While cigarette smoking has declined, e-cigarette use among young adults has increased in the USA. This cross-sectional study compared complete blood counts, C-reactive protein, and select blood metals (lead, cadmium, mercury, selenium, manganese) among exclusive combustible tobacco users, exclusive e-cigarette users, and non-users using NHANES data from 2013–2023 in the USA. The goal of this study was to compare biomarker data from e-cigarette users and combustible tobacco users to that of non-users. Among 756 participants aged 18–30, 229 reported no tobacco use, 74 used only e-cigarettes, and 453 smoked only combustible tobacco. Survey-weighted analyses adjusted for age, sex, race/ethnicity, and body mass index revealed that exclusive combustible use was associated with significantly elevated white blood cell counts, hemoglobin, hematocrit, mean corpuscular volume, lymphocytes, monocytes, neutrophils, and higher blood lead and cadmium. E-cigarette-only use showed fewer deviations overall but included higher mean corpuscular hemoglobin concentration and lower cadmium, selenium, and methyl mercury relative to non-users. Neither group differed significantly in red blood cell count or C-reactive protein, and inorganic/ethyl mercury and manganese levels were largely unchanged. These findings underscore pronounced hematologic and metal-related alterations in combustible tobacco users and fewer, but not negligible, changes among e-cigarette users. Further research is needed to determine the long-term health implications of exclusive e-cigarette use, including potential impacts on antioxidant micronutrient levels.

Background: Gastroesophageal reflux disease (GERD) and obstructive sleep apnea (OSA) may negatively impact idiopathic pulmonary fibrosis (IPF), but data on their concurrent contributions are lacking. We aimed to test the contributions of GERD and sleep‐disordered breathing (SDB) to IPF outcomes. Methods: We performed a cross‐sectional, exploratory study on subjects with IPF. Clinically established GERD diagnosis, questionnaires (Nocturnal GERD Symptom Severity and Impact Questionnaire [N‐GSSIQ], the NIH Patient‐Reported Outcomes Measurement Information System [PROMIS] sleep impairment and fatigue scales, and Short Form‐36 [SF‐36]), full pulmonary function tests (PFT), six‐minute walk test (6MWT), and nocturnal polysomnography (PSG) were obtained. Results: Among n = 24 subjects, 17 (71%) had clinically diagnosed GERD. N‐GSSIQ scores indicated a nocturnal burden, which was adversely related to sleep impairment ( p = 0.010) and daytime fatigue ( p = 0.001), tiredness ( p = 0.026) and SF‐36 social functioning ( p = 0.005), energy/fatigue ( p = 0.015), pain ( p = 0.030), and health change in the prior year ( p = 0.035). From PSG, GERD correlated with worse sleep architecture (GERD diagnosis, all p < 0.05) and periodic leg movements index (PLMI) (N‐GSSIQ, p = 0.02). GERD was not associated with pulmonary or exercise physiology. Overall, apnea–hypopnea index (AHI) was (median [25% quartile, 75% quartile]) 18.2 (8.1, 27.8)/h, and 19 (79%) subjects had OSA (AHI ≥ 5/h), with most (15/19 [79%]) having moderate or severe disease. SDB measures adversely related to gas exchange and distance walked (all p < 0.05). Conclusions: A nocturnal burden of GERD was detected and related to sleep disruption, including PLMs, and to daytime complaints. SDB/OSA, of a severity known to have significant health consequences, was common; it was adversely related to pulmonary diffusion and exercise capacity. These findings call for comprehensive, early evaluation of GERD and OSA for improved IPF outcomes.

