United States

Abstract

Introduction. Vaccine hesitancy is a significant threat to public health, and its contributing factors remain understudied. This study sought to better understand COVID-19 vaccination rates in Kansas and to compare vaccine perception between rural and urban communities.

Methods. Cross-sectional survey data of 2,196 Kansas residents were obtained through the Rapid Acceleration of Diagnostics Underserved Populations (RADx-UP) grant project at the University of Kansas Medical Center, which utilized convenience sampling to survey individuals residing in 10 Kansas counties. Demographic profiles, vaccination status, and vaccine perceptions were analyzed.

Results. RADx-UP survey data indicated a significant relationship between rurality and vaccine acceptance, with rural participants reporting lower vaccination rates compared to urban counterparts (70.1% vs 79.9%; X2 [1, n = 1995] = 24.2; P &lt; .001). Family safety emerged as a

primary motivator for vaccination across all respondents. Concerns about vaccine side effects were the dominant reason cited for vaccine hesitancy, most prominently in rural areas.

Conclusions. Our findings suggest significant differences between rural and urban populations regarding vaccination uptake and hesitancy. Nuanced understanding of target populations and vaccine hesitancy will facilitate more effective vaccination efforts. Future research would benefit from investigation of optimizing delivery of trustworthy and accessible information to the public regarding vaccinations.

AMA Research Challenge 2024 

Understanding COVID-19 Vaccine Hesitancy in Rural and Urban Kansas: A Cross-Sectional Survey Analysis

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Charles Lopresto, DO

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AMA Research Challenge 2022

Welcome to the largest national, multi-specialty research event featuring research from 750 medical students, residents and fellows, and international medical graduates.


Abstract

Introduction. Vaccine hesitancy is a significant threat to public health, and its contributing factors remain understudied. This study sought to better understand COVID-19 vaccination rates in Kansas and to compare vaccine perception between rural and urban communities.

Methods. Cross-sectional survey data of 2,196 Kansas residents were obtained through the Rapid Acceleration of Diagnostics Underserved Populations (RADx-UP) grant project at the University of Kansas Medical Center, which utilized convenience sampling to survey individuals residing in 10 Kansas counties. Demographic profiles, vaccination status, and vaccine perceptions were analyzed.

Results. RADx-UP survey data indicated a significant relationship between rurality and vaccine acceptance, with rural participants reporting lower vaccination rates compared to urban counterparts (70.1% vs 79.9%; X2 [1, n = 1995] = 24.2; P < .001). Family safety emerged as a

primary motivator for vaccination across all respondents. Concerns about vaccine side effects were the dominant reason cited for vaccine hesitancy, most prominently in rural areas.

Conclusions. Our findings suggest significant differences between rural and urban populations regarding vaccination uptake and hesitancy. Nuanced understanding of target populations and vaccine hesitancy will facilitate more effective vaccination efforts. Future research would benefit from investigation of optimizing delivery of trustworthy and accessible information to the public regarding vaccinations.

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AMA would like to thank Laurel Road for sponsoring a $10,000 grand prize for the winner of the AMA Research Challenge. Laurel Road is not involved in winner selection process. The winner will be announced on February 20, 2025 during the AMA Research Challenge finals. Payment of the grand prize will be directly from Laurel Road. See the AMA Research Challenge Official Rules for terms and conditions.

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Background
Clinical trials are the gold standard for generating evidence on the safety and efficacy of potential new treatments. Yet, Black patients are historically underrepresented in clinical trials for the diseases that disproportionately affect this group. The lack of inclusivity in clinical trials impacts the generalizability of findings and contributes to disparities in health outcomes. To better understand the factors contributing to African American enrollment in trials, we conducted a survey to evaluate the factors contributing to African American’s willingness to participate in clinical trials. The purpose of the study was to identify barriers and facilitators to African Americans' willingness to participate in clinical trials and develop culturally sensitive strategies to enhance the enrollment of diverse patient populations in clinical trials. 
Methods
We created a web-based survey consisting of 38 questions subdivided into three sections: (1) cultural affinity, (2) trust, and (3) background information. The survey was administered via Jotform, a HIPAA-compliant web application. Our target population was Black Americans in the Southern U.S. Participants were recruited using a combination of community-based recruitment and traditional recruitment methods, such as social media and radio advertisements.
Results
260 Black adults completed the survey. The most commonly reported barriers to participation included the history of medical research on African Americans, concerns about potential side effects of an experimental treatment, and the absence of Black clinicians involved in research. Facilitators to research participation included greater representation of African Americans in medical research, physician recommendation, IRBs with African American members, thorough explanations about the study, and relevance of the study to the black community. Other notable findings include that only 27.6% and 37.5% of respondents indicated that free transportation to and from the research sites and being paid for participation would make them more willing to participate in clinical research.
Conclusion
Our findings indicate that Black Americans are open to participating in clinical research. However, culturally sensitive trust and safety measures should be implemented to address the negative effects of a history of abuse, dishonesty, and lack of Black leadership in medicine on people of color’s ability to trust medical research. Plain language study material and explanations, diverse representation in leadership, and active community engagement in the study process are vital steps toward increasing African American research participation.


