Massachusetts Prevalence of Opioid Use Disorder Estimation Revisited: Comparing a Bayesian Approach to Standard Capture-Recapture Methods.

BACKGROUND: The National Survey on Drug Use and Health (NSDUH) estimated the prevalence of opioid use disorder (OUD) among the civilian, noninstitutionalized people aged 12 years or older in Massachusetts as 1.2% between 2015 and 2017. Accurate estimation of the prevalence of OUD is critical to the success of treatment and resource planning. Various indirect estimation approaches have been used but are subject to data availability and infrastructure-related issues. METHODS: We used 2015 data from the Massachusetts Public Health Data Warehouse (PHD) to compare the results of two approaches to estimating OUD prevalence in the Massachusetts population. First, we used a seven-dataset capture-recapture analysis under log-linear model parameterization, controlling for the source dependence and effects of age, sex, and county through stratification. Second, we applied a benchmark-multiplier method in a Bayesian framework by linking health care claims data to death certificate data assuming an extrapolation of death rates from observed untreated OUD to unobserved OUD. RESULTS: Our estimates for OUD prevalence among Massachusetts residents (aged 18-64 years) were 4.62% (95% CI = 4.59%, 4.64%) in the capture-recapture approach and 4.29% (95% CrI = 3.49%, 5.32%) in the Bayesian model. Both estimates were approximately four times higher than NSDUH estimates. CONCLUSION: The synthesis of our findings suggests that the disease surveillance system misses a large portion of the population with OUD. Our study also suggests that concurrent use of multiple methods improves the justification and facilitates the triangulation and interpretation of the resulting estimates. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04111939.

Socioecological Predictors of Change in Adolescent Tobacco Use Across Waves 1-4 of the Population Assessment of Tobacco and Health Study.

BACKGROUND: Despite decreases in adolescents' cigarette use over the past decade, overall rates of adolescent tobacco use have increased. Research examining adolescents' changes across a range of tobacco products reflective of the current market, as well as multilevel predictors of use trajectories is needed. METHODS: Data derive from Waves 1-4 (W1-4; 2013-2018) of the Population Assessment of Tobacco and Health (PATH) study. Participants included 975 adolescents who used ≥1 tobacco product (cigarettes, electronic cigarettes [ECIGs], traditional cigars, cigarillos, filtered cigars, snus, smokeless tobacco [SLT], hookah) at any wave (W1 Mage = 13.29 [0.86], 54.2% male; 54.5% White, 25.9% Hispanic). RESULTS: Utilizing latent growth curve modeling (separate models per product), adolescents displayed increases in their past 30-day use of all tobacco products from W1-4. Greater W1 use was predicted by identifying as non-Hispanic (cigarettes); lower parent education (SLT); greater externalizing problems (cigarillos); greater motives (all products except cigarillos); greater youth-reported household smoking rules (cigarillos); and greater isolation (ECIGs). More use across time (i.e., higher slope) was predicted by older age (cigarettes); identifying as male (ECIGs, SLT), Black (vs. White; cigarillos), White (vs. Black, Hispanic; ECIGs, SLT); fewer externalizing problems (SLT); fewer motives (ECIGs); fewer youth-reported rules (cigarillos, SLT); and greater geographic isolation (cigarettes, SLT). DISCUSSION: Although some individual-level factors (i.e., motives, externalizing problems) predicted greater W1 use (i.e., intercept) only, interpersonal- (parent rules) and community-level (geographic isolation) factors were associated with changes in use over time (i.e., slope). Intervention efforts may address such factors to reduce adolescents' escalations in use.

Dynamic Interdependence of Advice Seeking, Loaning, and Recovery Characteristics in Recovery Homes.

Recovery homes in the US provide stable housing for over 200,000 individuals with past histories of homelessness, psychiatric co-morbidity and criminal justice involvement. We need to know more about how these settings help those remain in recovery. Our study measured advice seeking and willingness-to-loan relationships and operationalized them as a dynamic multiplex social network-multiple, simultaneous interdependent relationships--that exist within 42 Oxford House recovery homes over time. By pooling relationship dynamics across recovery houses, a Stochastic Actor-Oriented Modeling (SAOM) framework (Snijders et al., 2010) was used to estimate a set of parameters governing the evolution of the network and the recovery attributes of the nodes simultaneously. Findings indicated that advice and loan relationships and recovery-related attitudes were endogenously interdependent, and these results were affected exogenously by gender, ethnicity, and reason for leaving the recovery houses. Prior findings had indicated that higher advice seeking in recovery houses was related to higher levels of stress with more negative outcomes. However, the current study found that recovery is enhanced over time if advice was sought from residents with higher recovery scores. Our study shows that social embedding, i.e. one's position in relationship networks, affects recovery prospects. More specifically, the formation of ties with relatively more recovered residents as an important predictor of better outcomes.

