scholarly journals Smoking and Vaping Among a National Sample of U.S. Adults During the COVID-19 Pandemic

2021 ◽  
Author(s):  
Sara Kalkhoran ◽  
Douglas E Levy ◽  
Nancy A Rigotti
Keyword(s):  
Cigarette Smoking ◽  
Perceived Risk ◽  
Severe Disease ◽  
National Sample ◽  
Cigarette Use ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Cigarette Smokers ◽  
Use Patterns ◽  
Product Use

Introduction: With concerns about cigarette smoking as a risk factor for severe disease from COVID-19, understanding nicotine and tobacco use patterns is important for preventive efforts. We aimed to understand changes in product use behaviors among U.S. adult combustible cigarette smokers and electronic cigarette (e-cigarette) users. Methods: In August 2020, we conducted a cross-sectional survey of a nationally-representative sample of adults age >18 in the NORC AmeriSpeak Panel who reported past 6-month use of combustible cigarettes or e-cigarettes. Multivariable logistic regression assessed factors associated with increased product use and quit attempts since hearing about COVID-19. Results: 1024 past 6-month cigarette smokers and/or e-cigarette users were surveyed. Among cigarette smokers, 45% reported no change in cigarette smoking and 33% increased cigarette smoking since hearing about COVID-19. Higher stress was associated with increased cigarette smoking. Among e-cigarette users, 41% reported no change in and 23% reported increasing e-cigarette use. 26% of cigarette smokers and 41% of e-cigarette users tried to quit because of COVID-19. Higher perceived risk of COVID-19 was associated with attempts to quit combustible cigarettes (AOR 2.37, 95% CI 1.59-3.55) and e-cigarettes (AOR 3.14, 1.73-5.70). Conclusions: Cigarette and e-cigarette use patterns varied in response to the COVID-19 pandemic. Most cigarette smokers and e-cigarette users perceived product use as increasing COVID-19-related health risks, and this was associated with attempts to quit. Others, especially those reporting higher stress, increased product use. Proactive provision of cessation support to smokers and e-cigarette users may help mitigate stress-related increases in product use during the COVID-19 pandemic.

scholarly journals Characterization of Volatile Organic Compound Metabolites in Cigarette Smokers, Electronic Nicotine Device Users, Dual Users, and Nonusers of Tobacco

2019 ◽  
Vol 22 (2) ◽  
pp. 264-272 ◽  
Author(s):  
Rachel J Keith ◽  
Jessica L Fetterman ◽  
Olusola A Orimoloye ◽  
Zeina Dardari ◽  
Pawel K Lorkiewicz ◽  
...  
Keyword(s):  
Cardiovascular Effects ◽  
Cross Sectional Study ◽  
Tobacco Product ◽  
Linear Regression Models ◽  
Cross Sectional ◽  
Potential Health ◽  
Cigarette Smokers ◽  
Use Patterns ◽  
Product Use ◽  
Volatile Organic

Abstract Introduction Limited research exists about the possible cardiovascular effects of electronic nicotine delivery systems (ENDS). We therefore sought to compare exposure to known or potentially cardiotoxic volatile organic compounds (VOCs) in ENDS users, smokers, and dual users. Methods A total of 371 individuals from the Cardiovascular Injury due to Tobacco Use study, a cross-sectional study of healthy participants aged 21–45 years, were categorized as nonusers of tobacco (n = 87), sole ENDS users (n = 17), cigarette smokers (n = 237), and dual users (n = 30) based on 30-day self-reported tobacco product use patterns. Participants provided urine samples for VOC and nicotine metabolite measurement. We assessed associations between tobacco product use and VOC metabolite measures using multivariable-adjusted linear regression models. Results Mean (SD) age of the population was 32 (±6.8) years, 55% men. Mean urinary cotinine level in nonusers of tobacco was 2.6 ng/mg creatinine, whereas cotinine levels were similar across all tobacco product use categories (851.6–910.9 ng/mg creatinine). In multivariable-adjusted models, sole ENDS users had higher levels of metabolites of acrolein, acrylamide, acrylonitrile, and xylene compared with nonusers of tobacco, but lower levels of most VOC metabolites compared with cigarette smokers or dual users. In direct comparison of cigarettes smokers and dual users, we found lower levels of metabolites of styrene and xylene in dual users. Conclusion Although sole ENDS use may be associated with lower VOC exposure compared to cigarette smoking, further study is required to determine the potential health effects of the higher levels of certain reactive aldehydes, including acrolein, in ENDS users compared with nonusers of tobacco. Implications ENDS use in conjunction with other tobacco products may not significantly reduce exposure to VOC, but sole use does generally reduce some VOC exposure and warrants more in-depth studies.