Understanding factors inﬂuencing African Americans' participation in clinical trials

Background
First-generation low-income (FGLI) medical students face unique challenges that influence their career paths. These students often encounter significant socioeconomic barriers, including financial burdens, lack of mentorship, and limited diversity within medical fields. The journey through medical school is particularly arduous for FGLI students who often lack the financial resources and professional networks available to their peers from more affluent backgrounds. Additionally, the high cost of medical education and the substantial debt burden can discourage these students from pursuing lower-paying specialties, further limiting their career choices. Understanding these factors is crucial for developing strategies to support FGLI students and enhance diversity within the medical profession.

Methods
A comprehensive literature search was conducted across PubMed, CINAHL via Ebsco, and Embase via Elsevier databases from January 1, 2018, to June 27, 2024. Included studies were randomized controlled trials, cohort studies, case-control studies, cross-sectional studies, surveys, or systematic reviews focusing on FGLI medical students in the United States. Interventions involving support from medical schools, such as financial aid, mentorship programs, and early exposure to various specialties, were also considered.

Results
The review identified that financial burdens, particularly student debt, are significant barriers that often deter FGLI students from pursuing lower-paying specialties such as primary care. The lack of diversity and mentorship within certain medical fields further exacerbates these challenges, making it difficult for minority and low-income students to find role models and supportive networks. Studies highlighted the effectiveness of interventions such as pipeline programs, which provide early exposure to various specialties and financial support mechanisms, in addressing these barriers. These interventions provide FGLI students with the tools and confidence needed to pursue a broader range of specialties, including those traditionally less accessible to them.

Conclusion
Addressing the financial, social, and educational barriers faced by FGLI medical students through comprehensive and targeted interventions is essential. By implementing strategies that include financial support, enhanced mentorship, and early exposure to various specialties, medical schools can foster a more inclusive and diverse medical workforce. This approach will not only improve the recruitment and retention of FGLI students in a broader range of specialties but also enhance patient care and health outcomes across communities. Future research should focus on examining the long-term effects of these interventions and uncovering additional barriers and solutions to support the career development of FGLI medical students.

What are the primary factors influencing specialty choice among FGLI medical students?

Title: Missed Opportunities in HIV Screening and Transmission Prevention in Southeastern United States: A Retrospective Cohort Study 

Authors: Cecily Kaufmann, BSN, RN, David Hudon, MPH, Phillip Moschella, MD, Heather Brown, MD, Caroline Derrick, PharmD, Sharon Weissman, MD, Divya Ahuja, MD, Sarah Battle, MD 

Background: Despite extensive HIV prevention efforts, the high incidence of HIV in the Southeastern United States underscores the urgent need for enhanced public health initiatives. This study examined new HIV diagnoses in the Midlands of South Carolina and identified missed opportunities (MOs) for early detection in the 365 days prior to new HIV diagnosis. In addition, MOs for pre-exposure prophylaxis (PrEP) discussion for HIV transmission prevention were evaluated. 

Methods: This retrospective cohort study analyzed 127 new HIV diagnoses in adults ≥ 18 years of age in the Midlands area of South Carolina between January 1, 2022 and December 31, 2023. Patient demographics, risk factors, and clinical characteristics of all healthcare visits from the 365 days prior to HIV diagnosis were evaluated. Descriptive statistical analysis focused on characterizing HIV screening MOs and PrEP discussion MOs. 

