Trends in cigarette use and health insurance coverage among US adults with mental health and substance use disorders.

AIMS: To estimate recent trends in cigarette use and health insurance coverage for United States adults with and without mental health and substance use disorders (MH/SUD). DESIGN: Event study analysis of smoking and insurance coverage trends among US adults with and without MH/SUD using 2008-19 public use data from the National Survey on Drug Use and Health, an annual, cross-sectional survey. SETTING: USA. PARTICIPANTS: A nationally representative sample of non-institutionalized respondents aged 18-64 years (n = 448 762). MEASUREMENTS: Outcome variables were three measures of recent cigarette use and one measure of past-year health insurance coverage. We compared outcomes between people with and without MH/SUD (MH disorder: past-year mental illness, predicted from Kessler-6 and the World Health Organization-Disability Assessment Schedule impairment scale; SUD: met survey-based DSM-IV criteria for past-year alcohol, cannabis, cocaine or heroin use disorder) and over time. FINDINGS: Comparing pooled data from 2008 to 2009 and from 2018 to 2019, current smoking rates of adults with MH/SUD decreased from 37.9 to 27.9% while current smoking rates of adults without MH/SUD decreased from 21.4 to 16.3%, a significant difference in decrease of 4.9 percentage points (pts) [95% confidence interval (CI) = 3.3-6.6 pts]. Daily smoking followed similar patterns (difference in decrease of 3.9 pts (95% CI = 2.3-5.4 pts). Recent smoking abstinence rates for adults with MH/SUD increased from 7.4 to 10.9%, while recent smoking abstinence rates for adults without MH/SUD increased from 9.6 to 12.0%, a difference in increase of 1.0 pts (95% CI = -3.0 to 0.9 pts). In 2018-19, 11% of net reductions in current smoking, 12% of net reductions in daily smoking and 12% of net increases in recent smoking abstinence coincided with greater gains in insurance coverage for adults with MH/SUD compared to those without MH/SUD. CONCLUSIONS: Improvements in smoking and abstinence outcomes for US adults with mental health and substance use disorders appear to be associated with increases in health insurance coverage.

Assessing racial/ethnic disparities in treatment across episodes of mental health care.

OBJECTIVE: To investigate disparities in mental health care episodes, aligning our analyses with decisions to start or drop treatment, and choices made during treatment. STUDY DESIGN: We analyzed whites, blacks, and Latinos with probable mental illness from Panels 9-13 of the Medical Expenditure Panel Survey, assessing disparities at the beginning, middle, and end of episodes of care (initiation, adequate care, having an episode with only psychotropic drug fills, intensity of care, the mixture of primary care provider (PCP) and specialist visits, use of acute psychiatric care, and termination). FINDINGS: Compared with whites, blacks and Latinos had less initiation and adequacy of care. Black and Latino episodes were shorter and had fewer psychotropic drug fills. Black episodes had a greater proportion of specialist visits and Latino episodes had a greater proportion of PCP visits. Blacks were more likely to have an episode with acute psychiatric care. CONCLUSIONS: Disparities in adequate care were driven by initiation disparities, reinforcing the need for policies that improve access. Many episodes were characterized only by psychotropic drug fills, suggesting inadequate medication guidance. Blacks' higher rate of specialist use contradicts previous studies and deserves future investigation. Blacks' greater acute mental health care use raises concerns over monitoring of their treatment.

Revisiting the evidence on health and health care disparities among the Roma: a systematic review 2003-2012.

OBJECTIVES: To conduct a systematic review of the epidemiological and health service utilization literature related to the Roma population between 2003 and 2012. METHODS: Systematic review of empirical research related to Roma health and health care utilization published between 2003 and 2012 identified through electronic databases (PsycInfo, Medline, Google Scholar). Methodological rigor was evaluated using a six-point set of design criteria. RESULTS: We found evidence for lower self-reported health and significantly higher mortality risk for Roma compared to non-Roma, and greater prevalence of health risk factors for Roma children, including environmental risks, low birth weight, and lower vaccination coverage. Studies of non-communicable and infectious disease remain insufficient to make firm conclusions on disparities. Barriers to care include lack of documentation and affordability of care, though more studies on health care utilization are needed. CONCLUSIONS: Roma youth and adults are in need of programs that reduce health disparities and their increased mortality risk. Reducing exposure to risk factors such as smoking, obesity, and poor living conditions may be a target for interventions. More intervention studies and rigorous evaluations are needed.