Opioid Use Disorder Among Ohio's Medicaid Population: Prevalence Estimates From 19 Counties Using a Multiplier Method.

The decades-long overdose epidemic in the United States is driven by opioid misuse. Overdoses commonly, although not exclusively, occur in individuals with opioid use disorder (OUD). To allocate adequate resources and develop appropriately scaled public health responses, accurate estimation of the prevalence of OUD is needed. Indirect methods (e.g., a multiplier method) of estimating prevalence of problematic substance-use behavior circumvent some limitations of household surveys and use of administrative data. We used a multiplier method to estimate OUD prevalence among the adult Medicaid population (ages 18-64 years) in 19 Ohio counties that are highly affected by overdose. We used Medicaid claims data and the US National Vital Statistics System overdose death data, which were linked at the person level. A statistical model leveraged opioid-related death rate information from a group with known OUD to estimate prevalence among a group with unknown OUD status given recorded opioid-related deaths in that group. We estimated that 13.6% of the total study population had OUD in 2019. Men (16.7%) had a higher prevalence of OUD than women (11.4%), and persons aged 35-54 had the highest prevalence (16.7%). Our approach to prevalence estimation has important implications for OUD surveillance and treatment in the United States.

Construction of the Ohio Children's Opportunity Index.

Objective: To describe the development of an area-level measure of children's opportunity, the Ohio Children's Opportunity Index (OCOI). Data Sources/Study Setting: Secondary data were collected from US census based-American Community Survey (ACS), US Environmental Protection Agency, US Housing and Urban Development, Ohio Vital Statistics, US Department of Agriculture-Economic Research Service, Ohio State University Center for Urban and Regional Analysis, Ohio Incident Based Reporting System, IPUMS National Historical Geographic Information System, and Ohio Department of Medicaid. Data were aggregated to census tracts across two time periods. Study Design: OCOI domains were selected based on existing literature, which included family stability, infant health, children's health, access, education, housing, environment, and criminal justice domains. The composite index was developed using an equal weighting approach. Validation analyses were conducted between OCOI and health and race-related outcomes, and a national index. Principal Findings: Composite OCOI scores ranged from 0-100 with an average value of 74.82 (SD, 17.00). Census tracts in the major metropolitan cities across Ohio represented 76% of the total census tracts in the least advantaged OCOI septile. OCOI served as a significant predictor of health and race-related outcomes. Specifically, the average life expectancy at birth of children born in the most advantaged septile was approximately 9 years more than those born in least advantaged septile. Increases in OCOI were associated with decreases in proportion of Black (48 points lower in the most advantaged vs. least advantaged septile), p < 0.001) and Minority populations (54 points lower in most advantaged vs. least advantaged septile, p < 0.001). We found R-squared values > 0.50 between the OCOI and the national Child Opportunity Index scores. Temporally, OCOI decreased by 1% between the two study periods, explained mainly by decreases in the children health, accessibility and environmental domains. Conclusion: As the first opportunity index developed for children in Ohio, the OCOI is a valuable resource for policy reform, especially related to health disparities and health equity. Health care providers will be able to use it to obtain holistic views on their patients and implement interventions that can tackle barriers to childhood development using a more tailored approach.

Developing Dashboards to Address Children's Health Disparities in Ohio.

