Creating a Transdisciplinary Research Center to Reduce Cardiovascular Health Disparities in Baltimore,Maryland: Lessons Learned

Cardiovascular disease (CVD) disparities continue to have a negative impact on African Americans in the United States, largely because of uncontrolled hypertension. Despite the availability of evidence-based interventions, their use has not been translated into clinical and public health practice. The Johns Hopkins Center to Eliminate Cardiovascular Health Disparities is a new transdisciplinary research program with a stated goal to lower the impact of CVD disparities on vulnerable populations in Baltimore, Maryland. By targeting multiple levels of influence on the core problem of disparities in Baltimore, the center leverages academic, community, and national partnerships and a novel structure to support 3 research studies and to train the next generation of CVD researchers. We also share the early lessons learned in the center’s design.Racial disparities in hypertension prevalence, control rates with care, and related cardiovascular complications and mortality, are persistent and extensively documented in the United States.1–5 Cardiovascular disease (CVD) accounts for 35% of the excess overall mortality in African Americans, in large part because of hypertension.6,7 Nationwide, eliminating racial disparities in hypertension control would result in more than 5000 fewer deaths from coronary heart disease and more than 2000 fewer deaths from stroke annually in African Americans.8 Despite numerous studies establishing the efficacy of pharmacologic and lifestyle therapies9–12 in African Americans and Whites, blood pressure control rates remain suboptimal, even among persons receiving regular health care.13,14 Barriers to hypertension control exist at multiple levels, including individual patients, health care professionals, the health care system, and patients’ social and environmental context. Although successful interventions exist,15–18 these strategies have not been translated into clinical and public health practice.In Baltimore, Maryland, like in the rest of the United States, CVD, including coronary heart disease and stroke, is the leading cause of death. Approximately 2000 people die from CVD in Baltimore each year; these deaths disproportionately affect African Americans,19 making health disparities from CVD a key factor in the racial discrepancy in life expectancy in the city. Cardiovascular disease is a key reason for the 20-year difference in life expectancy between those who live in more affluent neighborhoods (83 years) and those who reside in poorer neighborhoods (63 years) of Baltimore.20

Effectiveness of Case Management for Homeless Persons: A Systematic Review

We reviewed the literature on standard case management (SCM), intensive case management (ICM), assertive community treatment (ACT), and critical time intervention (CTI) for homeless adults. We searched databases for peer-reviewed English articles published from 1985 to 2011 and found 21 randomized controlled trials or quasi-experimental studies comparing case management to other services.We found little evidence for the effectiveness of ICM. SCM improved housing stability, reduced substance use, and removed employment barriers for substance users. ACT improved housing stability and was cost-effective for mentally ill and dually diagnosed persons. CTI showed promise for housing, psychopathology, and substance use and was cost-effective for mentally ill persons.More research is needed on how case management can most effectively support rapid-rehousing approaches to homelessness.Homelessness is a serious and widespread public health problem. In the United States and Europe, estimates for the lifetime prevalence of homelessness range between 5.6% and 13.9%.1 The global financial crisis has negatively affected the prevalence of homelessness. In the United States, certain groups, such as families and people living in suburban and rural areas, have become more vulnerable to homelessness.2 In Europe, austerity measures implemented after the start of the crisis have increased poverty and homelessness, with possibly the worst to come because of a strong time lag effect.3Homelessness is often accompanied by other problems. People who are homeless experience a lower quality of life than those who are domiciled.4,5 Several longitudinal studies have found that quality of life improves as independent housing is obtained.5–7 Societal participation is limited; many homeless persons are unemployed, have few sources of income, and have a limited social network. They often experience extreme poverty and a lack of social support.8,9 Although few are felony offenders, homeless persons are at risk of arrest for transgressions resulting from their lifestyle (e.g., panhandling, public intoxication, squatting, and failing to pay fines).8,10 Moreover, estimates suggest that almost 40% of homeless people are dependent on alcohol and 25% on drugs. Many suffer from a mental disorder, such as a psychotic illness (13%), major depression (11%), or personality disorder (23%).11 Physical health problems are more prevalent among this group than in the general population.12,13 Recent studies found that up to 73% of homeless individuals have unmet health needs.14,15 Consequently, homelessness should be regarded as a significant and increasing threat to public health, which should be addressed.In recent years, the focus of policy measures to reduce homelessness has changed. The Homeless Emergency and Rapid Transition to Housing Act, an amendment to the McKinney–Vento Homeless Assistance Act, was enacted in 2009 to modernize the US Department of Housing and Urban Development’s homelessness assistance programs.16 In 2010, the jury recommendations of the European Consensus Conference on Homelessness laid out a road map for ending homelessness in the European Union.3 Both proposals called for a shift away from the "staircase" approach, which requires homeless persons to prove housing readiness while transferring through shelters and transitional housing situations before they become eligible for independent housing. The proposed alternative is a rapid-rehousing,16 or housing-led,3 approach, which focuses on providing access to permanent independent housing as the initial response to resolving situations of homelessness, in conjunction with flexible support services as required by the service needs of those who are rehoused to prevent recurrent homelessness.17 Case management has been identified as a strategy to support rapid rehousing, especially for those with complex needs.3 Little is known, however, about what patterns of services are most suitable to accompany housing for different subgroups of homeless people.16,18Since the 1980s, several models of case management have been developed that provide the same basic functions: outreach, assessment, planning, linkage, monitoring, and advocacy.19,20 Services delivered by case managers often include practical support, help with developing independent living skills, acute care in crisis situations, support with medical and psychiatric treatment, and assistance with contacts between clients and people in their social and professional support systems.20We focused on 4 models of case management that have been recommended and widely implemented for homeless persons19: standard case management (SCM), intensive case management (ICM), assertive community treatment (ACT), and critical time intervention (CTI). The models are distinguished by the functions they emphasize (21 ICM is typically targeted to individuals with the greatest service needs and prescribes more intensive services, more frequent client contact, and smaller individual caseloads than does SCM.22 ACT is closely related to ICM; however, in ACT the responsibility for providing services to clients is shared by a multidisciplinary team that is accessible 24 hours a day, 7 days a week.23 CTI is an intensive time-limited case management approach to enhance continuity of care by bridging the gap between services and strengthening clients’ social and professional networks. CTI is designed to be deployed at critical moments in the lives of clients, for instance, when a person is about to make a transition from a shelter to independent housing.24

TABLE 1—

Characteristics of Case Management Models for Homeless Adults

Spousal Violence in 5 Transitional Countries: A Population-Based Multilevel Analysis of Individual and Contextual Factors