Role of cigarette sensory cues in modifying puffing topography.

BACKGROUND: Human puffing topography promotes tobacco dependence by ensuring nicotine delivery, but the factors that determine puffing behavior are not well explained by existing models. Chemosensory cues generated by variations in cigarette product design features may serve as conditioned cues to allow the smoker to optimize nicotine delivery by adjusting puffing topography. Internal tobacco industry research documents were reviewed to understand the influence of sensory cues on puffing topography, and to examine how the tobacco industry has designed cigarettes, including modified risk tobacco products (MRTPs), to enhance puffing behavior to optimize nicotine delivery and product acceptability. METHODS: Relevant internal tobacco industry documents were identified using systematic searching with key search terms and phrases, and then snowball sampling method was applied to establish further search terms. RESULTS: Modern cigarettes are designed by cigarette manufacturers to provide sensory characteristics that not only maintain appeal, but provide cues which inform puffing intensity. Alterations in the chemosensory cues provided in tobacco smoke play an important role in modifying smoking behavior independently of the central effects of nicotine. CONCLUSIONS: An associative learning model is proposed to explain the influence of chemosensory cues on variation in puffing topography. These cues are delivered via tobacco smoke and are moderated by design features and additives used in cigarettes. The implications for regulation of design features of modified risk tobacco products, which may act to promote intensive puffing while lowering risk perceptions, are discussed.

Human electroencephalography and the tobacco industry: a review of internal documents.

OBJECTIVE: To determine the extent and implications of internal human electroencephalography (EEG) research conducted by the tobacco industry. METHODS: This study analysed internal documents that describe the results of human EEG studies conducted by tobacco manufacturers. Emphasis was placed on documents that pertain to the application of EEG to product evaluation efforts. RESULTS: Internal EEG research was used to determine dose-response relations and effective threshold levels for nicotine, emphasising the importance of form and mechanism of nicotine delivery for initiating robust central nervous system (CNS) effects. Internal studies also highlight the importance of human behaviour during naturalistic smoking, revealing neurophysiological markers of compensation during smoking of reduced nicotine cigarettes. Finally, internal research demonstrates the effectiveness of EEG for the evaluation of non-nicotine phenomena including smoke-component discrimination by smokers, classification of sensory characteristics and measurement of hedonics and other subjective effects. CONCLUSIONS: Tobacco manufacturers successfully developed objective, EEG-based techniques to evaluate the influence of product characteristics on acceptance and use. Internal results suggest that complex interactions between pharmacological, sensory and behavioural factors mediate the brain changes that occur with smoking. These findings have implications for current proposals regarding the regulation of tobacco products and argue for the incorporation of objective measures of product effects when evaluating the health risks of new and existing tobacco products.

Tobacco industry manipulation of nicotine dosing.

For more than a half century, tobacco manufacturers have conducted sophisticated internal research to evaluate nicotine delivery, and modified their products to ensure availability of nicotine to smokers and to optimize its effects. Tobacco has proven to be a particularly effective vehicle for nicotine, enabling manipulation of smoke chemistry and of mechanisms of delivery, and providing sensory cues that critically inform patterns of smoking behavior as well as reinforce the impact of nicotine. A range of physical and chemical product design changes provide precise control over the quantity, form, and perception of nicotine dose, and support compensatory behavior, which is driven by the smoker's addiction to nicotine. Cigarette manufacturers also enhance the physiological effects of nicotine through the introduction and use of compounds that interact with nicotine but do not directly alter its form or delivery. A review of internal documents indicates important historical differences, as well as significant differences between commercial brands, underscoring the effectiveness of methods adopted by manufacturers to control nicotine dosing and target the needs of specific populations of smokers through commercial product development. Although the focus of the current review is on the manipulation of nicotine dosing characteristics, the evidence indicates that product design facilitates tobacco addiction through diverse addiction-potentiating mechanisms.

Puffing style and human exposure minimally altered by switching to a carbon-filtered cigarette.