OBJECTIVES: Social determinants of health (SDoH) can be measured at the geographic level to convey information about neighborhood deprivation. The Ohio Children's Opportunity Index (OCOI) is a composite area-level opportunity index comprised of eight health domains. Our research team has documented the design, development, and use cases of a dashboard solution to visualize OCOI. METHODS: The OCOI is a multidomain index spanning the following eight domains: (1) family stability, (2) infant health, (3) children's health, (4) access, (5) education, (6) housing, (7) environment, and (8) criminal justice. Information on these eight domains is derived from the American Community Survey and other administrative datasets. Our team used the Tableau Desktop visualization software and applied a user-centered design approach to developing the two OCOI dashboards-main OCOI dashboard and OCOI-race dashboard. We also performed convergence analysis to visualize the census tracts where different health indicators simultaneously exist at their worst levels. RESULTS: The OCOI dashboard has multiple, interactive components as follows: a choropleth map of Ohio displaying OCOI scores for a specific census tract, graphs presenting OCOI or domain scores to compare relative positions for tracts, and a sortable table to visualize scores for specific county and census tracts. A case study using the two dashboards for convergence analysis revealed census tracts in neighborhoods with low infant health scores and a high proportion of minority population. CONCLUSION: The OCOI dashboards could assist health care leaders in making decisions that enhance health care delivery and policy decision-making regarding children's health particularly in areas where multiple health indicators exist at their worst levels.

Geographic isolation predicts tobacco product use among youth: A latent class analysis.

PURPOSE: The purpose of the current study was to evaluate associations between geographic rurality and tobacco use patterns among adolescents. METHODS: High school students (N = 566) from north-central Appalachia reported on their lifetime and/or current use of cigarettes, electronic cigarettes (ECIGs), cigars, and smokeless tobacco. Geographic rurality was measured via the Isolation scale, whereby residential ZIP Codes determined the degree to which respondents have access to health-related resources. Latent class analysis (LCA) was used to identify discrete classes of adolescent tobacco users based on their use of tobacco products. Then, associations between participants' geographic rurality and class membership were evaluated using a series of multinomial logistic regressions. FINDINGS: LCA classified participants as Nonusers, Current ECIG Users, Cigarette/ECIG Experimenters, and Polytobacco Users. Individuals with higher Isolation scores were more likely to be Polytobacco Users and Cigarette/ECIG Experimenters than Nonusers, and were more likely to be Polytobacco Users than Current ECIG Users. CONCLUSIONS: The continuous Isolation scale used in the present study predicted polytobacco use patterns among adolescents in a manner that is consistent with, while simultaneously expanding upon, prior work. Tobacco control practices and policies should be viewed through a lens that considers the unique needs of geographically isolated areas.

Examining differences in retention on medication for opioid use disorder: An analysis of Ohio Medicaid data.

BACKGROUND: Medications for opioid use disorder (MOUDs), including methadone, buprenorphine and naltrexone, are associated with lower death rates and improved quality of life for people in recovery from opioid use disorder (OUD). Less is known about each MOUD modality's association with treatment retention and the contribution of behavioral health therapy (BHT). The objectives of the current study were to estimate the association between MOUD type and treatment retention and determine whether BHT was associated with length of time retained. METHODS: We investigated the time from initiation to discontinuation from MOUD by medication type and exposure to BHT using statewide Medicaid Claims data (N = 81,752). We estimated covariate adjusted hazard ratios (AHR) using a Cox proportional hazards model. RESULTS: Compared to methadone, buprenorphine was associated with a higher risk of discontinuation at the time of initiation (AHR = 2.41, 95% CI = 2.28-2.55), however that difference decreased over one year of maintained retention (AHR = 1.44, 95% CI = 1.37-1.50). Compared to methadone and buprenorphine, naltrexone was associated with a higher risk of discontinuation at the time of initiation (naltrexone vs. methadone AHR = 2.49, 95% CI = 2.30-2.65; naltrexone vs. buprenorphine AHR 1.03, 95% CI = 1.00-1.07), and that relative risk increased over the course of one year of retention (naltrexone vs. methadone AHR = 3.85, 95% CI = 3.63-4.09; naltrexone vs. buprenorphine AHR = 2.67, 95% CI = 2.54-2.81). In general, independent of MOUD type, exposure to BHT during MOUD treatment was associated with a lower risk of discontinuation (AHR = 0.94, 95% CI = 0.92-0.96). However, BHT during the treatment episode was not associated with retention in the adolescent/young adult and pregnant women subpopulations. DISCUSSION: From the standpoint of early success, methadone was associated with the lowest risk of treatment discontinuation. While buprenorphine and naltrexone were associated with similar risks at the beginning of treatment, the relative discontinuation risk for buprenorphine was less than half that of naltrexone at one year of retention. In general, BHT with MOUD was associated with a lower risk of treatment discontinuation.

Difference in Response to Feedback and Gender in Three Therapeutic Community Units.