Objectives. I examined the individual- and community-level factors associated with spousal violence in post-Soviet countries.Methods. I used population-based data from the Demographic and Health Survey conducted between 2005 and 2012. My sample included currently married women of reproductive age (n = 3932 in Azerbaijan, n = 4053 in Moldova, n = 1932 in Ukraine, n = 4361 in Kyrgyzstan, and n = 4093 in Tajikistan). I selected respondents using stratified multistage cluster sampling. Because of the nested structure of the data, multilevel logistic regressions for survey data were fitted to examine factors associated with spousal violence in the last 12 months.Results. Partner’s problem drinking was the strongest risk factor associated with spousal violence in all 5 countries. In Moldova, Ukraine, and Kyrgyzstan, women with greater financial power than their spouses were more likely to experience violence. Effects of community economic deprivation and of empowerment status of women in the community on spousal violence differed across countries. Women living in communities with a high tolerance of violence faced a higher risk of spousal violence in Moldova and Ukraine. In more traditional countries (Azerbaijan, Kyrgyzstan, and Tajikistan), spousal violence was lower in conservative communities with patriarchal gender beliefs or higher financial dependency on husbands.Conclusions. My findings underscore the importance of examining individual risk factors in the context of community-level factors and developing individual- and community-level interventions.Understanding factors that contribute to intimate partner violence (IPV) is essential to reducing it and minimizing its deleterious effect on women’s functioning and health. Most evidence comes from studies conducted in western industrialized countries or in the developing countries of Africa, Latin America, and Asia1–5; there is scarce knowledge available on IPV in the transitional countries of the former Soviet Union (fSU) region,6 which represents different geopolitical, socioeconomic, and cultural environments.7 Studies from other countries often demonstrate mixed findings regarding key risk factors for spousal violence, which suggests that their effects are context specific.8–11 An examination of cross-country similarities and differences within the fSU region may contribute to the understanding of risk factors for spousal violence in a different sociocultural context.As a part of the Soviet Union for approximately 70 years until its collapse in 1991, the fSU countries shared similar sociopolitical contexts,12 with a legacy of well-established public services, stable jobs, and high levels of education dating back to the Soviet era.13 The political turmoil and economic crisis of the 1990s following the collapse of the Soviet Union and the transition from a socialist to a market economy resulted in high unemployment, deterioration of public services, and growth in poverty and social inequalities, which increased family stress.14My study focused on 5 countries of the fSU that included an additional Domestic Violence (DV) module in the Demographic and Health Survey (DHS), which presented the first opportunity for cross-country comparison in this region using recent nationally representative data. The DHS survey was conducted in 2 Eastern European countries of the fSU (Moldova and Ukraine) and 2 countries located in the Central Asian region (Kyrgyz Republic and Tajikistan); the Caucasus region was represented by Azerbaijan. Previous DHS and other nationally representative studies from the fSU region included only individual-level predictors of violence without examining the role of contextual factors and focused predominantly on Eastern European countries of the fSU.8,15–17Despite shared Soviet background, the 5 countries differ in terms of gender norms and current socioeconomic situations (7 Eastern European countries (Ukraine and Moldova) share relatively more egalitarian gender norms, whereas Azerbaijan, Tajikistan and Kyrgyzstan, which are secular Muslim nations, have more traditional values and conservative norms. Women in Kyrgyzstan fall in the middle because of a historically large Russian-speaking population.18–21 Nevertheless, Azerbaijan, Kyrgyzstan, and Tajikistan—where the female literacy rate is close to 100% and polygamous marriages are illegal22—differ from many countries with a traditional Muslim culture because of a history of socialistic ideology, suppression of religion, and universal public education. Although Azerbaijan and Ukraine have exhibited significant economic growth because of rich energy resources, Moldova remains one of the poorest countries in Eastern Europe,23 and Tajikistan maintains the status of the poorest republic in the entire fSU region.

TABLE 1—

Selected Country-Level Indicators for 5 Former Soviet Union Countries: 2005–2012

Assessing Proposals for New Global Health Treaties: An Analytic Framework

We have presented an analytic framework and 4 criteria for assessing when global health treaties have reasonable prospects of yielding net positive effects.First, there must be a significant transnational dimension to the problem being addressed. Second, the goals should justify the coercive nature of treaties. Third, proposed global health treaties should have a reasonable chance of achieving benefits. Fourth, treaties should be the best commitment mechanism among the many competing alternatives.Applying this analytic framework to 9 recent calls for new global health treaties revealed that none fully meet the 4 criteria. Efforts aiming to better use or revise existing international instruments may be more productive than is advocating new treaties.The increasingly interconnected and interdependent nature of our world has inspired many proposals for new international treaties addressing various health challenges,1 including alcohol consumption,2 elder care,3 falsified/substandard medicines,4 impact evaluations,5 noncommunicable diseases,6 nutrition,7 obesity,8 research and development (R&D),9 and global health broadly.10 These proposals claim to build on the success of existing global health treaties (Year AdoptedTreaty Name1892International Sanitary Convention1893International Sanitary Convention1894International Sanitary Convention1897International Sanitary Convention1903International Sanitary Convention (replacing 1892, 1893, 1894, and 1897 conventions)1912International Sanitary Convention (replacing 1903 convention)1924Brussels Agreement for Free Treatment of Venereal Disease in Merchant Seamen1926International Sanitary Convention (revising 1912 convention)1933International Sanitary Convention for Aerial Navigation1934International Convention for Mutual Protection Against Dengue Fever1938International Sanitary Convention (revising 1926 convention)1944International Sanitary Convention (revising 1926 convention)1944International Sanitary Convention for Aerial Navigation (revising 1933 convention)1946Protocols to Prolong the 1944 International Sanitary Conventions1946Constitution of the World Health Organization1951International Sanitary Regulations (replacing previous conventions)1969International Health Regulations (replacing 1951 regulations)1972Biological Weapons Convention1989Basel Convention on Transboundary Movements of Hazardous Wastes1993Chemical Weapons Convention1994World Trade Organization Agreement on the Application of Sanitary and Phytosanitary Measures1997Convention on the Prohibition of Anti-Personnel Mines and Their Destruction1998Rotterdam Convention on Hazardous Chemicals and Pesticides in International Trade2000Cartagena Protocol on Biosafety to the Convention on Biological Diversity2001Stockholm Convention on Persistent Organic Pollutants2003World Health Organization Framework Convention on Tobacco Control2005International Health Regulations (revising 1969 regulations)2007United Nations Convention on the Rights of Persons With Disabilities2013Minamata Convention on MercuryOpen in a separate windowNote. Global health treaties are those that were adopted primarily to promote human health.

TABLE 2—

Examples of the Diverse Regulatory Functions Among Existing International Treaties

Industry Self-Regulation to Improve Student Health: Quantifying Changes in Beverage Shipments to Schools