Results: The cohort predominantly consisted of Black or African American males, but included 18.8% females and 12.5% Caucasians. While men who only have sex with men (MSM) was common (28.3%), exclusive heterosexual activity (43.3%) was surprisingly more prevalent. Of the 117 patients without a diagnosis of acute retroviral syndrome (ARS), 40.1% had severe immunosuppression (CD4 <200 cells/mm³). In the year prior to non-ARS HIV diagnosis, there were a total of 414 MOs for HIV screening (mean of 3.5 per patient), with 45.7% in the Emergency department visits and 12.1% in urgent care, and 42.3% in outpatient clinics. The most common clinics for screening MOs were Family Medicine, Internal Medicine, Cardiology, and Orthopedic Surgery. In the year prior to ARS diagnosis, there were 34 MOs for PrEP discussions (mean of 3.4 per patient). The most common clinics for PrEP MOs were Family Medicine and Orthopedic Surgery. For both types of MOs, patients were most frequently seen for chronic health conditions (10.5% of the MOs for screening and 14.1% of the MOs for HIV PrEP). Only ten patients (7.8%) had ever had a previous negative HIV screen, and only one (0.8%) had a screen done in the year prior to HIV diagnosis. Only seven patients had previously been offered PrEP. 

Conclusions: This study highlights the substantial number of missed opportunities for HIV screening and PrEP discussions in all locations of medical care, from the Emergency Department to subspecialty clinics. Given the diverse risk factors seen in this study, not only should universal opt-out HIV screening be implemented in high incidence regions, but consideration should be given to frequent HIV screening and PrEP discussions in all adults irrespective of their sexual orientation.

Missed Opportunities in HIV Screening and Transmission Prevention in Southeastern United States: A Retrospective Cohort Study

Background:
Heart failure (HF) is a complex medical condition associated with high hospital readmission rates, placing a significant burden on hospital resources. Attempts to improve outcomes and quality of life for these patients have led to significant advances in patient care in terms of medical therapies and risk reduction measures. However, the increased complexity of treating HF associated with these advances has also made healthcare navigation and patient compliance more difficult. For patients hospitalized with heart failure, goal-directed medical therapy (GDMT) leads to improved patient outcomes and reduces rehospitalizations, thus reducing the cost of care. Inadequate GDMT translates to a 29% excess mortality risk over just a 2-year period of follow-up. While patient compliance encompasses a large realm of social determinant factors, the consistent prescription of GDMT by physicians is the first step. 

Methods:
We analyzed prescription rates of patients hospitalized between 2/1/2024 – 5/1/2024 with HF with reduced ejection fraction (HFrEF). This included 54 patients who were pre-educational interventions and 80 patients who were post-educational interventions. The Quality Improvement (QI) project intervention included an in-person presentation as well as an email sent to all internal medicine residents with a succinct one-pager and full PowerPoint presentation. It additionally involved the creation of an HF order set hard-coded into the hospital’s electronic medical record. This included but was not limited to a list of GDMT medications (angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARB) or angiotensin receptor/neprilysin inhibitor (ARNI), beta blockers (BB), mineralocorticoid receptor antagonist (MRA)), daily weights, ins and outs, a therapeutic diet, elevation of the bed, cardiac rehabilitation referral, and other useful lab work. Of note, sodium-glucose cotransporter 2 (SGLT-2) inhibitors were excluded as part of GDMT as they are not on the formulary at our institution.

Results: 
After the QI project intervention, beta blocker prescription rates rose from 77.8% to 92.5%. Angiotensin receptor blocker prescription rates changed from 81.5% to 76.3%. Mineralocorticoid receptor antagonist prescription rates rose from 46.3% to 57.5%. 

Conclusion: 
This project demonstrated that educational sessions as well as HF order sets can improve GDMT prescription rates. However, our results also indicate the need for continued improvements. Repeat educational sessions as well as improvement of order sets with the incorporation of heart failure coordinators and care management consults are starting points to continue optimizing GDMT rates.

