke, and it can be difficult to determine whether the condition is causal or resultant. Evidence suggests that OSA is associated with an increased risk of stroke in elderly patients, and untreated OSA after stroke increases mortality risk during 10-year follow-up . Another disease state affected by sleep apnea is heart failure. Both OSA and central sleep apnea are common in patients with acute and chronic systolic and diastolic heart failure. Untreated OSA in this patient population has been associated with an increased risk of death. However, screening for sleep disordered breathing can be difficult because patients with OSA and heart failure often do not report excessive daytime sleepiness. This absent symptom raises challenges in diagnosis and treatment adherence for OSA . Untreated OSA can affect many cognitive domains, including learning, memory, attention, and executive functioning. Data suggest that OSA is linked with cognitive impairment and may advance cognitive decline or dementia . In addition, intermittent hypoxemia and sleep fragmentation have been linked to structural changes in the brain that may be responsible for cognitive impairment . Given the increased prevalence of obesity and the common nature of diagnoses such as hypertension, coronary artery disease, atrial fibrillation, heart failure, and neurocognitive impairment, healthcare providers should be cognizant of the hazards of untreated OSA .Positive airway pressure therapy is highly efficacious in treating OSA, but its effectiveness relies on adherence. There is a dose–response relationship between continuous PAP usage and clinical outcomes in OSA, although the optimal adherence threshold may vary depending on the clinical outcome of interest . Consequently, recognition of barriers to use and interventions to augment adherence are pivotal to the successful management of patients with OSA. Studies have explored potential modifiable and non-modifiable predictors of PAP adherence with inconsistent results . Most adherent patients have higher baseline daytime somnolence, possibly worse OSA severity based on the apnea– hypopnea index , higher self-efficacy ,4×8 tray grow and confidence for troubleshooting as well as greater social support, including bed partner engagement. Patients who have challenges with PAP adherence tend to have lower socioeconomic status, type D personality, high expectations in treatment outcome, claustrophobia, and small nasal passages. Patient age, sex, marital status, and amount of anxiety and depression have not been shown to consistently predict PAP adherence . Therefore, an individualized patient centered approach is recommended to optimize PAP adherence in OSA. Interrogation of PAP tracking systems can reveal patterns and the duration of PAP use and may help identify potential modifiable targets to improve adherence, such as mask leak . High residual AHI can point toward suboptimally treated obstructive events or the emergence of central events. Prompt and early troubleshooting of any side effects is important, as the pattern of PAP usage is established early and has been shown to predict long-term use.
Attention to mask fitting is essential, with otolaryngologic evaluation helpful in patients with narrow nasal passages or nasal congestion that may be amenable to surgery . Given the psychological influences on PAP adherence, educational and behavioral interventions aim to address patient perceptions and promote self efficacy. Motivational counseling by psychologists during appointments with follow-up phone calls has been shown to increase adherence by 99 min/night compared with control subjects . In a meta-analysis, behavioral therapy improved average PAP usage by 1.44 h/night and increased the number of nights with >4 hours usage from 28% to 47%, although the quality of evidence was low . In addition, studies exploring educational and behavioral strategies are limited by heterogeneity, often combining various modalities and thus making generalizations difficult. Increasingly, technological innovations are being used to improve PAP management and adherence. Cloud-based platforms and wireless capabilities offer real-time monitoring and active patient engagement. In a retrospective analysis of two cloud based databases, patients who actively engaged in real-time feedback through a website connected to their PAP devices had 87% compliance compared with 70% compliance in the usual-care group , as defined by the U.S. Medicare criteria for compliance . These technologies are also being incorporated in telemedicine. In a recent trial on telemedicine education and telemonitoring on CPAP adherence, patients randomized to receive web-based education and automated message feedback through telemonitoring had a Medicare adherence rate of 73% compared with 55% in the usual-care group . Modern PAP devices are including features in an attempt to improve comfort and adherence, including ramp, automatically adjusting pressures , expiratory pressure relief technologies, lighter interfaces such as nasal pillows, and heated humidification . Although none of these have been shown to consistently improve adherence, these technological advancements reflect ongoing efforts to personalize OSA management.Chronic insomnia, characterized by difficulties falling asleep, staying asleep, or early morning awakenings, is the most prevalent sleep disorder in the United States, affecting an estimated 10–15% of Americans. Symptoms occur despite adequate opportunity to sleep and are associated with daytime impairment, including impaired attention and cognition, increased risk of industrial and motor vehicle accidents, reduced work productivity, and increased healthcare costs . Insomnia is also a risk factor for multiple chronic health conditions, including cardiovascular disease , mood disorders, and pain conditions . Despite the widespread public health impact, insomnia remains both under recognized and under treated. Nearly two-thirds of patients with insomnia are unaware of available treatment options, and ~40% self medicate with alcohol and unproven over-the-counter sleep aids . Evaluation of insomnia should include a comprehensive sleep history, including sleep/wake routines , daily behaviors that impact sleep , and screening for comorbid sleep disorders . Given the high prevalence of concurrent mood disorders and other comorbidities, a thorough medical and psychiatric history is also warranted. Prior treatments for insomnia should also be reviewed. Use of a sleep diary to capture the patient’s habitual sleep patterns, including differences between weekday and weekend sleep routines, is very helpful. Comorbid depression and anxiety as well as pain syndromes are distinct but overlapping entities and should be treated concurrently . Current guidelines recommend multi-component cognitive behavioral therapy for insomnia as first-line treatment for chronic insomnia in adults . Data suggest that compared with pharmacotherapy, the effects of CBT-I are similar but more durable and have a better safety profile . CBT-I is also effective for insomnia in adults with comorbid moodand medical conditions, including conditions in which sleep medication may be contraindicated. The key components of CBT-I include sleep hygiene, stimulus control, sleep restriction, cognitive restructuring, and relaxation techniques .