Objectives. We developed a data collection and monitoring system to independently evaluate the self-regulatory effort to reduce the number of beverage calories available to children during the regular and extended school day. We have described the data collection procedures used to verify data supplied by the beverage industry and quantified changes in school beverage shipments.Methods. Using a proprietary industry data set collected in 2005 and semiannually in 2007 through 2010, we measured the total volume of beverage shipments to elementary, middle, and high schools to monitor intertemporal changes in beverage volumes, the composition of products delivered to schools, and portion sizes. We compared data with findings from existing research of the school beverage landscape and a separate data set based on contracts between schools and beverage bottling companies.Results. Between 2004 and the 2009–2010 school year, the beverage industry reduced calories shipped to schools by 90%. On a total ounces basis, shipments of full-calorie soft drinks to schools decreased by 97%.Conclusions. Industry self-regulation, with the assistance of a transparent and independent monitoring process, can be a valuable tool in improving public health outcomes.Improving public health outcomes involves various policy strategies, from national laws and state mandates to local initiatives and industry self-regulation. Previous self-regulatory efforts, in particular, demonstrate both the merits and limitations of relying on industry to address public health challenges.1 These experiences have spawned a debate among public health professionals about whether self-regulation is merely a self-serving tool used by industry to forestall government action or an effective way of responding to market failures.1–3 Ultimately, the success of these efforts is tied to the strength of the commitment to achieve meaningful, measurable, and verifiable outcomes.This debate extends to the regulation of sugar-sweetened beverages (SSBs) in schools. Although the Child Nutrition Act regulates SSBs, the limited stringency of these regulations has prompted states and communities to take further action.2 In addition, the Alliance for a Healthier Generation worked with representatives of the 3 largest US beverage companies to further address the issue of SSB availability in schools through self-regulation. In 2006, they reached an agreement to implement School Beverage Guidelines to reduce the number of beverage calories available to children at school.4 At that time, the signatories commissioned us to design and implement a multiyear data collection and monitoring system.We assessed the extent to which the School Beverage Guidelines have achieved meaningful outcomes by (1) describing the data collection procedures created to verify data supplied by the beverage industry, (2) quantifying changes in the school beverage landscape between 2004 and the 2009–2010 school year, and (3) identifying the strengths and weaknesses of industry self-regulation in this specific case.Public health experts, dieticians, and nutritionists frame the obesity epidemic in terms of behavioral, psychological, cultural, social, and genetic factors.5 Public attention, however, tends to focus on diet and how competitive food and beverages specifically contribute to obesity.6 Studies showing a positive relationship between higher energy intake and obesity support many of these concerns.7–9 These studies have also raised questions about external drivers of consumption behaviors, such as the school nutrition environment.10–12 A common research hypothesis pertaining to external conditions and consumption is that people tend to consume foods and beverages that are most accessible.13 Evidence from natural experiments and randomized controlled trials shows a positive relationship between the availability of SSBs and consumption patterns.14–16 Although some studies suggest that availability alone may not alter students’ beverage choices significantly,17 there is evidence showing that restrictions on SSBs may reduce their consumption.18–20In response, federal and state policymakers, school administrators, and private entities have enacted regulatory measures to create healthier food environments in schools. For instance, under the Child Nutrition Act, the US Department of Agriculture regulates foods sold in conjunction with the National School Breakfast Program and National School Lunch Program.21 The recent reauthorization of this act permits the US Department of Agriculture to regulate foods sold in vending machines, a la carte lunch lines, and school stores during the school day, although some believe that its regulations do not go far enough.22 Therefore, in the absence of more stringent federal laws, some states have placed further restrictions on SSBs, including portion and content standards, limitations on when SSBs can be sold, and, in the case of some states (e.g., Connecticut), bans on SSB sales in schools.2 Likewise, some local communities have adopted regulations to restrict access to SSBs during the school day.2Additionally, food and beverage companies have voluntarily offered to restrict marketing to children, alter product content, and limit beverage access in schools.23 In May 2006, the Alliance for a Healthier Generation worked with representatives of the Coca-Cola Company, Dr. Pepper Snapple Group, PepsiCo, and the American Beverage Association (the national trade association representing the nonalcoholic refreshment beverage industry) to agree on implementation of the Alliance School Beverage Guidelines. As outlined in the Memorandum of Understanding (MOU), beverage companies and their largest bottlers voluntarily agreed to phase out sales of full-calorie carbonated soft drinks (CSDs) and other beverages, shift the product mix toward no or low-calorie beverages, and reduce portion sizes over a period of 3 academic years (Beverage Types PermittedElementary SchoolsMiddle Schools^aHigh Schools^aBottled WaterYesYesYes100% juice (no added sweeteners), ≤ 120 cal/8 oz and ≥ 10% of the recommended value for ≥ 3 vitamins and mineralsYesYesYesFat-free or low-fat regular and flavored milk and nutritionally equivalent milk alternatives per US Department of Agriculture (e.g., soy milk)YesYesYesMilk alternatives with ≤ 150 cal/8 ozYesYesYesNo or low-calorie beverages with ≤ 10 calories/8 oz (including diet sodas, teas, and flavored waters)NoNoYesOther drinks with ≤ 66 cal/8 ozNoNoYesOther drinks with ≥ 66 cal/8 ozNoNoNoMaximum serving size for milks, juices, and (in high schools) other allowable beverages with more than 10 cal/8 oz81012Open in a separate windowNote. These guidelines apply to beverages sold on school grounds during the regular and extended school day. (The extended school day includes before and after school activities such as clubs, band, student government, drama, and childcare and latchkey programs.) These guidelines do not apply to school-related events in which parents and other adults are part of an audience or are selling beverages as boosters during intermission as well as immediately before or after an event. Examples of these events include sporting events, school plays, and band concerts.Source. American Beverage Association.4^aIf middle school and high school students have shared access to areas on a common campus or in buildings, the school community has the option to adopt the high school standards.Since the signing of the MOU, several studies have focused on the qualitative merits of the School Beverage Guidelines and self-regulation more generally. In a review of regulations on SSB sales in schools, Mello et al.2 offered conclusions about different policy strategies, comparing the relative and expected effectiveness of government regulation and industry self-regulation. The authors outlined concerns about certain aspects of the School Beverage Guidelines, including the lack of noncompliance provisions, the less restrictive nature of the School Beverage Guidelines compared with some existing state and local regulations, and the inability to affect preexisting contracts. They acknowledged that the beverage industry’s pledge represents a “significant step forward in industry self-regulation”2^(p600) but also concluded that the stringency and staying power of state and local policies make them more effective instruments for regulating SSBs in schools.2Sharma et al.1 proposed 8 general standards for evaluating the effectiveness of self-regulation. They examined these standards in the context of existing food and beverage industry self-regulations and then contextualized the discussion with a historical sketch of self-regulation in other industries. Through these examples, they identified potential pitfalls associated with industry self-regulation and reviewed the conditions that encourage successful outcomes. Regarding the School Beverage Guidelines, the authors outlined many of the same concerns as Mello et al.2 but did not conclude whether past self-regulation in the food and beverage industry has been a success or a failure.1Finally, Solomon3 analyzed instances of public and private regulation, including the School Beverage Guidelines, to outline the merits and limitations of various regulatory approaches. Solomon stated that 1 of the distinct aspects of the School Beverage Guidelines self-regulatory effort was the binding provisions created to track compliance. The author concluded that future state-level policy initiatives to address obesity should include objective and quantitative mechanisms for reporting and tracking progress, similar to the monitoring procedures for the School Beverage Guidelines.3     

Understanding Evidence-Based Public Health Policy

Public health policy has a profound impact on health status. Missing from the literature is a clear articulation of the definition of evidence-based policy and approaches to move the field forward. Policy-relevant evidence includes both quantitative (e.g., epidemiological) and qualitative information (e.g., narrative accounts).We describe 3 key domains of evidence-based policy: (1) process, to understand approaches to enhance the likelihood of policy adoption; (2) content, to identify specific policy elements that are likely to be effective; and (3) outcomes, to document the potential impact of policy.Actions to further evidence-based policy include preparing and communicating data more effectively, using existing analytic tools more effectively, conducting policy surveillance, and tracking outcomes with different types of evidence.IT HAS LONG BEEN KNOWN that public health policy, in the form of laws, regulations, and guidelines, has a profound effect on health status. For example, in a review of the 10 great public health achievements of the 20th century,¹ each of them was influenced by policy change such as seat belt laws or regulations governing permissible workplace exposures. As with any decision-making process in public health practice, formulation of health policies is complex and depends on a variety of scientific, economic, social, and political forces.²There is a considerable gap between what research shows is effective and the policies that are enacted and enforced. The definition of policy is often broad, including laws, regulations, and judicial decrees as well as agency guidelines and budget priorities.^2–4 In a systematic search of “model” public health laws (i.e., a public health law or private policy that is publicly recommended by at least 1 organization for adoption by government bodies or by specified private entities), Hartsfield et al.⁵ identified 107 model public health laws, covering 16 topics. The most common model laws were for tobacco control, injury prevention, and school health, whereas the least commonly covered topics included hearing, heart disease prevention, public health infrastructure, and rabies control. In only 6.5% of the model laws did the sponsors provide details showing that the law was based on scientific information (e.g., research-based guidelines).Research is most likely to influence policy development through an extended process of communication and interaction.⁶ In part, the research–policy interface is made more complex by the nature of scientific information, which is often vast, uneven in quality, and inaccessible to policymakers. Several models for how research influences policymaking have been described,^7–9 most of which involve moving beyond a simple linear model to more nuanced and indirect routes of influence, as in gradual “enlightenment.”¹⁰ Such nonlinear models of policymaking and decision-making take into consideration that research evidence may hold equal, or even less importance, than other factors that ultimately influence policy, such as policymakers'' values and competing sources of information, including anecdotes and personal experience.¹¹ Although not exhaustive, 12–16

TABLE 1

Barriers to Implementing Effective Public Health Policy

The Adoption and Discontinuation of Clinical Services by Local Health Departments