scholarly journals COMPARING THE EFFECTS OF INSPIRATORY RESERVE VOLUME IN CIGARETTE AND SHISHA SMOKERS BY USING SPIROMETER

2015 ◽  
Vol 4 (2) ◽  
pp. 38-44
Author(s):  
Muhammad Usman Khan ◽  
Alisha Noreen ◽  
Ramsha Kafeel ◽  
Yusra Sabahat
Keyword(s):  
Cigarette Smoking ◽  
Sampling Technique ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Cigarette Smokers ◽  
The Public ◽  
Life Threatening ◽  
Potential Risks ◽  
College Of Nursing ◽  
Functional Capacities

BACKGROUND Shisha and cigarette are the two most common type of tobacco smoking. Cigarette and shisha smoking have grown fast in different ages globally. Shisha and cigarette both contain chemicals that affect health badly and can cause common diseases such as cough and some life threatening diseases like cancer, emphysema and bronchitis also affect bones causing osteoporosis and decrease functional capacities of lung. There are no proper guidelines for the awareness of the public about the hazards of shisha smoking as they are present for cigarette smoking but it’s a fact that shisha smoking is as harmful as cigarette smoking. OBJECTIVES To compare the effect of Inspiratory Reserve Volume (IRV) on shisha and cigarette smokers by using spirometer. STUDY DESIGN AND SAMPLING TECHNIQUE Cross-sectional survey was steered, convenient sampling was used. STUDY SETTINGS & PARTICIPANTS The study was conducted on 50 participants of Ziauddin College of Nursing and Ziauddin College of Physical Therapy RESULTS IRV is more compromised in shisha smokers than in cigarette smokers. As far as deciding between health concerning effects of shisha and cigarette smokers, the shisha smoking effects are same as cigarette smoking. CONCLUSION Shisha smokers have more exposure to tobacco than cigarette smokers. IRV is disturbed by both means of smoking but shisha smoking has more potential risks. Keywords Inspiratory Reserve Volume, Spirometer, Cigarette, Smokers, Shisha, Emphysema, Bronchitis

scholarly journals Association of initial e-cigarette and other tobacco product use with subsequent cigarette smoking in adolescents: a cross-sectional, matched control study

2020 ◽  
pp. tobaccocontrol-2019-055283 ◽  
Author(s):  
Lion Shahab ◽  
Emma Beard ◽  
Jamie Brown
Keyword(s):  
Propensity Score ◽  
Cigarette Smoking ◽  
Matched Control ◽  
Tobacco Product ◽  
Cigarette Use ◽  
Cross Sectional ◽  
Cigarette Smokers ◽  
Group A ◽  
Synthetic Controls ◽  
Control Study

IntroductionThis study assessed whether initiating e-cigarette use increases the uptake of cigarette smoking in US adolescents compared with behavioural and synthetic controls.MethodsData come from 78 265 adolescents in the National Youth Tobacco Survey (2014–2017) of whom 38 630 provided information about the first tobacco product they had used in 2014/15. Ever, past 30 day and established (30 day use and 100+ lifetime cigarettes) cigarette smoking was compared in adolescents who first used an e-cigarette (exposure group), a non-cigarette combustible (CT) or other non-combustible tobacco (NT) product (behavioural controls), and propensity score matched adolescents without initial e-cigarette use (synthetic controls).ResultsRelative to behavioural controls, adolescents who tried e-cigarettes first were less likely to have ever smoked cigarettes (26% vs CT (42.4%; OR 0.48, 95% CI 0.40 to 0.57), or NT initiators (52.7%; OR 0.32, 95% CI 0.26 to 0.39)), to be past 30 day (6% vs CT (11.9%; OR 0.48, 95% CI 0.36 to 0.62), or NT initiators (20.0%; OR 0.26, 95% CI 0.19 to 0.35)) or be established cigarette smokers (0.7% vs CT (3.9%; OR 0.17, 95% CI 0.10 to 0.30), or NT initiators (8.4%; OR 0.08, 95% CI 0.04 to 0.13)). E-cigarette initiators were also less likely than synthetic controls (without initial e-cigarette use) to have ever smoked cigarettes (OR 0.76, 95% CI 0.62 to 0.93), be past 30 day (OR 0.71, 95% CI 0.55 to 0.91) or be established cigarette smokers (OR 0.26, 95% CI 0.13 to 0.51).ConclusionLess than 1% of US adolescents who use e-cigarettes first were established cigarette smokers. They were less likely to be smokers than adolescents who tried other combustible or non-combustible tobacco products first and propensity score matched adolescents without initial e-cigarette use.