OBJECTIVE: Potential Reduced Exposure tobacco Products (PREP) are intended to lower human exposure to toxic constituents of tobacco smoke, but rigorous clinical evaluations are required to assess such claims. The present study assessed human smoking behavior and short-term exposure to a new carbon-filtered PREP, Marlboro UltraSmooth (MUS). Two MUS prototypes with filter carbon loads of 120 and 180 mg were compared with low and ultralow-yield conventional cigarettes. METHODS: After a 48-hour baseline period, 32 adult Marlboro Lights smokers were switched in a counterbalanced order, to MUS and Marlboro Ultra Lights for 48 hours each. Measures of smoking topography, subjective response, change in cardiac response, and carbon monoxide boost were obtained under supervised test conditions on separate days. After each test, topography measures were obtained via a 48-hour free smoking phase for each brand. Salivary cotinine was measured at the end of each 48-hour period. RESULTS: Although MUS was generally smoked in a style similar to conventional cigarettes, compensatory smoking was observed with 1 MUS prototype (P = 0.003). Carbon monoxide boost was lower for MUS compared with Marlboro Lights, but salivary cotinine and cardiac function measures after smoking of MUS did not vary from conventional brands. CONCLUSIONS: Smoking MUS produced few differences in smoking topography and exposure compared with conventional low and ultralow-yield cigarettes. Results suggest that the manner in which MUS is smoked by humans is unlikely in the short term to reduce exposure among smokers who switch from a conventional brand.

Tobacco industry control of menthol in cigarettes and targeting of adolescents and young adults.

OBJECTIVES: We examined whether tobacco manufacturers manipulate the menthol content of cigarettes in an effort to target adolescents and young adults. METHODS: We analyzed data from tobacco industry documents describing menthol product development, results of laboratory testing of US menthol brands, market research reports, and the 2006 National Survey on Drug Use and Health. RESULTS: The tobacco industry attracted new smokers by promoting cigarettes with lower menthol content, which were popular with adolescents and young adults, and provided cigarettes with higher menthol content to long-term smokers. Menthol cigarette sales remained stable from 2000 to 2005 in the United States, despite a 22% decline in overall packs sold. CONCLUSIONS: Tobacco companies manipulate the sensory characteristics of cigarettes, including menthol content, thereby facilitating smoking initiation and nicotine dependence. Menthol brands that have used this strategy have been the most successful in attracting youth and young adult smokers and have grown in popularity.

Tobacco industry research and efforts to manipulate smoke particle size: implications for product regulation.

Over the past half-century of cigarette design, tobacco manufacturers have prioritized efficiency of delivery alongside ease of inhalation and use. As a result, the modern cigarette is uniquely effective at facilitating the absorption of nicotine as well as carcinogens and other toxins. The present study draws on internal tobacco company documents to assess industry consideration of the role of smoke particle size as a potentially controllable influence over inhalation patterns and lung exposure. Tobacco manufacturers evaluated particle size manipulation both as a means of controlling physical and sensory product attributes and as a possible approach to reducing health hazards related to exposure. Industry scientists concluded that the smoke aerosol particle distribution of conventional cigarettes, constructed within common parameters, falls within a narrow and effective inhalation range. However, the internal findings suggest that differences in smoke particle size distribution are possible through less conventional approaches to product design. We propose that particle size be included among the many design features to be considered in emerging tobacco product regulation. However, the present review does not address whether particle size regulation would be a plausible means of substantially reducing addictiveness or harmfulness of cigarettes, and therefore we do not propose it as a high-priority target for regulation.

The menthol smoker: tobacco industry research on consumer sensory perception of menthol cigarettes and its role in smoking behavior.

The use of menthol in cigarettes is actively promoted by the tobacco industry for its perceived sensory benefits, and smokers of menthol cigarettes commonly differ from nonmenthol smokers in markers of smoking behavior and addiction. In this study, we analyzed internal tobacco industry documents to describe the relationships between sensory perception and the attitudes, preferences, and patterns of cigarette use among menthol smokers. Two unique types of menthol smoker emerged from this analysis: those who cannot tolerate the harshness and irritation associated with smoking nonmenthol cigarettes, and those who seek out the specific menthol flavor and associated physical sensation. Among the first segment of menthol smokers, menthol reduces negative sensory characteristics associated with smoking. This segment of smokers may include a large proportion of occasional smokers or young people, as well as smokers who have "traded down" to a less strong cigarette because of perceived harshness or negative health effects. Some established menthol smokers, on the other hand, appear to be tolerant of and even actively seek stronger sensory attributes, including higher menthol levels. Smokers of these "stronger" menthols have traditionally been disproportionately Black and male. Some beginning or occasional smokers may adopt menthols for their mild properties and to cover up the taste of tobacco, but then develop a stronger desire for the menthol taste over time. Future research measuring smoking behavior and evaluating cessation outcomes of menthol smokers should consider the duration of menthol use and differentiate smokers according to their reasons for using menthols.