Objectives. We identified factors associated with local health department (LHD) adoption and discontinuation of clinical services.Methods. We used multivariate regression with 1997 and 2008 LHD survey and area resource data to examine factors associated with LHDs maintaining or offering more clinical services (adopter) versus offering fewer services (discontinuer) over time and with the number of clinical services discontinued among discontinuers.Results. Few LHDs (22.2%) were adopters. The LHDs were more likely to be adopters if operating in jurisdictions with local boards of health and not in health professional shortage areas, and if experiencing larger percentage increase in non-White population and Medicaid managed care penetration. Discontinuer LHDs eliminated more clinical services in jurisdictions that decreased core public health activities’ scope over time, increased community partners’ involvement in these activities, had larger increases in Medicaid managed care penetration, and had lower LHD expenditures per capita over time.Conclusions. Most LHDs are discontinuing clinical services over time. Those that cover a wide range of core public health functions are less likely to discontinue services when residents lack care access. Thus, the impact of discontinuation on population health may be mitigated.The role of local health departments (LHDs) in offering clinical services is hotly contested in public health practice. Some LHD leaders believe that offering clinical services is critical to their mission1 and public image.2 Others embrace the position of the Institute of Medicine (IOM) on the future of public health, which calls for LHDs to focus on core public health functions of assessment, assurance, and policy development and away from clinical services.3,4Most LHDs have decreased clinical service offerings over time (discontinued).1,3,5,6 Some have done so because their leaders believe that offering clinical services is inconsistent with the LHD’s mission,6,7 diverts resources from population-based services,3,8 or distracts from core public health functions.1,7 Leaders of LHDs may rely on non-LHD public health system partner organizations to provide clinical services for vulnerable populations rather than providing them directly.1 They may see the private sector as more appropriate than LHDs in delivering clinical care.1,6,9 For example, in some regions, Medicaid managed care organizations collaborate with LHDs to ensure clinical services.5,10,11However, some LHDs have maintained or increased their clinical service offerings over time (adopted) because their leaders view clinical services as part of their mission,1 derive satisfaction from patient contact,5 or believe that offering such services is part of the core public health function of ensuring access to care to their patients if care is not available elsewhere.2,3,8,12 They offer clinical services if no private sector alternatives exist,6,12 or if the LHD is uniquely qualified in dealing with specific vulnerable populations2,5 or for certain conditions (e.g., infectious disease control).1 These LHDs may offer clinical services if no other safety net providers are available or community need is high. For instance, 63.3% of LHD directors in 2000 believed that LHDs should offer clinical services when no other organization was available to do so, compared with 23.6% of directors who believed that LHDs should offer clinical services unequivocally.7 Other LHDs may offer clinical services to generate revenue to fund other operations.1,13,14We posit that 3 main drivers underlie LHD decisions to offer clinical services. First, a conflicting goal driver suggests that LHD leaders may view offering clinical services as conflicting with core public health functions, particularly when they have few resources.1,7 Performance of these functions by LHDs varies with jurisdiction-level sociodemographic factors, and LHD organizational and public health system attributes.15–18 Second, an assurance driver suggests that LHDs offer clinical services if leaders believe that residents lack access to care, that the LHD has important expertise in providing clinical services to vulnerable patient populations, and that LHDs should provide these services when these services are limited. Third, an entrepreneurial driver suggests that LHDs leverage revenue-generating clinical services to fund needed public health services.5,13,19 The 3 drivers are not mutually exclusive. For instance, an LHD may stop offering comprehensive primary care because of the conflicting goal driver, and simultaneously start offering tuberculosis screening because of the assurance driver.The drivers provide a framework for understanding LHD decisions about the provision of clinical services, elucidating how LHDs change their clinical service offerings in response to strategic and environmental changes. We explored how the 3 drivers relate to 2 decisions: (1) whether an LHD departs from the majority and the IOM recommendations and maintains or offers more clinical services over time (an adoption decision) and (2) conditional on the LHD’s decision to discontinue services, how many fewer clinical services to offer over time (a degree of discontinuation decision). Institutional theory suggests that conformity pressures lead organizations to become more similar in behavior over time,20 but others resist such pressures for strategic reasons.21 Thus, we expected that LHDs adopting clinical services over time (adopters) would do so for different reasons than LHDs following the norm of discontinuing clinical services over time (discontinuers), and that leaders at discontinuer LHDs deciding how many clinical services to discontinue may do so for yet other reasons. Because we compared LHDs that followed the norm of decreasing the number of clinical service offerings1,3,5,6 with those that departed from the norm, we defined adoption to include offering the same number of clinical services over time. Our focus on the number of clinical services does not mean that the actual mix of clinical services offered stayed the same across time.2,5 number of community clinical service providers, and Medicaid reimbursement levels. Public health system attributes measure the LHD jurisdiction’s delivery on core public health functions across 3 dimensions: differentiation, integration, and concentration. Differentiation indicates the jurisdiction’s emphasis on public health needs, with high differentiation indicating that the jurisdiction offers many core programs or services. Integration indicates how different organizations interact in providing these services, with high integration indicating that many partnering organizations offer these services. Concentration measures the LHD’s role, with high LHD concentration indicating that the LHD bears primary responsibility for offering these services. Mays et al.22 described these 3 dimensions in further detail.

TABLE 1—

Conceptual Model Describing the Conflicting Goal, Assurance, and Entrepreneurial Drivers and the Factor Categories Associated With Adoption and Degree of Discontinuation of Clinical Services by Local Health Departments

Tobacco Companies�� Use of Developing Countries�� Economic Reliance on Tobacco to Lobby Against Global Tobacco Control: The Case of Malawi

Transnational tobacco manufacturing and tobacco leaf companies engage in numerous efforts to oppose global tobacco control. One of their strategies is to stress the economic importance of tobacco to the developing countries that grow it.We analyze tobacco industry documents and ethnographic data to show how tobacco companies used this argument in the case of Malawi, producing and disseminating reports promoting claims of losses of jobs and foreign earnings that would result from the impending passage of the Framework Convention on Tobacco Control (FCTC). In addition, they influenced the government of Malawi to introduce resolutions or make amendments to tobacco-related resolutions in meetings of United Nations organizations, succeeding in temporarily displacing health as the focus in tobacco control policymaking. However, these efforts did not substantially weaken the FCTC.Malawi began exporting tobacco in 1893,¹ and today it is the world''s most tobacco-dependent economy. Tobacco accounts for 70% of Malawi''s foreign earnings,^2,3 and 600 000 to 2 million members of the country''s total workforce of 5 million people are directly employed in the tobacco sector, which consists primarily of tobacco farming and factory processing jobs.⁴ US-based tobacco leaf–buying companies Universal Corporation and Alliance One International control tobacco prices and influence trade policies in Malawi, restricting competition, depressing tobacco prices for Malawi''s farmers, and contributing to the country''s poverty.⁵ Cigarette manufacturers and global leaf companies (merchant companies that buy tobacco leaf through prearranged contracts with manufacturers) fund child labor “corporate social responsibility” projects in Malawi to distract public attention from how they profit from low wages and cheap tobacco.⁶In addition, British American Tobacco (BAT), other cigarette manufacturers, and the International Tobacco Growers’ Association (ITGA), an organization created by tobacco companies in 1984 to weaken global tobacco control activities,^7–9 have used the governments of Malawi and other developing countries to lobby against global tobacco control efforts,^7,10 particularly the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC; 11 The FCTC is an international treaty designed to reduce the health damage of tobacco by committing signatories to enact laws that control the tobacco industry''s production and promotion of tobacco, increase taxes, and promote education about the dangers of tobacco use and secondhand smoke. The FCTC was passed in February 2005, and, as of April 2009, 164 countries (not including the United States) had ratified and were implementing the framework.