scholarly journals Cross-sectional Survey to Assess Tobacco and Nicotine Product Use since the Introduction of Tobacco Heating Products in Japan: Wave 1

2021 ◽  
Vol 7 (3) ◽  
pp. 210-220
Author(s):  
Joshua D. Jones ◽  
Jason Adamson ◽  
Claudia Kanitscheider ◽  
Krishna Prasad ◽  
Oscar M. Camacho ◽  
...  
Keyword(s):  
Population Level ◽  
Tobacco Product ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Use Patterns ◽  
Product Use ◽  
Key Population ◽  
Level Data ◽  
Japanese Residents ◽  
And Behavior

Objective: In this study, we obtained key population-level data on use patterns and behavior relating to tobacco and nicotine products in Japan. Methods: We performed a nationwide cross-sectional survey of the general population in Japan in 2019 to assess use patterns after the introduction of tobacco heating products (THPs). Eligible participants were Japanese residents, aged 20 years or older who consented to complete the survey. Individuals living in institutions were excluded. A 3-stage probability sampling method was applied that was geographically stratified by street blocks proportionate to population density. Respondents self-reported patterns of product use and reasons for THP use. Results: Complete responses were available from 5306 individuals, of whom 933.5 (17.6%) were current users, 984.2 (18.5%) were former users, and 3388.4 (63.9%) were never users of tobacco products (weighted respondent totals). Cigarettes were used by 14.6% of current tobacco product users and THPs by 5.3%. Cigarettes and THPs were used exclusively by 64.5% and 12.2%, respectively, and both were used by 12.7%. The most common reasons reported for THP use were perceived reduction in harm to self and others compared to cigarettes. Conclusions: Whereas the prevalence of cigarette use in Japan is decreasing, THPs seem to be increasingly used as long-term alternatives to cigarette smoking.

scholarly journals Changes in substance use among young adults during a respiratory disease pandemic

2020 ◽  
Vol 8 ◽  
pp. 205031212096532
Author(s):  
Pravesh Sharma ◽  
Jon O Ebbert ◽  
Jordan K Rosedahl ◽  
Lindsey M Philpot
Keyword(s):  
Substance Use ◽  
Young Adults ◽  
Confidence Interval ◽  
Affective State ◽  
Prevalence Ratio ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Health Crisis ◽  
Use Patterns ◽  
Product Use

Background: News articles, commentaries, and opinion articles have suggested that ongoing social distancing measures coupled with economic challenges during COVID-19 may worsen stress, affective state, and substance use across the globe. We sought to advance our understanding of the differences between individuals who change their substance use patterns during a public health crisis and those who do not. Methods: Cross-sectional survey of young adults (18–25 years of age) assessing respondent characteristics and vaping, tobacco, alcohol, and/or marijuana use. We calculated prevalence estimates, prevalence changes, and prevalence ratios with associated 95% confidence intervals and looked for differences with the chi-square test. Results: Of the total sample, 53.2% ( n = 542/1018) young adults reported vaping or using tobacco, alcohol, and/or marijuana. Among the 542 respondents reporting use, 34.3% reported a change in their use patterns. Among respondents reporting changes in substance use patterns during the pandemic ( n = 186), 68.8% reported an increase in alcohol use, 44.0% reported a decrease in vaping product use, and 47.3% reported a decrease in tobacco product use due to COVID-19. Substance use changed significantly for respondents with increasing degree of loneliness (continuous loneliness score: prevalence ratio = 1.12, 95% confidence interval = 1.01–1.25), anxiety (prevalence ratio = 1.45, 95% confidence interval = 1.14–1.85), and depression (prevalence ratio = 1.44, 95% confidence interval = 1.13–1.82). Conclusion: Self-reported substance use among young adults was observed to change during a pandemic, and the degree of loneliness appears to impact these changes. Innovative strategies are needed to address loneliness, anxiety, depression, and substance use during global health crises that impact social contact.