Therapeutic communities (TCs) for substance abuse incorporate a system of peer feedback through written affirmations and corrections. Previous research has found that TC residents show a response to affirmations that is detectable for roughly 8 weeks, with response to corrections being of shorter duration and weaker overall. It is not clear whether and to what extent response to feedback in TCs varies between men and women. Previous research in other settings suggests that women should be more responsive to feedback than men. In order to test this hypothesis we draw on a large dataset of affirmations and corrections sent and received in three 80 bed TC units, two of which house men and one of which houses women. The analysis uses a multilevel negative binomial model, treating affirmations and corrections that TC residents receive as predictors of affirmations that they send over a 9 week period (week 0, the week during which affirmations and corrections are actually sent, and eight subsequent weeks). The model controls for gender, age, race, unit and scores on the Level of Service Inventory-Revised (LSI-R). The relationship between affirmations received and those sent is stronger for women during the initial week and on lags 1-2 and 5-8. The relationship between corrections received and affirmations sent is stronger for women on lags 2 and 8. Graphs suggest that response to affirmations falls off in an exponential curve, while that to corrections appears to include a periodic element. These results indicate that both men and women respond to feedback, but that the strength of the women's response is somewhat greater. These results suggest that any difference in suitability by gender to the feedback approach that characterizes TCs may favor women.

How should we define "rural" when investigating rural tobacco use in the United States?

Purpose: Investigations into rural tobacco-related disparities in the U.S. are hampered by the lack of a standardized approach for identifying the rurality-and, consequently, the urbanicity-of an area. Therefore, the purpose of this study was to compare the most common urban/rural definitions (Census Bureau, OMB, RUCA, and Isolation) and determine which is preferable for explaining the geographic distribution of several tobacco-related outcomes (behavior, receiving a doctor's advice to quit, and support for secondhand smoke policies). Methods: Data came from The Current Population Survey Tobacco Use Supplement. For each tobacco-related outcome, one logistic regression was conducted for each urban/rural measure. Models were then ranked according to their ability to explain the data using Akaike information criterion (AIC). Results: Each definition provided very different estimates for the prevalence of the U.S. population that is considered "rural" (e.g., 5.9% for the OMB, 17.0% for the Census Bureau). The OMB definition was most sensitive at detecting urban/rural differences, followed by the Isolation scale. Both these measures use strict, less-inclusive criteria for what constitutes "rural." Conclusions: Overall, results demonstrate the heterogeneity across urban/rural measures. Although findings do not provide a definitive answer for which urban/rural definition is the best for examining rural tobacco use, they do suggest that the OMB and Isolation measures may be most sensitive to detecting many types of urban/rural tobacco-related disparities. Caveats and implications of these findings for rural tobacco use disparities research are discussed. Efforts such as these to better understand which rural measure is appropriate for which situation can improve the precision of rural substance use research.

Network measures of advice-seeking and resource sharing are related to well-being in recovery homes.

BACKGROUND: There is a need to better understand the extent to which social capital (reflected in social networks tapping friendship, financial support, advice/informational support) can aid recovery for those residents living in abstinence-based recovery homes. METHODS: Social network characteristics of 42 recovery homes (Oxford Houses) were examined, including friendship, willingness to loan money, and advice-seeking to assess the extent to which house network patterns were related to house-level resident measures of proximal recovery outcomes of well-being (e.g. social support, self-esteem, stress) and financial health (e.g. earned wages). RESULTS: We found that the density of the willingness to loan money network within a house was positively associated with house-level earned wages, social support, and self-esteem, and negatively associated with stress. Conversely, the density of house advice-seeking relationships was positively related to house-level stress. CONCLUSIONS: Houses in which residents are willing to share resources with other members who may be in need showed higher rates of well-being at the house-level. Advice-seeking in itself may signal stress, as stress may motivate residents to seek advice from more peers. The implications of these findings are discussed.

Resident interactions when affirming and correcting peers in a therapeutic community for women.