Optimization of GDMT prescription rates for patients with HFrEF following educational interventions

Background: Early detection has been the historical strategy for improving outcomes in patients diagnosed with melanoma. Since the 1960s, physicians have focused on interventions to educate the public about the nature of melanoma and the importance of sun protection and regular skin cancer screening. Despite these efforts, publications have highlighted the rapid increase in melanoma incidence over the past four decades with minimal changes in the mortality rates. In fact, the recent drop in melanoma mortality has been widely attributed to the introduction of newer medications such as molecular and immune checkpoint therapies approved in the mid 2010’s. However, the impact of ongoing public efforts remains unknown. We thus set out to more closely examine the dynamics of melanoma mortality in the “pre-therapeutic era” and test the hypothesis that death rates have been unwavering. To accomplish this, we characterized and modeled mortality trends between 1969-2014 in both the U.S. and Australia. 

Methods: We performed a differential time series analysis based on population-ascertained mortality rates (total, male, and female) from the United States (SEER) and Australia (Cancer Australia). To this end, we calculated the first derivative of yearly mortality rates between 1969-2014 and analyzed trends using linear regression. Melanoma mortality rates were then modeled using a second-order polynomial regression and compared to mortality trajectories of 10 other cancers. 

Results: Melanoma mortality rates have been significantly decelerating since the 1970s in both the U.S. (p<0.0001) and Australia (p=0.0021). Zero acceleration occurred around 2001 (95% CI: 1996, 2008) for the U.S. and 2004 (95% CI: 1999, 2011) for Australia. The male mortality rates decelerated 3-4 times faster than females in both countries, though the absolute male mortality rates were much higher. Melanoma mortality followed a quadratic function (R2>0.9). Compared to total U.S. cancer death rates and mortality among ten other cancer types, melanoma showed a similar quadratic distribution albeit with a later inflection point (1986 vs. 2001) and broader focal width. 

Conclusion: Deaths due to melanoma have been decelerating for the past five decades, reaching an inflection point around 2001 prior to the advent of modern therapies. These findings suggest that mitigating campaigns had already taken afoot in both the U.S. and Australia.

Differential Time Series Analysis Shows Deceleration in Melanoma Mortality Prior to the Widespread Use of Highly Effective Therapies

Background
In the wake of COVID-19, a vaccine outreach program was designed in 2021. A component of this study involved assessing patients' attitudes toward receiving additional vaccinations in dermatology offices. The survey data showed high degrees of satisfaction with vaccines administered at the dermatology office, and 90.9% of patients stated they would receive other vaccines at their dermatology clinic if recommended and available. It is important to note that less than half of patients in the cohort who received COVID-19 vaccines (48.2%) had been vaccinated with a shingles (varicella zoster virus) vaccine despite being age-eligible. Patients view physicians as a trusted source of information regarding vaccines. We believe that after physician-directed education, patients may be more willing to receive a shingles vaccine. We sought to test this hypothesis, by collecting survey data to evaluate shingles vaccination rates and patients’ perspectives among individuals seen in a multipractice dermatology group. 
Methods
Patients who were eligible for vaccination and being seen by a resident physician were identified upon intake. The patients were surveyed before and after education about the shingles vaccine was provided. Education included resident-administered verbal education following the Center for Disease Control's vaccine information sheet. Survey data was recorded anonymously and is therefore IRB exempt. A total of 62 subjects were surveyed, and 59 surveys were completed.
Results
Only 24% of subjects had received the vaccine, despite being eligible to receive it. The most cited reason (27.8%) for being unvaccinated was that subjects had never been offered to receive it. Of the unvaccinated respondents, 53% initially indicated considering vaccination, and this increased to 69% post-education (p-value= 0.06). 88% of subjects who were unvaccinated and changed from “not considering” to “considering” vaccination attributed their decision to the educational materials.
Conclusion
We see vaccine availability as a major barrier to unvaccinated individuals. Provider directed education can mitigate vaccine hesitancy, as demonstrated in a 2022 study which showed the efficacy of physician recommendations in reducing COVID-19 vaccine hesitancy. This study is limited by population size, and a greater difference would likely be shown if performed on a larger scale. We believe these results will nonetheless inform and provide support for the valuable role that dermatology practices can play in improving public health, specifically when it comes to shingles vaccination rates.