Background . Stringent regulations restricting tobacco access to those under 21 are in place, yet young people continue accessing tobacco products. This study aimed to assess the knowledge, opinions, resource utilization, and training needs of tobacco retailers in terms of preventing underage tobacco sales. Methodology . This cross-sectional study analyzed anonymized responses from 467 licensed tobacco retailers in 16 southern counties of Illinois. The survey included 29 questions adapted from validated items, utilized a hybrid methodology (online and in-person), and targeted both retail store owners and managers. Results . Among 118 respondents, 98.3% were aware of the Tobacco-21 law, but 56.8% doubted its impact on reducing underage sales. Gaps in knowledge persisted, especially regarding policies and enforcement laws for Electronic Nicotine Delivery Systems (ENDS). Overall, there was a disparity in preventive measures and program utilization with a low engagement in rural areas and smaller stores. Approximately 48.3% encountered older youths attempting to purchase tobacco. Most respondents (72.9%) supported training for newly hired clerks, focusing on underage sales refusal (54.2%) and ID verification (62.7%). Nearly half (44.9%) felt the need for training in handling aggressive young buyers. The main barrier to training was time constraints for in-person sessions (28.0%), although 41.5% reported no barriers. While “We Card” was widely used (82.2%), only 38.5% displayed the FDA’s “This is Our Watch.” Conclusion . A discrepancy exists between awareness and effective practice among retailers, especially in rural areas and smaller establishments. Findings highlighted the need for targeted retailer training and resource utilization to combat underage tobacco access.

Sexual-identity disparities in substance use among U.S. veterans, and whether mental-health treatment mitigates risk for those with depression, remain under-examined. Using data on veterans from the 2021–2023 National Survey on Drug Use and Health (NSDUH; N = 7,212), disparities were estimated in past-30-day nicotine, marijuana, binge drinking, and polysubstance use, as well as severe psychological distress (K6≥13) and past-year suicidal ideation. Guided by a biosocial/minority-stress framework, multiple imputation was applied ( m = 20) and survey-weighted logistic regression adjusting for age, year, race/ethnicity, sex, education, metro status, insurance, marital status, employment, and income; among veterans with a past-year major depressive episode (MDE), interactions were tested between sexual identity and (a) depression-related clinical contact (DRC) and (b) prescription medication for depressive feelings. Bisexual veterans showed the highest prevalence of marijuana (33.5%) and polysubstance use (30.6%), exceeding that of heterosexual (11.8%, 14.9%) and gay/lesbian veterans (24.0%, 18.8%). Models restricted to veterans with MDE, past-year DRC (DRC defined as any visit or conversation with a health professional about depressive feelings) moderated risk for gay/lesbian veterans, with DRC associated with lower odds of binge drinking and polysubstance use; prescription medication showed a similar moderating pattern for nicotine and polysubstance outcomes. Findings for severe psychological distress and suicidal ideation were mixed and consistent with confounding by indication. Results should be interpreted cautiously given the cross-sectional data, self-report, small sexual-minority subgroups, and non-aligned recall windows (past-year mental health/treatment vs past-30-day substance use). Overall, sexual-identity disparities in substance use are evident, with bisexual veterans bearing the greatest burden, and engagement in DRC and medication among veterans with MDE, particularly gay/lesbian veterans, showing associations consistent with a buffering effect of affirming care. Longitudinal and qualitative studies are needed to test causal pathways and to illuminate lived experiences, and policy/clinical efforts should expand culturally competent, integrated services and routine SOGI data collection to monitor and reduce inequities.

Summary: In modern healthcare, decision-making favours neatly delineated, categorical imperatives. We prefer to say: ‘This practice is good’ and ‘That one is bad’, believing that each decision has a straightforward yes-or-no resolution. However, medicine thrives in uncertainty, partial improvements and small steps that can lead to life-altering gains. Harm reduction, whether for tobacco use, opioid dependence or beyond, embodies the acceptance of imperfect solutions. It is precisely in these areas that black-or-white thinking can be most destructive. Insisting on total cessation or complete eradication of risk, rather than supporting incremental progress, alienates many patients and perpetuates preventable morbidity and mortality. Recognising this pattern and transcending ‘all-or-nothing’ mindsets is crucial for compassionate, evidence-based care. Accordingly, we ask: ‘How does binary thinking in medical decision-making impact the effectiveness of harm reduction strategies?’ Such an inquiry addresses how well we can truly meet patient needs in real-world practice, especially amid complexity.