until 2010 but has slowed recently. Although multiple patient characteristics, comorbidities, and treatment factors were associated with the receipt of SCP, these were outweighed by the hospital where the patient received care. Indeed, 1 hospital achieved an administration rate of 64%, but more than 40% of hospitals administered SCP to fewer than 20% of eligible patients. These findings may reflect differences in hospital policies, physician inexperience with prescribing SCP, or lingering concerns about the safety of SCP in patients with CHD.One limitation of our study is that we did not have information about whether patients were offered and refused medications. Another limitation is that our database may not be fully representative of the United States. In addition, the ICD-9-CM code for tobacco use has high specificity but low sensitivity. 5 Although some active smokers could have been missed in our analyses, we are confident that patients included were indeed smokers.

Background: As vaping rapidly becomes more prevalent, social media data can be harnessed to capture individuals’ discussions of e-cigarette products quickly. The JUUL vaporizer is the latest advancement in e-cigarette technology, which delivers nicotine to the user from a device that is the size and shape of a thumb drive. Despite JUUL’s growing popularity, little research has been conducted on JUUL. Here we utilized Twitter data to determine the public’s early experiences with JUUL describing topics of posts. Methods: Twitter posts containing the term “JUUL” were obtained for 1 April 2107 to 14 December 2017. Text classifiers were used to identify topics in posts (n = 81,689). Results: The most prevalent topic wasPerson Tagging (use of @username to tag someone in a post) at 20.48% followed by Pods (mentions of JUUL’s refill cartridge) at 14.72% and Buying (mentions of purchases) at 10.49%. The topic School (posts indicative of using JUUL or seeing someone use JUUL while at elementary, middle, or high school) comprised 3.66% of posts. The topic of Quit Smoking was rare at 0.29%. Conclusions: Data from social media may be used to extend the surveillance of newly introduced vaping products. Findings suggest Twitter users are bonding around, and inquiring about, JUUL on social media. JUUL’s discreetness may facilitate its use in places where vaping is prohibited. Educators may be in need of training on how to identify JUUL in the classroom. Despite JUUL’s branding as a smoking alternative, very few Twitter users mentioned smoking cessation with JUUL.

BackgroundAs e-cigarette use rapidly increases in popularity, data from online social systems (Twitter, Instagram, Google Web Search) can be used to capture and describe the social and environmental context in which individuals use, perceive, and are marketed this tobacco product. Social media data may serve as a massive focus group where people organically discuss e-cigarettes unprimed by a researcher, without instrument bias, captured in near real time and at low costs.ObjectiveThis study documents e-cigarette–related discussions on Twitter, describing themes of conversations and locations where Twitter users often discuss e-cigarettes, to identify priority areas for e-cigarette education campaigns. Additionally, this study demonstrates the importance of distinguishing between social bots and human users when attempting to understand public health–related behaviors and attitudes.MethodsE-cigarette–related posts on Twitter (N=6,185,153) were collected from December 24, 2016, to April 21, 2017. Techniques drawn from network science were used to determine discussions of e-cigarettes by describing which hashtags co-occur (concept clusters) in a Twitter network. Posts and metadata were used to describe where geographically e-cigarette–related discussions in the United States occurred. Machine learning models were used to distinguish between Twitter posts reflecting attitudes and behaviors of genuine human users from those of social bots. Odds ratios were computed from 2x2 contingency tables to detect if hashtags varied by source (social bot vs human user) using the Fisher exact test to determine statistical significance.ResultsClusters found in the corpus of hashtags from human users included behaviors (eg, #vaping), vaping identity (eg, #vapelife), and vaping community (eg, #vapenation). Additional clusters included products (eg, #eliquids), dual tobacco use (eg, #hookah), and polysubstance use (eg, #marijuana). Clusters found in the corpus of hashtags from social bots included health (eg, #health), smoking cessation (eg, #quitsmoking), and new products (eg, #ismog). Social bots were significantly more likely to post hashtags that referenced smoking cessation and new products compared to human users. The volume of tweets was highest in the Mid-Atlantic (eg, Pennsylvania, New Jersey, Maryland, and New York), followed by the West Coast and Southwest (eg, California, Arizona and Nevada).ConclusionsSocial media data may be used to complement and extend the surveillance of health behaviors including tobacco product use. Public health researchers could harness these data and methods to identify new products or devices. Furthermore, findings from this study demonstrate the importance of distinguishing between Twitter posts from social bots and humans when attempting to understand attitudes and behaviors. Social bots may be used to perpetuate the idea that e-cigarettes are helpful in cessation and to promote new products as they enter the marketplace.