The Impact of Education in Reducing Shingles Vaccine Hesitancy in Dermatology

Background 
Burn injuries are a major public health concern and in the US alone, making up about 500,000 ED visits per year. While most of these burn injuries are minor, the ones that do require hospital admission are often directed towards specialized burn centers. These burn centers, which provide optimal burn care, involve a team of healthcare workers from many different specialties including highly trained burn surgeons along with other rehabilitation services. EMS official guidelines concerning pre-hospital management of burn patients state that patients should be transported to either the nearest emergency department, or if protocols allow, directly to a burn center. With the emergence of more specialized burn centers, pre-hospital providers must triage their patients to an appropriate destination. And despite the prevalence of burns, less than 1% of all EMS calls from 2020-2023 in North Carolina were burn related. Such a low occurrence means that pre-hospital providers have minimal experience with this population of patients. The pre-hospital transport destination, burn center or local hospital, depends on the burn classification. Burn classifications are highly dependent on the clinical examination, which is subjective especially for providers without specialty training in burns. 
Methods 
In this retrospective study, all emergency response calls categorized as burn-related were analyzed using the NC Continuum Database from 2020-2023. A total of 3467 transports were evaluated. Based on the chief complaint, the determination was made, according to the American Burn Association and UNC Jaycee Burn Center criteria, whether the patient should have been transferred to a burn center, or local hospital. If there was not enough data to determine this information, the record was categorized as unknown. 
Results 
Of the patients we determined as needing specialized care from a burn center (n=246), 68% were not transported appropriately, while only 32% were. Of the patients who we determined that local hospital care was appropriate (n=111), 14% were transported inappropriately to a burn center. Less than 2% of charts reported percentage of total body surface area (TBSA) of burn within the chief complaint. We classified 2868 number of transports as “unknown” due to lack of fully descriptive criteria that would allow us to correctly categorize the transport decision. 
Conclusion 
The lack of appropriate triage and destination for burn patients can negatively impact patient outcomes. This highlights the need for a standardized approach to pre-hospital burn management which can be facilitated by further education of EMS providers.

Burns: Destination Evaluation for Patients Transported by EMS ​

Objective: Hispanic immigrant populations vary greatly regarding demographic and economic factors based on their country of origin. Understanding the factors that influence healthcare disparities in the United States is essential to creating sustainable change in the healthcare system, and it begins with understanding the unique differences between the communities experiencing these disparities. Studies on emergency room utilization from non-native immigrants are limited in the current literature. This study sought to use country of origin as a predictor of emergency room usage from four Hispanic countries to demonstrate the disparities within the Hispanic community.

Methods: This cross-sectional study used the 2020 Medical Expenditure Panel Survey that collects information on utilization and expenditure of emergency room (ER) among foreign-born Hispanic adults aged 18 and above (N=1,838). We examined the association between four countries of origin and two outcomes, including the number of ER visits per person and average cost per visit. Survey-weighted multivariable regression models were conducted to evaluate how average cost varied by country of origin while considering demographics and socioeconomic factors including but not limited to insurance status, region, and language spoken.

Results: The results show that Dominicans spent $474.84 more than Mexicans per emergency room visit (p = .044). Dominicans spent the most out of the four countries, costing a total of $534.13 (p = .053). Average expenditures per emergency room visit for Mexicans were negatively associated with speaking a language other than English or Spanish and having a master’s degree (p = .029 and p = .003, respectively). For Puerto Ricans, average expenditures were negatively associated with low incomes (p = .044). Additionally, the average spending for Dominicans was negatively associated with living in the Midwest and positively related to having a doctorate degree (p = .006 and p = .022, respectively). No variables were identified as a strong predictor of average emergency room expenditures for Cubans.

Conclusion: Unexpected costs that arise with emergency room visits can be taxing on individuals and their families, especially those experiencing financial distress to begin with. This study demonstrates intra-group disparities in emergency room costs among Hispanic populations from four countries. However, very few variables could predict the reason for these observed findings, which are largely misunderstood. Understanding the reasons for the increased costs accompanying specific populations when they receive emergency services is vital in guiding treatment and ensuring that patients are treated equitably. More research needs to be done on hispanic immigrants that recognizes country of origin as a contributing factor to the health care they receive in the United States. With more awareness of the disparities present between Hispanic immigrant populations, extra precautions can be taken to ensure patients are not being undertreated or overtreated and erase the gap in associated costs.