Internal tobacco industry research on olfactory and trigeminal nerve response to nicotine and other smoke components.

Evidence has shown that factors other than the central pharmacological effects of nicotine are important in promoting smoking behavior. One such non-nicotine effect includes sensory stimulation, which may promote smoking by developing learned associations with nicotine's rewarding effects, or by constituting a rewarding experience independent of nicotine. The present study used internal tobacco industry documents to examine industry efforts to understand and manipulate stimulation of the sensory nerves by tobacco smoke, and the influence of sensory stimulation on smoker behavior. Research focused on sensory nerves of the head and neck, including the olfactory nerve, which carries flavor and odor, and the trigeminal nerve, which carries irritant information. The tobacco industry maintained a systematic research program designed to elucidate an understanding of responses of sensory nerves to nicotine and other components of tobacco smoke, and attempted to develop nicotine-like compounds that would enhance sensory responses in smokers. Industry research appeared intended to aid in the development of new products with greater consumer appeal. The potential influence of sensory response in enhancing nicotine dependence through an associative mechanism was acknowledged by the tobacco industry, but evidence for research in this area was limited. These findings add to evidence of industry manipulation of sensory factors to enhance smoking behavior and may have implications for development of more effective treatment strategies, including more "acceptable" nicotine replacement therapies.

Physical design analysis and mainstream smoke constituent yields of the new potential reduced exposure product, Marlboro UltraSmooth.

Potential reduced exposure products (PREPs) purport to lower toxicant emissions, but without clinical and long-term health outcome data, claims for reduced harm status of PREPs depend heavily on standard machine yield smoke constituent data. Two prototypes of the new carbon-filtered PREP Marlboro UltraSmooth (MUS) were investigated using both standard (FTC/ISO) and intensive (Health Canada) machine methods to measure gas/vapor- and particulate-phase smoke constituents. Basic physical design characteristics that may influence smoke constituent yields, such as ventilation, pressure drop (resistance to draw), quantity of tobacco, and quantity and type of carbon, were measured. The possible presence of added chemical flavorant compounds was investigated using gas chromatography-mass spectroscopy. MUS prototypes were found to have several key differences in physical design compared with a conventional cigarette, including higher ventilation, lower draw resistance, and in the case of the Salt Lake City prototype, the use of vitreous carbon beads and the presence of chemical flavorants on both the beads and an embedded filter fiber. When tested under the standard regimen, gas-phase constituents of MUS prototypes were reduced compared with a conventional low-yield cigarette. However, far smaller reductions in gas-phase constituents were observed under the intensive regimen, suggesting that the carbon technology used in MUS is less effective when smoked under more intensive conditions. Particulate-phase constituents were not reduced by the carbon filter under either machine-smoking regimen. The data suggest that MUS has been designed to reduce toxic yields while preserving consumer appeal. However, MUS is less effective in reducing toxic smoke constituents when smoked under intensive conditions.

Trends in nicotine yield in smoke and its relationship with design characteristics among popular US cigarette brands, 1997-2005.

OBJECTIVES: To determine whether nicotine yields in the smoke of cigarettes would show an overall increase over time or an increasing trend limited to any particular market category (eg, full flavour vs light, medium (mild) or ultralight; mentholated vs non-mentholated), manufacturer, or brand family or brand style, and whether nicotine yields in smoke would be associated with measurable trends in cigarette design. METHODS: Machine-based measures of nicotine yield in smoke and measures of cigarette design features related to nicotine delivery (ventilation, nicotine content in the tobacco rod and number of puffs), as well as market category descriptors, were obtained from annual reports filed with the Massachusetts Department of Public by tobacco manufacturers for 1997-2005. Trends in nicotine yield and its relationship with design features and market parameters were analysed with multilevel mixed-effects regression modelling procedures. RESULTS: A statistically significant trend was confirmed in increased nicotine yield, of 0.019 (1.1%) mg/cig/year over the period 1997-2005 and 0.029 (1.6%) mg/cig/year over the period 1998-2005. The increasing trend was observed in all major market categories (mentholated vs non-mentholated, and full flavour vs light, medium (mild) or ultralight). Nicotine yield in smoke was positively associated with nicotine concentration in the tobacco and number of puffs per cigarette, both of which showed increasing trends during the study period. CONCLUSIONS: This study confirms increased machine-measured levels of nicotine, the addictive agent in cigarettes, in smoke, to be a result of increased nicotine in the tobacco rod and other design modifications.