The reasons for using electronic nicotine delivery systems (ENDS) are poorly understood and are primarily documented by expensive cross-sectional surveys that use preconceived close-ended response options rather than allowing respondents to use their own words. We passively identify the reasons for using ENDS longitudinally from a content analysis of public postings on Twitter. All English language public tweets including several ENDS terms (e.g., “e-cigarette” or “vape”) were captured from the Twitter data stream during 2012 and 2015. After excluding spam, advertisements, and retweets, posts indicating a rationale for vaping were retained. The specific reasons for vaping were then inferred based on a supervised content analysis using annotators from Amazon’s Mechanical Turk. During 2012 quitting combustibles was the most cited reason for using ENDS with 43% (95%CI 39–48) of all reason-related tweets cited quitting combustibles, e.g., “I couldn’t quit till I tried ecigs,” eclipsing the second most cited reason by more than double. Other frequently cited reasons in 2012 included ENDS’s social image (21%; 95%CI 18–25), use indoors (14%; 95%CI 11–17), flavors (14%; 95%CI 11–17), safety relative to combustibles (9%; 95%CI 7–11), cost (3%; 95%CI 2–5) and favorable odor (2%; 95%CI 1–3). By 2015 the reasons for using ENDS cited on Twitter had shifted. Both quitting combustibles and use indoors significantly declined in mentions to 29% (95%CI 24–33) and 12% (95%CI 9–16), respectively. At the same time, social image increased to 37% (95%CI 32–43) and lack of odor increased to 5% (95%CI 2–5), the former leading all cited reasons in 2015. Our data suggest the reasons people vape are shifting away from cessation and toward social image. The data also show how the ENDS market is responsive to a changing policy landscape. For instance, smoking indoors was less frequently cited in 2015 as indoor smoking restrictions became more common. Because the data and analytic approach are scalable, adoption of our strategies in the field can inform follow-up survey-based surveillance (so the right questions are asked), interventions, and policies for ENDS.

Introduction This study documented images posted on Instagram of electronic cigarettes (e-cigarette) and vaping (activity associated with e-cigarette use). Although e-cigarettes have been studied on Twitter, few studies have focused on Instagram, despite having 500 million users. Instagram’s emphasis on images warranted investigation of e-cigarettes, as past tobacco industry strategies demonstrated that images could be used to mislead in advertisements, or normalise tobacco-related behaviours. Findings should prove informative to tobacco control policies in the future. Methods 3 months of publicly available data were collected from Instagram, including images and associated metadata (n=2208). Themes of images were classified as (1) activity, for example, a person blowing vapour; (2) product, for example, a personal photo of an e-cigarette device; (3) advertisement; (4) text, for example, ‘meme’ or image containing mostly text and (5) other. User endorsement (likes) of each type of image was recorded. Caption text was analysed to explore different trends in vaping and e-cigarette-related text. Results Analyses found that advertisement-themed images were most common (29%), followed by product (28%), and activity (18%). Likes were more likely to accompany activity and product-themed images compared with advertisement or text-themed images (p<0.01). Vaping-related text greatly outnumbered e-cigarette-related text in the image captions. Conclusions Instagram affords its users the ability to post images of e-cigarette-related behaviours and gives advertisers the opportunity to display their product. Future research should incorporate novel data streams to improve public health surveillance, survey development and educational campaigns.