Purpose ­: While recent years have seen a number of studies of social networks in therapeutic communities (TCs) and other residential settings, these have primarily focused on male residents. This paper aims to conduct a longitudinal social network analysis of interpersonal interactions in a TC for women. Design/methodology/approach ­: The data consists of a longitudinal directed social network of instances of feedback between 56 residents of a 16 bed TC for women over a period of 611 days. Mean age of the participants was 33.1 years, mean length of stay was 133.9 days and 91% of the participants were female. Feedback consisted of written affirmations for prosocial behavior and written corrections for contravening TC norms. Data was analyzed using a latent factor longitudinal social network model. Findings ­: Residents react to peer intervention in complex ways. Residents reciprocated affirmations (B = 0.14, 95% confidence interval = 0.10, 0.18) and corrections (B = 0.20, 95% CI = 0.13, 0.25). Controlling for reciprocity, participants who received affirmations were more likely to affirm and correct peers (B = 0.10, 95% CI = 0.06, 0.15; B = 0.17, 95% CI = 0.10, 0.23), suggesting that the encouragement offered by affirmations leads to increased activity. Homophily by admission time occurred in both affirmations and corrections (B = 0.23, 95% CI = 0.10, 0.37; B = 0.51, 95% CI = 0.29, 0.74). Originality/value ­: While affirmations and corrections serve as vehicles for behavioral reinforcement and social learning, they also allow residents to interact in ways that strengthen social bonds.

An Empirically-based Theory of the Relationships Among Social Embeddedness, Economic Viability, Learned Recovery Skills and Perceived Quality of Life in Recovery Homes.

Key characteristics of recovery homes include governance style (which can play a central role in structuring recovery mechanisms), social embeddedness (e.g., social relationships within the home), economic viability (e.g., the individual's ability to be self-supporting), and learned recovery skills (such as coping with stress, avoiding putting one's self in risky situations, etc.). These domains can have important associations with perceived quality of life (measured across physical, psychological, social relationships, and environmental domains). The current study investigated relationships among these key "active ingredients" (Moos, 2007) of recovery homes. In addition, we present dynamic model consistent with these observed relationships, to illustrate how relevant mechanisms interact over time to and affect system evolution. Data were collected from recovery home residents in three states. Findings supported our overall hypotheses indicating that social embeddedness, stress, and self-efficacy were related to quality of life, and policy and treatment-design implications are further examined by simulating system dynamics.

Recovery homes: A social network analysis of Oxford Houses for Native Americans.

Social network data were collected among residents of an Oxford House (OH) recovery home, which was located on Suquamish Tribal territory. Data were collected on the social connections of eight male residents (including four Native Americans and four non-Native Americans) using a social network instrument. A number of social network relationship types were examined, including friendship, trust, and mentorship. Social network data assessed included diameter, reciprocity, the average path length, cohesion, density, transitivity, and centrality. Findings indicated that the OH provided residents a well-integrated network with multiple sources of friendship, trust, and mentors. This is of importance as recovery from substance abuse is facilitated when recovering individuals are provided stable and well-functioning networks that foster social support, access to resources, and mentorship.

Building the community: Endogenous network formation, homophily and prosocial sorting among therapeutic community residents.

BACKGROUND: Researchers have begun to consider the ways in which social networks influence therapeutic community (TC) treatment outcomes. However, there are few studies of the way in which the social networks of TC residents develop over the course of treatment. METHODOLOGY: We used a Temporal Exponential Random Graph Model (TERGM) to analyze changes in social networks totaling 320,387 peer affirmations exchanged between residents in three correctional TCs, one of which serves men and two of which serve both men and women. The networks were analyzed within weekly and monthly time-frames. RESULTS: Within a weekly time-frame residents tended to close triads. Residents who were not previously connected tended not to affirm the same peers. Residents showed homophily by entry cohort. Other results were inconsistent across TC units. Within a monthly time-frame participants showed homophily by graduation status. They showed the same patterns of triadic closure when connected, tendency not to affirm the same peers when not connected and homophily by cohort entry time as in a weekly time frame. CONCLUSIONS: TCs leverage three human tendencies to bring about change. The first is the tendency of cooperators to work together, in this case in seeking graduation. The second is the tendency of people to build clusters. The third is homophily, in this case by cohort entry time. Consistent with TC clinical theory, residents spread affirmations to a variety of peers when they have no previous connection. This suggests that residents balance network clustering with a concern for the community as a whole.

A promising recovery housing model for American Indian communities.