scholarly journals Smoking habits and the influence of war on cigarette and shisha smoking in Syria

PLoS ONE ◽  
2021 ◽  
Vol 16 (9) ◽  
pp. e0256829
Author(s):  
Ameer Kakaje ◽  
Mohammad Marwan Alhalabi ◽  
Ayham Alyousbashi ◽  
Ayham Ghareeb ◽  
Loura Hamid ◽  
...  
Keyword(s):  
Cigarette Smoking ◽  
Tobacco Use ◽  
University Education ◽  
Cross Sectional Survey ◽  
Related Factors ◽  
Cross Sectional ◽  
Cigarette Smokers ◽  
Lower Odds ◽  
Males And Females ◽  
Current Tobacco

Tobacco smoking might be impacted by various influences, including psychological, socio-cultural, and economic factors. A community-based cross-sectional survey was conducted in Syrian Arab Republic from March to April 2019 using a web-based questionnaire. The survey aimed at assessing tobacco use (shisha and cigarettes) as well as examining the association between current tobacco use and various sociodemographic and war-related factors. The sample comprised 978 participants (251 males: 727 females) and had a mean age of 24.7 years (SD: 7.60). Most participants were single (n = 825, 84.4%), reside in Damascus and Rif-Dimashq (n = 579, 59.2%), and had a college/university education (n = 911, 93.1%). Concerning smoking, a total of 371 participants (37.9%) were identified to be current tobacco smokers, of whom 211, 84, 76 were exclusive shisha smokers, exclusive cigarette smokers, and dual smokers, respectively. The prevalence of cigarette smoking (exclusive and dual) among males and females was found to be 34.7%, and 10.0%, respectively. On the other hand, the prevalence of shisha smoking (exclusive and dual) among males and females was around 34.3% and 27.6%, respectively. Additionally, various factors have predicted a higher likelihood of cigarette smoking including male gender (AOR = 4.152; 95% CI: 2.842–6.064; p<0.001), and losing someone due to the war (AOR = 1.487; 95% CI: 1.028–2.151; p = 0.035), while unemployed individuals were found to have lower odds of being cigarette smokers (AOR = 0.634; 95% CI: 0.429–0.937; p = 0.022). Concerning shisha smoking, married (AOR = 0.622; 95% CI: 0.402–0.963; p = 0.033), and unemployed individuals (AOR = 0.679; 95% CI: 0.503–0.916; p = 0.011) were found to have lower odds of shisha smoking. Amid the tobacco epidemic in the region, rates of tobacco use in Syria are still worrying. The Syrian armed conflicts may possess a double-edged effect on smoking, and tobacco users who adopt smoking to cope with various stressors should be targeted with well-structured health education, along with appropriate psychological services.

Risk Minimization Measures in Off-Label Drug Use: A Survey of Community Pharmacists in Malaysia

2020 ◽  
Vol 15 (3) ◽  
pp. 181-189
Author(s):  
Omotayo Fatokun
Keyword(s):  
Informed Consent ◽  
Drug Use ◽  
Perceived Risk ◽  
Adverse Drug Events ◽  
Community Pharmacists ◽  
Risk Minimization ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Off Label ◽  
Written Informed Consent