The role of sensory perception in the development and targeting of tobacco products.

AIMS: To examine tobacco industry research on smoking-related sensory effects, including differences in sensory perception across smoker groups, and to determine whether this research informed targeted product development and impacted the development of commercial tobacco products. DESIGN: We searched previously secret internal tobacco industry documents available online through document databases housed at Tobacco Documents Online, the British American Tobacco Document Archive and the Legacy Tobacco Documents Library. We identified relevant documents using a snowball sampling method to first search the databases using an initial set of key words and to then establish further search terms. FINDINGS: Sensory research is a priority within the tobacco industry directly impacting commercial markets both in the United States and internationally. Sensory factors contribute to smoker satisfaction and product acceptance, and play an important role in controlling puffing behavior. Cigarette manufacturers have capitalized on distinct sensory preferences across gender, age and ethnic groups by tailoring products for specific populations. CONCLUSIONS: Regulation of tobacco products is needed to address product changes that are used to reinforce or contribute to tobacco dependence; for instance, the incorporation of additives that target attributes such as smoothness, harshness and aftertaste. Greater understanding of the role of sensory effects on smoking behavior may also help to inform the development of tobacco treatment options that support long-term tobacco abstinence.

Potential reduced exposure products (PREPs) in industry trial testimony.

OBJECTIVE: To identify patterns in trial testimony that may reflect on the intentions or expectations of tobacco manufacturers with regard to the introduction of potential reduced exposure products (PREPs). DESIGN: Research was conducted using the Deposition and Trial Testimony Archive (DATTA) collection of trial testimony and depositions housed online at Tobacco Documents Online (www.tobaccodocuments.org). Relevant testimony was identified through full-text searches of terms indicating PREPs or harm reduction strategies. The role and function of PREPs in testimony were classified according to common and contrasting themes. These were analysed in the context of broader trial arguments and against changes in time period and the market. RESULTS: Analysis of testimony suggests that the failure of PREPs in the market tempered initial industry enthusiasm and made protection of the conventional cigarette market its major priority. The "breakthrough" character of PREPs has been de-emphasised, with trial arguments instead positioning PREPs as simply another choice for consumers. This framework legitimises the sale of conventional brands, and shifts the responsibility for adoption of safer products from the manufacturer to the consumer. Likewise, testimony has abandoned earlier dramatic health claims made with regard to PREPs, which had undermined industry arguments regarding efforts to reduce harm in conventional products. More recent testimony advocates the broad acceptance of independent guidelines that would validate use of health claims and enable the industry to market PREPs to consumers. CONCLUSION: Trial testimony reflects the changing role and positioning of PREPs by the tobacco industry. The findings are of particular importance with regard to future evaluation and potential regulation of reduced harm products.

New cigarette brands with flavors that appeal to youth: tobacco marketing strategies.

Tobacco manufacturers have recently introduced a proliferation of exotic brands featuring candylike flavors. We reviewed internal tobacco industry documents and patents to assess the role of flavored cigarettes in the targeting of young smokers. This research revealed the development of flavor delivery technologies hidden from consumers and public health professionals, including the use of a plastic pellet placed in the cigarette filter. These findings raise concerns as to the potential added health risks associated with using new flavored tobacco products, and they underscore the need for effective assessment and monitoring of tobacco products.

Characterization of measured menthol in 48 U.S. cigarette sub-brands.