TABLE 1

Malawi, Global Tobacco Control, and the Framework Convention on Tobacco Control: Timeline

A Situated Practice of Ethics for Participatory Visual and Digital Methods in Public Health Research and Practice: A Focus on Digital Storytelling

This article explores ethical considerations related to participatory visual and digital methods for public health research and practice, through the lens of an approach known as “digital storytelling.” We begin by briefly describing the digital storytelling process and its applications to public health research and practice. Next, we explore 6 common challenges: fuzzy boundaries, recruitment and consent to participate, power of shaping, representation and harm, confidentiality, and release of materials. We discuss their complexities and offer some considerations for ethical practice. We hope this article serves as a catalyst for expanded dialogue about the need for high standards of integrity and a situated practice of ethics wherein researchers and practitioners reflexively consider ethical decision-making as part of the ongoing work of public health.Emergent digital methods are changing the field of public health and opening new possibilities for collaborative approaches. These methods encourage repositioning participants as coproducers of knowledge who partner “in the definition of problems, formulation of theories, and the application of solutions.”1^(p253) The simplification and affordability of technology has led to a rapid and diverse expansion of participatory video strategies.2–4In the early 1990s, the nonprofit Center for Digital Storytelling (CDS; http://www.storycenter.org) codified a process to create compelling 3-to-5-minute short films that synthesize still images, video, voice recordings, music or sound, and text.5 Digital stories privilege participant subjectivities: participants construct narratives, choose images and music or sound they feel best represents their experiences, and are guided through hands-on computer editing tutorials. The method is similar to Photovoice6,7 as both methods are visual and participants are central to the production of knowledge. However, as it is described in the literature the Photovoice approach codifies an explicit action component,8 whereas digital storytelling may not. However, we readily acknowledge exceptions as not all Photovoice projects contain action components,9 although many digital storytelling projects do.10Digital storytelling has multiple aims. Stories can be used to: empower participants through personal reflection, growth, and the development of new literacies11–13; educate and raise awareness among viewing audiences about issues presented in the stories14,15; inform public policy, advocacy, and movement building16; and provide visual, narrative, and multisensory data to support public health research and evaluation efforts.17,18Increasingly, digital storytelling is used in public health community-based participatory research and practice. Analysis of 250 digital stories produced with Northwest Alaska Native youths explores identity construction highlighting “sites of achievement” in young peoples’ lives.19 These findings can be used to inform the development of assets-based interventions that more closely align with local community values.20 Digital storytelling has also been used as a mechanism for youth empowerment in the context of diabetes prevention21 and as part of a participatory food security policy development effort.22 In another study,23,24 child participants showed increases in sustained asthma knowledge, as well as improvements in attitude scores after watching a composite digital story and writing their own. At the other end of the life spectrum, positive changes were observed with early stage dementia participants, including increased confidence, connection, sense of purpose, and improved speech.25Although digital storytelling has the potential to contribute to a participatory dimension of public health research and practice, these innovative approaches open up space for new ethical issues to emerge.26–28 Those adopting a principle-based approach,29 or an overly legalistic framework that focuses merely on risk mitigation, may not be adequately prepared to reflect on this new terrain. Drawing on the work of Clark et al., we advocate for an approach in which

ethical decisions are made on the basis of care, compassion and a desire to act in ways that benefit the individual or group who are the focus of the research…[where] ethical practice is appraised in the context of a particular case.26^(p82)

In this article, we follow the life course of several digital storytelling projects and highlight moments of ethical debate and tension. We begin by briefly describing the digital storytelling process, noting ways the approach has been applied in the context of public health research and practice. Next, we explore common situations, discuss the issues or complexities they create, and offer some considerations for ethical practice (summarized in ChallengesSituationIssuesConsiderations for Ethical Digital Storytelling PracticeFuzzy boundariesDST falls at the nexus of public health practice, research, and advocacy.Confusion between where priorities lie (research vs practice) can lead to very different implementation approaches.All partners should be in agreement about specific goals, objectives, policies, and procedures.Recruitment and consent to participateSponsors want to recruit diverse participants to share their stories.There is a fine balance between protecting individuals who are in the midst of trauma from further harm and patronizing potential participants through exclusion.Critically engage with potential participants about the realistic benefits and potential risks of participation. Provide cultural safety and supports (e.g., counselors or elders).Consent to participate is sometimes indirect: a story may feature people (voice, images, names) other than its author.Those featured in the digital story may be unaware of or upset about their inclusion.Optimally, oral or written consent is received from all of those featured in a story.Power of shapingStorytellers are encouraged to tell their own personal stories; however sometimes tensions arise between emphasizing processes versus products.Facilitators may help “shape” the narrative to produce stories that will resonate with audiences, inadvertently imposing their own agendas. Sharing power often means losing control over messaging.Reflexive attention to issues of power and a sense of cultural humility are key to excellent facilitation. Storyteller’s well-being and autonomy of voice should be at the center of a project.Representation and harmParticipants sometimes tell stories that make us uncomfortable or expose themselves to harm through the process.Digital stories can misrepresent communities or reify stereotypes. Exposing illegal or illicit activity might endanger storytellers or participants.Storytellers’ well-being should be at the center of a project. Supports should be in place. Guidelines should be established and implemented for risk management and harm reduction. Facilitators can engage in critical dialogue with storytellers or audiences to challenge messages.ConfidentialityConfidentiality may not always be possible or appropriate.Stories are sometimes so distinct that it is impossible to guarantee confidentiality. Often participants want to be credited by name for their contributions.Wherever possible, storytellers should be credited for their work by name (or chosen pseudonym) and maintain ownership over their stories.Release of materialsConsent to participate in a digital storytelling workshop is not the same thing as release of materials: giving permission for your story to be shared in a variety of manners.Release of materials needs to be negotiated on an ongoing basis. Some stories reveal very personal issues (e.g., HIV status, a history of violence) that can make participants vulnerable to stigma and discrimination. Storytellers might want to change their stories or to change their minds about dissemination over time.Workshops should include a session on the ethics of videography, which considers the power of images and the spoken voice. Where, why, how and by whom stories are released needs to be negotiated. Options range from publicly posting stories online, to sharing media files only for the purposes of education, research, and advocacy in closed workshop forums, to a decision not to share them at all. All options need to be discussed, and agreed upon on a case-by-case basis. Release of materials ought to be an iterative and ongoing process.Open in a separate windowNote. DST = digital storytelling.     