Background: While off-label drug use is common and sometimes necessary, it also presents considerable risks. Therefore, measures intended to prevent or reduce the potential exposure to off-label risks have been recommended. However, little is known about community pharmacists’ beliefs regarding these measures in Malaysia. Objectives: This study examined community pharmacists’ beliefs towards risk minimization measures in off-label drug use in Malaysia and assessed the relationship between perceived risk of off-label drug use and beliefs towards risk minimization measures. Methods: A cross-sectional survey was conducted among 154 pharmacists practicing in randomly selected community pharmacies in Kuala Lumpur and the State of Selangor, Malaysia. Results: The majority agreed or strongly agreed that adverse drug events from the off-label drug should be reported to the regulatory authority (90.9%) and the off-label drug should only be used when the benefit outweighs potential risks (88.3%). Less than half (48.1%) agreed or strongly agreed that written informed consent should be obtained before dispensing off-label drugs and a majority (63.7%) agreed or strongly agreed that the informed consent process will be burdensome to healthcare professionals. Beliefs towards risk minimization measures were significantly associated with perceived risk of off-label drug use regarding efficacy (p = 0. 033), safety (p = 0.001), adverse drug rection (p = 0.001) and medication errors (p = 0.002). Conclusion: The community pharmacists have positive beliefs towards most of the risk minimization measures. However, beliefs towards written informed consent requirements are not encouraging. Enhancing risk perception may help influence positive beliefs towards risk minimization measures.

scholarly journals Polytobacco product use among current cigarette smokers in Hong Kong, China: results from population surveys (2015–17)

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
S. L. Chau ◽  
M. P. Wang ◽  
Y. Wu ◽  
D. Y. T. Cheung ◽  
A. Kong ◽  
...  
Keyword(s):  
Control Policy ◽  
Tobacco Product ◽  
Cigarette Use ◽  
Related Factors ◽  
Cigarette Smokers ◽  
Tobacco Products ◽  
Product Use ◽  
Younger Age ◽  
Current Cigarette ◽  
Age And Sex

Abstract Background Polytobacco product use is increasingly popular, but little is known about the prevalence, trend, and factors of such use particularly in non-western countries. Method A representative sample of 1139 current cigarette smokers aged 15+ (84.1% male) were telephone interviewed in Tobacco Control Policy-related Surveys in 2015–2017. Information collected included poly-tobacco use (PTU), smoking and socio-demographic characteristics. Associations of current PTU with related factors were analyzed using logistic regression with adjustment for confounders. Prevalence was weighted by age and sex of current cigarette users in the general population. Results Eighty-four point one percent (95% CI 81.4–86.6%) were exclusive cigarette smokers. Fifteen point nine percent (13.4–18.6%) were current polytobacco product users, 12.3% (10.2–14.8%) used one tobacco product and 2.52% (1.59–3.97%) used two tobacco products in addition to cigarette. Cigarette use with cigar was more common (6.28%, 4.75–8.27%), and the least used product with cigarette was e-cigarette (1.05%, 0.44–2.50%). The changes in overall prevalence of PTU by number of products use varied in 3 years. Current PTU was associated with being male (AOR 2.01, 95% CI 1.12–3.61), younger age (AORs range from 1.34–4.65, P for trend < .001) and less ready to quit (2.08, 1.09–3.97). Conclusions Prevalence of PTU increased slowly by year, one tobacco product use with cigarette was more common. The most used tobacco product with cigarette was cigar. Being male, younger and less ready to quit were associated with current PTU.

scholarly journals Cigarette smoking and e-cigarette use among university students in Queensland, Australia and New Zealand: results of two cross-sectional surveys

BMJ Open ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. e041705
Author(s):  
Ben Wamamili ◽  
Sheleigh Lawler ◽  
Mark Wallace-Bell ◽  
Coral Gartner ◽  
David Sellars ◽  
...  
Keyword(s):  
New Zealand ◽  
Cigarette Smoking ◽  
University Students ◽  
Multinomial Logistic Regression ◽  
Smoking Status ◽  
Cigarette Use ◽  
Dual Use ◽  
Cross Sectional ◽  
Free Spaces ◽  
And Gender