In 2016, two Oxford House (OH) recovery homes were established for the Suquamish Tribal reservation. A group of researchers interviewed house members and key individuals responsible for the creation of these two unique OHs. Because American Indians are an at-risk population for substance use disorders, our study explored whether an OH-type recovery home model could be successfully adapted to this population, given the specific nature of tribal cultures. Findings indicated that the residents, composed of both American Indians and non-American Indians, found these OHs to be supportive of recovery in general and with the values of American Indians. The tribal community's positive attitudes toward these recovery homes may have been due to similarities between the Suquamish Tribal Government and OH's democratic structures, with all individuals having a voice in the decision making process. The overall findings suggest that these types of culturally modified recovery settings on American Indian tribal lands could be an important resource for individuals dealing with substance use disorders.

The impact of geographic isolation on mental disability in the United States.

Geographic isolation has long been hypothesized to have a role in the origins and development of mental disabilities. A considerable body of research has established such a correlation. However, study designs have limited researchers' ability to establish a causal connection and rule out rival hypotheses. This study, therefore, aims to assess the strength of the geographic isolation - mental disability relationship and to disentangle it from alternative possibilities, namely that it reflects socioeconomic status, social isolation, economic inequality, or reverse causation. The study employs an analysis of variations in the rates of mental disability throughout 2960 U.S. counties using both Census and CDC data. In addition to partial correlation and ordinary least square analyses, the study employs two-stage least squares regression with instrumental variables (2SLS-IV), a procedure that permits resolution of the problem of endogeneity involving the potential effects of unmeasured variables and reverse causation. Results reveal that the initial bivariate effects of geographic isolation on rates of mental disability are robust after controls for socioeconomic status, income inequality, social isolation, and other predictors are introduced and when tested with the 2SLS-IV procedure. Most variation (54.4%) in county mental disability rates is accounted for by the independent effects of geographic isolation, socioeconomic status, income inequality, and other variables. The results presented, although not conclusive, supports more targeted service planning and more equitable resource investments in rural parts of the United States and other nations.

Quality of life as a predictor of social relationships in Oxford House.

Improved access to housing and recovery support is a low-cost, high-potential opportunity to help people recovering from alcohol and substance use sustain their recoveries. Oxford House (OH) recovery homes represent a recovery-favorable social environment for at least some people, but it is still unclear which resident characteristics and relational dynamics affect the social integration of residents. In the current study, OH residents in three geographic locations completed a social network instrument and self-rated their quality of life (QOL). The instruments were administered to the current (per wave) residents of 42 OHs at three time points over a period of a year. Findings indicated that those with a higher QOL were more likely to form friendships with those with a lower QOL than with their similar QOL peers, and vice versa. This finding would not have been predicted based on relationship mechanisms typical of broader social contexts, where homophily (similarity-based assortativity) is common. The self-governance model that characterizes OH residences, in which success among residents is necessarily viewed as mutually dependent and therefore mutually beneficial, seems a likely explanation for our result. Specifically, and aligned with current knowledge about what works in peer oriented recovery, our results suggest the governance mechanisms of OH favor relationships between those more stable in their recovery and those who are at a higher risk of dropout or relapse. This study reveals a potential research avenue examining an important ingredient for the effectiveness of OH.

Regional Rural-Urban Differences in E-Cigarette Use and Reasons for Use in the United States.

PURPOSE: To determine whether there are rural/urban differences in e-cigarette use and reasons for use that vary across the 10 Health & Human Services (HHS) regions. METHODS: Age-adjusted bivariate and multivariable analyses were conducted for n = 225,413 respondents to the 2014-2015 Tobacco Use Supplement-Current Population Survey to estimate the prevalence of e-cigarette use. Reasons for e-cigarette use were collected from n = 16,023 self-respondents who reported ever using e-cigarettes. FINDINGS: While nationally rural residents appeared more likely to use e-cigarettes, adjusted results indicated that current e-cigarette use was significantly less likely across the northern and western regions (New England, East North Central, Heartland, North Central Mountain, Northwest, and Southwest Pacific regions). Reasons for e-cigarette use differed by urban/rural status and region; for example, the rationale to use e-cigarettes as a smoking cessation aid was significantly more common among rural compared to urban adults in the New England and New York/New Jersey regions, but less common in the Southeast. CONCLUSIONS: For several regions, there were no significant rural/urban differences in e-cigarette use and reasons for use. Yet those regions that present differences face the need to develop public health approaches to minimize urban/rural disparities in health education, services, and outcomes related to tobacco use, particularly where access to health care is limited. Public health campaigns and guidance for clinical care within HHS regions should be tailored to reflect regional differences in beliefs about e-cigarettes.