Self-Help Booklets for Preventing Postpartum Smoking Relapse: A Randomized Trial

Objectives. We tested a series of self-help booklets designed to prevent postpartum smoking relapse.Methods. We recruited 700 women in months 4 through 8 of pregnancy, who quit smoking for their pregnancy. We randomized the women to receive either (1) 10 Forever Free for Baby and Me (FFB) relapse prevention booklets, mailed until 8 months postpartum, or (2) 2 existing smoking cessation materials, as a usual care control (UCC). Assessments were completed at baseline and at 1, 8, and 12 months postpartum.Results. We received baseline questionnaires from 504 women meeting inclusion criteria. We found a main effect for treatment at 8 months, with FFB yielding higher abstinence rates (69.6%) than UCC (58.5%). Treatment effect was moderated by annual household income and age. Among lower income women (< $30 000), treatment effects were found at 8 and 12 months postpartum, with respective abstinence rates of 72.2% and 72.1% for FFB and 53.6% and 50.5% for UCC. No effects were found for higher income women.Conclusions. Self-help booklets appeared to be efficacious and offered a low-cost modality for providing relapse-prevention assistance to low-income pregnant and postpartum women.Tobacco smoking is the leading preventable cause of premature morbidity and mortality, and smoking cessation is associated with immediate and long-term improvement in quality of life and a wide range of health outcomes.1 Pregnant women represent a unique subgroup for whom continued smoking is associated with multiple immediate adverse outcomes, including increased risk of ectopic pregnancy, spontaneous abortion, preterm delivery, low birth weight, and perinatal mortality.2 Pregnant women who smoke exhibit a relatively high rate of spontaneous smoking cessation. Today, nearly 50% of female smokers report quitting during pregnancy,3 and the prevalence of smoking during pregnancy dropped from 18.4% in 1990 to 10.4% by 2007.4,5 Moreover, interventions designed to promote smoking cessation during pregnancy have demonstrated efficacy.6Unfortunately, smoking relapse rates following childbirth remain very high. Estimates range from 50% to 80% over the first year,7–9 and have shown little decline in recent years.3 Postpartum relapse is detrimental not only to the mother, but to the infant (and any other member of the household) who is exposed to secondhand smoke. Secondhand smoke is associated with a variety of health problems in children, including decreased lung growth, increased rates of respiratory tract infections, otitis media, childhood asthma, sudden infant death syndrome, behavioral problems, neurocognitive decrements, and increased rates of adolescent smoking.10 It has been estimated that secondhand smoke is responsible for nearly 6000 deaths annually among children younger than 5 years.11Numerous interventions have attempted to reduce postpartum smoking relapse, ranging from brief interventions during maternity hospitalization to intensive face-to-face counseling. However, recent meta-analyses concluded that postpartum relapse prevention has been ineffective.12,13 Thus, development and validation of effective interventions for preventing smoking relapse among pregnant and postpartum women remains a public health priority.The general problem of smoking relapse led to the development of relapse-prevention interventions designed to facilitate long-term tobacco abstinence and circumvent the progression from an initial slip or lapse to a complete return to regular smoking. These interventions have largely taken the form of cognitive-behavioral therapies delivered in conjunction with initial smoking cessation counseling.14 However, less than 10% of smokers attempting to quit enroll in counseling programs, with the majority attempting cessation with minimal assistance.15 This observation led to the development of a minimal “self-help” relapse-prevention intervention designed to communicate key elements of cognitive-behavioral counseling in a format and engaging modality that is more amenable to dissemination and implementation—a series of 8 booklets delivered by mail.These relapse-prevention booklets, currently titled Forever Free, include didactic information about the nature of tobacco dependence, instruction in the use of cognitive and behavioral coping skills to deal with urges to smoke, awareness of and preparation for high-risk “triggers” to smoke, strategies for managing an initial slip or lapse, and specific information and advice about weight control, stress, and health benefits associated with quitting smoking. The booklets were tested in 2 randomized controlled trials, with findings that they significantly reduced smoking relapse among recent quitters through at least 2 years after booklet delivery.16,17 Moreover, the intervention was highly cost-effective, with estimates as low as $83 per quality-adjusted life-year saved.17,18 A recent meta-analysis concluded that written self-help materials were the only type of relapse-prevention intervention for unaided quitters with established efficacy.12 Another meta-analysis concluded that self-help was more effective than standard care at producing initial smoking cessation among pregnant women,19 but self-help had not yet been tested for preventing postpartum relapse.Smoking has increasingly become a behavior of lower socioeconomic groups, with the highest prevalence found among those with the least education and income. For example, in 2009, the smoking prevalence among those below the poverty line was 31.1% compared with 19.4% for those above the poverty line.20 Additionally, lower income and financial strain are associated with poorer success rates among those attempting to quit smoking.21,22 Aside from the emotional burdens of financial stress, low-income smokers may be hampered in their quitting attempts because of the practical limitations (e.g., cost and transportation) of finding and attending smoking cessation programs or obtaining cessation medications, as well as by the multiple barriers that impede clinicians from providing smoking cessation services to disadvantaged populations.23 In short, having less money and fewer resources places a significant burden on the smoker who wants to quit.The association between income and smoking behavior extends to pregnant and postpartum women. For example, women with annual incomes less than $15 000 were found to be half as likely to quit smoking during their pregnancy (33% vs 67%), and among those who did quit, low-income women were nearly twice as likely to relapse within 4 months of delivery (63% vs 38%) compared with those with incomes of more than $15 000.3 Therefore, a low-cost, easily disseminated intervention, such as self-help booklets, might be particularly feasible for overcoming income-related barriers in this population.The primary aim of the present study was to test, via a randomized controlled trial, a self-help intervention for preventing smoking relapse among a vulnerable population of smokers at uniquely high risk of relapse—pregnant and postpartum women. We modified the Forever Free series of self-help relapse-prevention booklets for use with pregnant women based on previous research and a systematic formative evaluation.24 We tested the hypothesis that women who received the series of Forever Free for Baby and Me booklets (FFB) would demonstrate less relapse through the course of the intervention (8 months postpartum) and beyond (12 months postpartum), compared with women who received high-quality existing materials that were less comprehensive.In addition, we examined whether intervention efficacy was moderated by the key demographic, smoking, and pregnancy variables listed in Demographic Variables^aForever Free Booklets (n = 245), %, Median, or Mean (SD)Usual Care (n = 259), %, Median, or Mean (SD)Race/ethnicity, White93.990.7 Black3.75.0 Other2.44.2 Hispanic5.85.7Education < HS diploma9.48.9 HS diploma or GED36.334.0 College or technical school54.357.1Living with husband or boyfriend82.978.5Employed41.241.7Household income, $30 000–40 000 30 000–40 000Age, y26.2 (5.7)25.4 (5.4)Pregnancy No. of pregnancies2.2 (1.3)2.2 (1.6) Had previous miscarriage(s)27.325.1 Quit smoking before end of 1st trimester85.288.8Smoking Years of smoking8.7 (4.8)8.5 (4.8) Cigarettes/d15.0 (6.3)15.4 (6.9) Precessation FTND score3.6 (2.3)3.8 (2.2) Plan to quit for good64.568.7 Other smoker(s) in house53.154.1Open in a separate windowNote. FTND = Fagerström Test for Nicotine Dependence; GED = general equivalency diploma; HS = high school.^aThere were no significant group differences.     