ObjectivesExamine the patterns of cigarette smoking and e-cigarette use (vaping), the perceived harm of e-cigarettes compared with tobacco cigarettes, and associations between smoking and vaping with student characteristics.DesignCross-sectional studies.SettingThe University of Queensland (UQ), Australia and eight New Zealand (NZ) universities.ParticipantsStudents at UQ: 4957 (70.8% aged <25 years, 63.0% women) and NZ: 1854 (82.5% aged <25 years, 60.1% women).MethodsΧ2 tests compared smoking by age and gender, and vaping by age, gender and smoking status. Two-sided p<0.05 was considered significant and 95% CIs reported where appropriate. Multinomial logistic regression examined associations between smoking and vaping (exclusive smoking, exclusive vaping, dual use and non-use) with age, gender and student type (domestic vs international).ResultsSmoking (UQ vs NZ, 95% CI): ever 45.2% (43.8% to 46.6%) vs 50.0% (47.7% to 52.3%), current 8.9% (8.1% to 9.7%) vs 10.4% (9.1% to 11.9%) and daily 5.2% (4.6% to 5.8%) vs 5.6% (4.6% to 6.7%), and not smoking in indoor 98.3% vs 87.7% or outdoor smoke-free spaces 83.8% vs 65.3%.Vaping (UQ vs NZ, 95% CI): ever 20.9% (19.8% to 22.1%) vs 37.6% (35.4% to 39.9%), current 1.8% (1.5% to 2.2%) vs 6.5% (5.4% to 7.7%) and daily 0.7% (0.5% to 1.0%) vs 2.5% (1.9% to 3.4%), and not vaping in indoor 91.4% vs 79.6% or outdoor smoke-free spaces 84.4% vs 71.3%. Of respondents, 71.7% (70.3% to 73.2%) vs 75.3% (72.9% to 77.6%) perceived e-cigarettes as less harmful than tobacco cigarettes.Men were more likely than women to smoke and vape, and to believe that e-cigarettes are less harmful. Regression models containing all predictors for smoking and vaping were significant and the effect of gender was significant for dual use, exclusive smoking and exclusive vaping (all p<0.01). Men had higher odds for smoking, vaping or dual use.ConclusionsResults suggest significant differences in patterns of smoking and vaping of university students in Australia and NZ, and a strong influence of gender on smoking and vaping.

scholarly journals Examining Australian’s beliefs, misconceptions and sources of information for COVID-19: a national online survey

BMJ Open ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. e043421
Author(s):  
Rae Thomas ◽  
Hannah Greenwood ◽  
Zoe A Michaleff ◽  
Eman Abukmail ◽  
Tammy C Hoffmann ◽  
...  
Keyword(s):  
Public Health ◽  
Online Survey ◽  
Health Behaviours ◽  
National Sample ◽  
Sources Of Information ◽  
Cross Sectional Survey ◽  
Commercial Television ◽  
Cross Sectional ◽  
And Gender ◽  
Public Health Strategies

ObjectivePublic cooperation to practise preventive health behaviours is essential to manage the transmission of infectious diseases such as COVID-19. We aimed to investigate beliefs about COVID-19 diagnosis, transmission and prevention that have the potential to impact the uptake of recommended public health strategies.DesignAn online cross-sectional survey.ParticipantsA national sample of 1500 Australian adults with representative quotas for age and gender provided by an online panel provider.Main outcome measureProportion of participants with correct/incorrect knowledge of COVID-19 preventive behaviours and reasons for misconceptions.ResultsOf the 1802 potential participants contacted, 289 did not qualify, 13 declined and 1500 participated in the survey (response rate 83%). Most participants correctly identified ‘washing your hands regularly with soap and water’ (92%) and ‘staying at least 1.5 m away from others’ (90%) could help prevent COVID-19. Over 40% (incorrectly) considered wearing gloves outside of the home would prevent them from contracting COVID-19. Views about face masks were divided. Only 66% of participants correctly identified that ‘regular use of antibiotics’ would not prevent COVID-19.Most participants (90%) identified ‘fever, fatigue and cough’ as indicators of COVID-19. However, 42% of participants thought that being unable to ‘hold your breath for 10 s without coughing’ was an indicator of having the virus. The most frequently reported sources of COVID-19 information were commercial television channels (56%), the Australian Broadcasting Corporation (43%) and the Australian Government COVID-19 information app (31%).ConclusionsPublic messaging about hand hygiene and physical distancing to prevent transmission appears to have been effective. However, there are clear, identified barriers for many individuals that have the potential to impede uptake or maintenance of these behaviours in the long term. We need to develop public health messages that harness these barriers to improve future cooperation. Ensuring adherence to these interventions is critical.

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