More than 25% of cigarettes sold in the United States are branded as mentholated, and these cigarettes are smoked disproportionately among populations with disparate tobacco-related health outcomes. This study is the first (independent of the tobacco industry) to report menthol for 48 popular commercially available mentholated cigarette sub-brands. The dependent variable "menthol per cigarette" was obtained by gas chromatography-mass spectrometer assay, whereas average per-cigarette milligram weight of tobacco filler ("tobacco per cigarette") was determined gravimetrically. Pearson's correlations assessed associations among continuous variables. Analyses of variance assessed mean differences on the independent variables of interest: manufacturer, brand family, industry descriptors of length (100 mm and King [85 mm]) and label (ultralight, light, medium/mild, and regular/full flavor), and a category constructed by the authors of exclusively menthol brand families (those without a non-menthol offering; Kool, Newport, and Salem) versus others (GPC, Camel, and Marlboro). Results showed menthol per cigarette and menthol per tobacco (i.e., milligrams of menthol per gram of tobacco filler) to be significantly greater in cigarettes labeled with industry descriptors of ultralight or light, belying the common consumer perception that "light" means less. Menthol per cigarette and tobacco per cigarette were significantly greater in 100-mm compared with 85-mm cigarettes. The study results are consistent with prior research that suggests menthol may be used to offset reductions in smoke delivery or impact and to facilitate compensatory smoke inhalation behaviors in smokers of cigarettes with reduced machine-measured smoke delivery. Tobacco manufacturers should be required by federal or other regulatory agencies to report the amount of menthol added to cigarettes.

Designing cigarettes for women: new findings from the tobacco industry documents.

AIMS: To examine internal tobacco industry research on female smoking patterns and product preferences, and how this research has informed the design of female-targeted cigarettes and impacted smoking behavior among this target population. DESIGN: Research was conducted through a systematic web-based search of previously secret industry documents made publicly available through the 1998 Master Settlement Agreement. FINDINGS: This study provides evidence that the tobacco industry has conducted extensive research on female smoking patterns, needs and product preferences, and has intentionally modified product design for promotion of cigarette smoking among women. Cigarette manufacturers responded to changing female trends by focusing on social and health concerns as well as promoting dual-sex brands that also featured traditional female style characteristics. CONCLUSIONS: Product features responsive to female-identified needs and preferences may contribute to differences in female smoking patterns. Assessment of female-targeted product differences should inform smoking cessation and prevention programs tailored to women. Overall, these findings underscore the need for further investigation of effects of targeting on smoking behavior, health outcomes and regulation of tobacco products by public health agencies.

Assessing internal tobacco industry knowledge of the neurobiology of tobacco dependence.

The recent availability of internal tobacco industry documents provides a significant resource for evaluating industry understanding of the pharmacological, psychosocial, and behavioral mechanisms underlying tobacco dependence. In this study, we catalog the range of efforts undertaken by tobacco manufacturers seeking knowledge of these mechanisms. Some areas of industry research, such as cellular and molecular studies of nicotine and its effects, are widely available in the open literature. Of greater interest are internal research projects that have demonstrated direct influence on product development. These include studies of smoker psychology and behavior, evoked-response studies of tobacco-delivered nicotine, the effects of sensory perception, dose-related effects, and the development of nicotine analogs and synergists. Our findings suggest extensive industry knowledge of mechanisms that determine smoker perception and behavior, and application of this knowledge in product development, including control of sensory response, uptake of nicotine, and product effects. Independent research recently has begun to consider the contributions of tobacco product ingredients and design factors to the determination of risk, severity, and prevalence of addiction. However, the application of these findings to cessation and treatment efforts is still quite limited. We conclude that clinical research would greatly benefit from further examination of the decades of knowledge accumulated by tobacco manufacturers.

One size does not fit all: how the tobacco industry has altered cigarette design to target consumer groups with specific psychological and psychosocial needs.

AIMS: To identify whether the tobacco industry has targeted cigarette product design towards individuals with varying psychological/psychosocial needs. DESIGN: Internal industry documents were identified through searches of an online archival document research tool database using relevancy criteria of consumer segmentation and needs assessment. FINDINGS: The industry segmented consumer markets based on psychological needs (stress relief, behavioral arousal, performance enhancement, obesity reduction) and psychosocial needs (social acceptance, personal image). Associations between these segments and smoking behaviors, brand and design preferences were used to create cigarette brands targeting individuals with these needs. CONCLUSIONS: Cigarette brands created to address the psychological/psychosocial needs of smokers may increase the likelihood of smoking initiation and addiction. Awareness of targeted product development will improve smoking cessation and prevention efforts.