Digital Junk: Food and Beverage Marketing on Facebook

Objectives. We assessed the amount, reach, and nature of energy-dense, nutrient-poor (EDNP) food and beverage marketing on Facebook.Methods. We conducted a content analysis of the marketing techniques used by the 27 most popular food and beverage brand Facebook pages in Australia. We coded content across 19 marketing categories; data were collected from the day each page launched (mean = 3.65 years of activity per page).Results. We analyzed 13 international pages and 14 Australian-based brand pages; 4 brands (Subway, Coca-Cola, Slurpee, Maltesers) had both national and international pages. Pages widely used marketing features unique to social media that increase consumer interaction and engagement. Common techniques were competitions based on user-generated content, interactive games, and apps. Four pages included apps that allowed followers to place an order directly through Facebook. Adolescent and young adult Facebook users appeared most receptive to engaging with this content.Conclusions. By using the interactive and social aspects of Facebook to market products, EDNP food brands capitalize on users’ social networks and magnify the reach and personal relevance of their marketing messages.Obesity is a common, serious, and costly health issue.1 In the United States alone, the medical costs of obesity are estimated to be $147 billion.2 Although the prevalence of overweight and obesity among children and adolescents in countries such as the United States and Australia appears to have plateaued in recent years, rates remain high.3 Obesity rates generally increase with age among adults4; however, of urgent concern is the growing prevalence of overweight and obesity among young Australian adults, particularly women. Research has suggested that later generations have higher rates of excess body weight than generations before them. Current obesity-promoting environments likely mean people are now put at greater risk for weight gain in young adulthood.4One of the powerful environmental factors influencing the rise in obesity is the ubiquitous presence of food and beverage marketing.5–8 Research into the nature and extent of this marketing has primarily focused on television advertising.9,10 Although there is emerging research on how energy-dense, nutrient-poor (EDNP) food and beverages are being marketed in digital media,11–15 little of this research has closely examined online social media channels.14 Additionally, most of this research on digital media food marketing has focused on Web sites targeted at children and has not captured what types of food marketing adolescents and young adults are most likely to view. Given the exponential growth in popularity of social media Web sites such as Facebook, particularly among adolescents and young adults, there is a need to understand the techniques and reach of EDNP food and beverage marketing on these Web sites. Equally, although case studies of specific campaigns and food companies help to highlight the importance of social media in the marketing mix,16 a more complete picture of overall EDNP marketing strategies used through social media is needed to understand the extent of marketing across this media.Facebook is the most popular social networking site in the world. As of September 30, 2013, 1.19 billion users accessed the site at least monthly and 727 million users accessed the site daily.17 Approximately 80% of the daily active users are outside the United States and Canada. Australians are enthusiastic Facebook users, with 9 million people, or nearly 40% of the entire population, visiting the site every day.18 Social media use has reached near saturation among young Australians, with more than 85% of those aged 15 to 24 years accessing the Internet for social networking or online gaming.19The bulk of Facebook content is individual users’ personal profiles, but since November 2007, the site has embraced companies and brands developing their own pages.20 Facebook brand pages function in a similar fashion to personal pages, with the exception that to receive brand page updates and content in their news feed, users must “like” a brand page, as opposed to initiating a friend request as they would from individual users. Brands can post images, videos, links, contests, offers, applications, polls, quizzes, and a range of other digital and interactive media to their page timelines. Users who like brand pages can engage with the page by sharing their own content, commenting on page posts, and sharing page content with their own networks.21 Crucially, any activity that users engage with on brand pages may then appear in the news feed of the users’ friends, effortlessly spreading marketing messages across social networks. Facebook uses the EdgeRank algorithm to decide what content will appear in the news feed.22 Generally speaking, those brands with more engaging content have greater success in appearing higher up and more often in news feeds. Readers who are unfamiliar with the layout and function of Facebook pages should refer to online user guides23 and previously published work.24 Definitions of the Facebook terms used in this article are included in Facebook TermsDefinitionTalking aboutThe number of unique users who have created a story about a page in a 7-day period. On Facebook, stories are items that display in a news feed. Users create stories when they like a page, post on a page wall, like a post, comment on a post, share a post, answer a question, RSVP to a page’s event, mention the page in a post, tag the page in a photo, check in at a place, share a check-in deal, like a check-in deal, write a recommendation, or claim an offer. This figure is updated daily. (http://www.insidefacebook.com/2012/01/10/people-talking-about-this-defined/)Most popular age groupData publicly available through the Facebook page; a measure of which age group the page is most popular amongTimelineA sequential (by date) summary of all the activity posted on the Facebook page. It is possible to scroll back through the timeline until the date on which the page was launched.News feedA summary of the activity of the user’s Facebook network that appears when a user logs into the siteMarketing category (n = 19) Competitions, prizes, giveawaysAny contest involving a participant entry, including minimal requirements such as simply liking a post; giveaways also include free product samples and other items with purchase. Special price promotionsLimited-time offers, discount menus, 2 for 1 deals, or other reduced-price advertisements Vouchers, offers, rebatesIncludes those that consumers print off or for which they enter an electronic code; offers are specific to Facebook and made exclusively available to those who like the page. CelebritiesPeople with an entertainment or media profile, excluding athletes. Children’s charactersThird-party cartoons and characters, including characters from films, books, television programs, and the Internet SportspeopleAny person (adult or child) profiled for their athletic or sporting achievements Branded charactersAny characters featured on the page developed by the brand Branding elementsAny logos, colors, trademarks, or slogans GamesInteractive and entertaining applications that feature the brand PhotosDigital images of the product, users, and promotional events Quizzes and pollsCan be embedded directly into the Facebook timeline; they are a feature available to all brand pages as a way of encouraging participation and interaction. VideosCan either be posted directly to Facebook or linked through YouTube EventsSpecific Facebook category in which page owners can create events and invite page members AppsBoth links to any smartphone apps and any apps embedded in the Facebook page. Facebook allows page administrators to develop a variety of application tabs on their pages, including retail store location finders, other social media channel feeds, ordering platforms, feedback, and promotional offers. ConversationsThe page administrator responds to page member posts and comments and shares member content with other members. LinksAny page posts that include a link to an external page or additional content not found within the Facebook page User-generated contentDigital media (such as photos, videos, songs) created by users and either shared on the page timeline or tagged with the brand page by Facebook users Sponsorships and partnershipsAny events that the brand supports or other brands or services the brand partners with, excluding charitable organizations Corporate social responsibility and philanthropyPromotion of any ethical or sustainable initiative or charitable work undertaken by the brandOpen in a separate windowGiven that marketing influences food preferences, choice, and consumption,7 understanding how food is being promoted on social media is essential. The primary aim of this study was to assess the amount, reach, and nature of EDNP food marketing to Australians through Facebook. To begin to build a complete picture of the food and beverage marketing techniques being used on Facebook, we need to know the food and beverage brands that are most active on Facebook, how these brands promote their products in terms of the advertising techniques that are used, who is engaging with these brands, and how they engage. We also discuss the potential policy and practice implications of our findings.     

Mobilizing a Medical Home to Improve HIV Care for the Homeless in Washington, DC

African Americans face a higher burden of HIV infection, morbidity, and mortality than other ethnic groups in the United States. As an organization that exists to serve the homeless and impoverished of Washington, DC, So Others Might Eat (SOME) works diligently to address this disparity. SOME''s clients are primarily African Americans who often face obstacles to HIV care because of low socioeconomic status, mistrust of the medical establishment, and fear of being identified as HIV positive. We relate the lessons we learned at SOME''s medical clinic while trying to better address the needs of our clients living with HIV/AIDS. Chief among those lessons was the need to shift from considering our patients “noncompliant” with their HIV-related care to recognizing they had needs we were not addressing.AFRICAN AMERICANS ARE disproportionately affected at all stages of HIV infection. Though comprising only 13% of the population, non-Hispanic Blacks account for 50% of AIDS cases in the United States.¹ About 41% of US men and 64% of US women living with HIV/AIDS are African American.¹ African Americans are more likely to die from HIV/AIDS and less likely to have access to highly active antiretroviral therapy than are infected persons of other ethnic groups.^2,3Research indicates that people infected with HIV/AIDS without accumulated financial assets have an 89% greater risk of death than do their counterparts, and those with less than a high school education have a 53% greater risk of death than do those with more education.⁴ Many of these grim predictors of HIV/AIDS survival are present in clients served by So Others Might Eat (SOME), a community-based organization that serves the homeless and impoverished of Washington, DC. SOME works to address the public health emergency that exists for poor HIV-infected African Americans. The organization faces considerable barriers despite the Healthy People 2010 call to address the disproportionate impact of HIV/AIDS among African American and Hispanic populations, because reductions in Medicare and Medicaid reimbursements for medical care and more strict Medicaid eligibility criteria make it difficult to expand care to the most needy.⁵

FACTS ABOUT SOME MEDICAL CLINIC

Using Social Network Analysis to Clarify the Role of Obesity in Selection of Adolescent Friends

Objectives. We used social network analysis to examine how weight status affects friend selection, with an emphasis on homophily and the social marginalization of overweight youths.Methods. We used an exponential random graph model to assess the effects of body mass index (BMI) on friend selection while controlling for several alternative selection processes. Data were derived from 58 987 students in 88 US middle and high schools who took part in the 1994 to 1996 National Longitudinal Study of Adolescent Health.Results. On average, overweight youths were less likely than nonoverweight youths to be selected as a friend; however, this effect differed according to the BMI of the person initiating the friendship. Nonoverweight youths were 30% more likely to select a nonoverweight friend than an overweight friend, whereas overweight youths were largely indifferent to the weight status of their friends. Friendship ties from overweight youths to nonoverweight peers were more likely than ties in the reverse direction.Conclusions. We found evidence consistent with homophily and social marginalization but only for the selection behavior of nonoverweight youths. We conclude that avoidance of overweight friends is the primary determinant of friendship patterns related to BMI.Social network analysis offers a tool to understand the complex social and biological relationships that contribute to health.1–3 A tenet of the social network paradigm is that individual behaviors are interdependent owing to processes such as normative influences, social learning, and contagion.4–6 At the same time, network structure is not independent of behavior. Networks are dynamic, complex systems in which ties (e.g., friendships) are constantly evolving in conjunction with individual behaviors.Network selection processes are in part driven by individuals’ health,7 often including the very health behaviors that researchers treat as outcomes.8–10 However, several other processes also contribute to network structures. Friendships are more likely when individuals share commonalities with respect to sociodemographic attributes (i.e., homophily11), organizational affiliations,12 spatial proximity,13 and social connections (i.e., transitivity14). Also, individuals systematically vary in their sociability and popularity.15 Fully understanding health behavior thus requires an examination of network structures and the processes that create them.Several explanations have been invoked to understand the complex role of obesity in structuring friendships among young people. Two explanations in particular have received concerted attention. First, overweight adolescents are socially marginalized and less likely to be selected as a friend than their nonoverweight peers.9,16–18 This is troubling given that friendships are important sources of support and companionship throughout the life span.19 Not having or losing friends is associated with increased depression and decreased self-worth among young people, which could exacerbate the health problems associated with being overweight.20 These negative repercussions of friendlessness may be more pronounced in middle school and high school, when intimacy and fitting into peer groups are critical.20,21Second, adolescents tend to develop friendships with peers who have a similar body mass index (BMI).8,16,22,23 Friendships that are homophilous with respect to weight create the possibility for peer influence on behaviors and beliefs associated with weight. Friendships among overweight adolescents may reinforce unhealthy behaviors that further exacerbate weight problems.24Investigations of social marginalization and homophily have often been pursued independently, which we argue is a mistake. These patterns represent different perspectives on the more general question of how weight shapes friendship patterns. By adopting a network perspective, we recognize that the friend selection process depends on both the person initiating friendship (ego) and the friendship target (alter). Friendship likelihood can differ depending on the combination of ego and alter weight status. Assuming, for the sake of simplicity, that weight status is dichotomous, there are 4 types of friend selection dyads: overweight ego selecting overweight alter, nonoverweight ego selecting nonoverweight alter, overweight ego selecting nonoverweight alter, and nonoverweight ego selecting overweight alter.Examining marginalization requires that researchers compare friendship ties directed toward overweight versus nonoverweight alters, which disregards the ego’s weight status. By contrast, focusing solely on homophily entails comparing friendship dyads that are similar versus dissimilar, without considering whether the adolescents are overweight or nonoverweight. Examining either mechanism in isolation risks misidentifying the process underlying friend selection behaviors.A network approach demonstrates the interrelation between marginalization and homophily. Although the mechanism behind each pattern differs (e.g., avoidance of as opposed to preference for similarity), both predict that nonoverweight adolescents are more likely to befriend nonoverweight peers than overweight peers (Avoidance