Pokémon GO, an augmented reality game, has swept the nation. As players move, their avatar moves within the game, and players are then rewarded for collecting Pokémon placed in real-world locations. By rewarding movement, the game incentivizes physical activity. However, if players use their cars to search for Pokémon they negate any health benefit and incur serious risk. Motor vehicle crashes are the leading cause of death among 16-to 24-year-olds, whom the game targets. 1 Moreover, according to the American Automobile Association, 59% of all crashes among young drivers involve distractions within 6 seconds of the accident. 2 We report on an assessment of drivers and pedestrians distracted by Pokémon GO and crashes potentially caused by Pokémon GO by mining social and news media reports. 3

Introduction Public perceptions of electronic nicotine delivery systems (ENDS) remain poorly understood because surveys are too costly to regularly implement and when implemented there are large delays between data collection and dissemination. Search query surveillance has bridged some of these gaps. Herein, ENDS’ popularity in the U.S. is reassessed using Google searches. Methods ENDS searches originating in the U.S. from January 2009 through January 2015 were disaggregated by terms focused on e-cigarette (e.g., e-cig) versus vaping (e.g., vapers), their geolocation (e.g., state), the aggregate tobacco control measures corresponding to their geolocation (e.g., clean indoor air laws), and by terms that indicated the searcher’s potential interest (e.g., buy e-cigs likely indicates shopping); all analyzed in 2015. Results ENDS searches are increasing across the entire U.S., with 8,498,180 searches during 2014. At the same time, searches shifted from e-cigarette- to vaping-focused terms, especially in coastal states and states with more anti-smoking norms. For example, nationally, e-cigarette searches declined 9% (95% CI=1%, 16%) during 2014 compared with 2013, whereas vaping searches increased 136% (95% CI=97%, 186%), surpassing e-cigarette searches. More ENDS searches were related to shopping (e.g., vape shop) than health concerns (e.g., vaping risks) or cessation (e.g., quit smoking with e-cigs), with shopping searches nearly doubling during 2014. Conclusions ENDS popularity is rapidly growing and evolving, and monitoring searches has provided these timely insights. These findings may inform survey questionnaire development for follow-up investigation and immediately guide policy debates about how the public perceives ENDS’ health risks or cessation benefits.

BackgroundLittle cigar and cigarillo use is becoming more prevalent in the United States and elsewhere, with implications for public health. As little cigar and cigarillo use grows in popularity, big social media data (eg, Instagram, Google Web Search, Twitter) can be used to capture and document the context in which individuals use, and are marketed, these tobacco products. Big social media data may allow people to organically demonstrate how and why they use little cigars and cigarillos, unprimed by a researcher, without instrument bias and at low costs.ObjectiveThis study characterized Swisher (the most popular brand of cigars in the United States, controlling over 75% of the market share) little cigar- and cigarillo-related posts on Instagram to inform the design of tobacco education campaigns and the development of future tobacco control efforts, and to demonstrate the utility in using big social media data in understanding health behaviors.MethodsWe collected images from Instagram, an image-based social media app allowing users to capture, customize, and post photos on the Internet with over 400 million active users. Inclusion criteria for this study consisted of an Instagram post with the hashtag “#swisher”. We established rules for coding themes of images.ResultsOf 1967 images collected, 486 (24.71%) were marijuana related, 348 (17.69%) were of tobacco products or promotional material, 324 (16.47%) showed individuals smoking, 225 (11.44%) were memes, and 584 (29.69%) were classified as other (eg, selfies, food, sexually explicit images). Of the marijuana-related images, 157/486 (32.3%) contained a Swisher wrapper, indicating that a Swisher product was used in blunt making, which involves hollowing out a cigar and refilling it with marijuana.ConclusionsImages from Instagram may be used to complement and extend the study of health behaviors including tobacco use. Images may be as valuable as, or more valuable than, words from other social media platforms alone. Posts on Instagram showing Swisher products, including blunt making, could add to the normalization of little cigar and cigarillo use and is an area of future research. Tobacco control researchers should design social media campaigns to combat smoking imagery found on popular sites such as Instagram.