Cross-sectional Study of Emergency Room Visits Among Hispanic Immigrants by Country of Origin

Introduction
Reduction of overdose deaths by community naloxone education and distribution programs is well-established. The efficacy of teaching bystanders additional first aid measures is less clear. AHA recommends lay rescuers provide hands-only CPR for all unconscious patients with abnormal breathing as delaying CPR greatly worsens outcomes and bystanders may withhold chest compressions feeling for a pulse or worrying about rescue breaths. However, the WHO recommends CPR with rescue breathing for suspected overdose because the hypoxic etiology requires oxygenation. Other organizations recommend lay providers check a pulse to determine treatment since apnea with a pulse is more common in overdoses, particularly witnessed ones. The purpose of this study is to compare patient outcomes after community programs teach these varying strategies.

Methods
A literature review was conducted. Studies that did not specify recommendations for actions in addition to naloxone training or include measurement of patient outcomes were excluded. Twelve studies met the criteria for inclusion. Two studies described programs that recommended naloxone and CPR, while the remainder recommended naloxone and rescue breathing.

Results
After completing training programs recommending CPR, participants responded to 45 overdoses, with successful reversal 97.5% of the time (95% CI: 0.149-1.802). After programs recommending rescue breathing, participants responded to 1751 overdoses, with successful reversal 95.4% of the time (95% CI: 0.68-1.229). This information was usually obtained through voluntary self-reporting or interviewing when participants returned for naloxone refills. Numerous participants were lost to follow-up in all studies. “Reversal” was inconsistently defined but generally meant arousal and normal breathing. All patients received naloxone (dosing not recorded). Most studies did not record whether patients also received CPR and/or rescue breathing or whether this was associated with successful reversal. The published studies have significant deficiencies including limited measurement of outcomes, small sample sizes, and potential confounding variables.

Conclusion
The currently available scientific literature related to this topic is insufficient to make recommendations about how overdose response education should be structured. Further research is clearly needed.

We Taught How to Use Naloxone: Now What?

Background: Cigarette smoking during pregnancy is associated with increased infant mortality, low birth weight, and other poor outcomes. Pregnant patients who try to quit smoking are increasingly turning to electronic cigarettes (e-cigarettes), as they believe it is safer for the fetus. However, little is known about the relative safety of e-cigarettes as compared to cigarettes during pregnancy.
We evaluated whether e-cigarette use during pregnancy was associated with fewer infant health complications, lower toxicant biomarker levels, and better birth outcomes compared to cigarette smoking. We examined toxicant levels at delivery, birth outcomes, and health at 3-months postpartum of infants born to women who exclusively used e-cigarettes, only cigarettes, and those who used both during pregnancy.
Our objective is to understand the role of e-cigarettes in reducing infant health complications, improve physician counseling regarding e-cigarette safety, and evaluate e-cigarettes as a harm-reduction tool for pregnant patients who smoke.

Methods: This prospective cohort study followed n=179 (n=100 exclusive cigarette, n=40 dual use, and n=39 exclusive e-cigarette) pregnant women. At birth, neonatal urine and cord blood were analyzed for the tobacco metabolite NNAL; volatile organic compounds benzene, acrylamide, acrolein, acrylonitrile; and nicotine metabolite (cotinine) levels. Birth outcomes, such as APGAR score, gestational age, and weight were collected from medical charts. 3-month postpartum surveys assessed infant health complications, such as infection, hospitalizations, and respiratory problems. Kruskal Wallis and Chi-square tests were conducted using SPSS statistical software.

Results: Infants of women who exclusively smoked cigarettes had the highest mean NNAL level at birth (30.32, SD=43.39), followed by those who dual used (17.24, SD=15.90), and those who used e-cigarettes (2, SD= .77, p=0.004). Similarly, infants of women who exclusively smoked cigarettes and who dual used had the highest mean acrylonitrile values (22.74, SD= 34.32, and 23.06, SD=22.97, respectively), while those born to exclusive e-cigarette users had the lowest (18.16, SD=56.91, p=0.008). No differences were observed in cotinine levels, birth outcomes, or 3-month postpartum health complications across the groups.

Conclusion: Exclusive maternal e-cigarette use during pregnancy correlates with lower infant NNAL and acrylonitrile levels at birth. However, exclusive e-cigarette use during pregnancy does not reduce rates of adverse 3-month health outcomes or poor birth outcomes. Further research is needed to determine whether these infants achieve age-appropriate developmental milestones in motor, social, and cognitive domains. Our results suggest e-cigarettes are not clinically safer than cigarettes during pregnancy, and physicians should counsel patients on alternative forms of nicotine replacement therapy to support smoking cessation.

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