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Homophily

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Alter non-OVAlter OVAlter non-OVAlter OVEgo non-OVHighLowEgo non-OVHighLowEgo OVHighLowEgo OVLowHighOpen in a separate windowNote. OV = overweight. Ego refers to the person initiating the friendship; alter is the recipient.The network approach also makes clear that friend selection is multifaceted. Associations between friendship and weight status could develop indirectly through friend selection processes other than homophily or marginalization.25 The first of these processes is social withdrawal of overweight adolescents. Overweight adolescents may be less sociable than nonoverweight adolescents, possibly because of perceived stigma26 or lower rates of involvement in school-based activities that promote friendship.21 Second, selection may occur on attributes correlated with weight, such as depression. Overweight adolescents may be excluded because of aversive behaviors that accompany their weight status, not because of weight itself.Third, the endogenous nature of network evolution means that the current network structure promotes some ties over others in the future. For instance, triad closure occurs when 2 individuals become friends because they have a mutual acquaintance. Consider person A, whose nonoverweight friend B has no overweight friends. Should person A form a friendship with any of person B’s friends through triad closure, those friendships will not include overweight peers. Thus, small tendencies toward homophily can become magnified over time.27 Failure to control for alternative friend selection processes can result in biased parameter estimates.15,28,29 Because of the equifinality of network structure, each of these processes could produce social marginalization or homophily as a spurious outcome.Our goal in this study was to offer a more detailed account of how weight status predicts friendship patterns, with an eye on homophily and the social marginalization of overweight youths. We addressed this goal by modeling friendship network data collected in several middle and high schools. Our models estimated effects related to BMI while controlling for alternative friend selection mechanisms.     

Self-Management: A Comprehensive Approach to Management of Chronic Conditions

For both clinical and economic reasons, the increasing number of persons living with chronic conditions represents a public health issue of growing importance. Emphasizing patient responsibility, and acting in concert with the provider community, self-management represents a promising strategy for treating chronic conditions—moving beyond education to teaching individuals to actively identify challenges and solve problems associated with their illness. Self-management also shows potential as an effective paradigm across the prevention spectrum (primary, secondary, and tertiary) by establishing a pattern for health early in life and providing strategies for mitigating illness and managing it in later life. We suggest ways to advance research methods and practical applications of self-management as steps in its future development and implementation.Improvements in health care have resulted in greater numbers of people living with multiple chronic conditions for longer periods of time. With this change, chronic illness is now a major focus of health care.1 At the same time, increased attention has been concentrated on approaches to manage chronic symptoms to maintain patient independence and quality of life over longer periods of time. Approaches to managing chronic illness are shifting from the traditional provider–patient relationship to a paradigm in which individuals with chronic conditions play a key role in guiding their care, in partnership with health care providers.2,3Many prevalent chronic conditions, such as heart disease, diabetes, and arthritis, though unique in their own attributes and demands, share common challenges associated with their management. These include dealing with symptoms and disability; monitoring physical indicators; managing complex medication regimens; maintaining proper levels of nutrition, diet, and exercise; adjusting to the psychological and social demands, including difficult lifestyle adjustments; and engaging in effective interactions with health care providers.4,5The identification and elaboration of common patient-centric strategies to deal with these challenges is the focus of the field of self-management.6,7 Regardless of the chronic condition, the development of a generic set of skills has proven successful in allowing individuals to effectively manage their illness and improve health outcomes.8 A 2010 report by the Department of Health and Human Services included self-management as one of 4 goals in a strategic framework for improving the health status of individuals with multiple chronic conditions.9 More recently, the 2012 Institute of Medicine report “Living Well With Chronic Illness: A Call for Public Health Action” included self-management10 as one of several models of living well interventions, noting that self-management programs instill individual responsibility and offer tools for patients to use in caring for their chronic illness.10There is increasing recognition that chronic illness, including its prevention, treatment and management, represents a public health as well as a clinical issue.11,12 Indeed, the Institute of Medicine report noted that a population health perspective for developing strategies, interventions, and policies to combat chronic illness is critical.10 Community-based self-management intervention programs are one aspect of a population-based approach addressing the larger public health problem of chronic conditions in the United States and across the globe. There is an extensive body of literature related to self-management of chronic conditions, but our intent with this article is not to provide a comprehensive review, but rather to highlight the unique contribution of nurse scientists to the field.Nursing science has enhanced the care of individual patients and has tested interventions that can be scaled up for implementation at the population level. We present examples of nursing science that demonstrate effectiveness, promise sustainability and scalability, and set the foundation for implementing wide-reaching public health actions for managing chronic illness.12There is increased awareness of the need to promote conceptual clarity regarding self-management and its integration into clinical practice. Equally important is the requirement to develop more sophisticated models of self-management, tailored to various health conditions and situations. Fundamental to the development of such models and their practical application is the need to conduct research that informs self-management practice and contributes to health policy.The nursing community, comprising both researchers and clinicians, plays a crucial role in efforts to provide the evidence base for innovative self-management practices, and is ideally positioned to implement those advances in a practical manner. Over the course of its history, the National Institute of Nursing Research (NINR) at the National Institutes of Health (NIH) has promoted self-management science as one of its core areas of investigation, supporting research to improve and manage symptoms of acute and chronic illness.13 Recognizing that self-management represents a topic of ever-increasing importance, a goal of NINR is to advance the science of self-management and, ultimately, disseminate results widely for translation into clinical practice.Recently, a group of nurse scientist leaders assembled to discuss “The Science of Chronic Illness Self-Management” as the topic of the 2013 National Nursing Research Roundtable. The Roundtable is an annual meeting with the purpose of providing a regular forum of communication about the direction and conduct of nursing research. Discussions from this year’s meeting resulted in a set of recommended areas of focus and approaches to advance the field and practice of self-management (see the box on this page).

Recommended Areas of Focus and Approaches to Advancing Self-Management

Smokers With Behavioral Health Comorbidity Should Be Designated a Tobacco Use Disparity Group

Smokers with co-occurring mental illness or substance use disorders are not designated a disparity group or priority population by most national public health and tobacco control groups.These smokers fulfill the criteria commonly used to identify groups that merit special attention: targeted marketing by the tobacco industry, high smoking prevalence rates, heavy economic and health burdens from tobacco, limited access to treatment, and longer durations of smoking with less cessation. A national effort to increase surveillance, research, and treatment is needed.Designating smokers with behavioral health comorbidity a priority group will bring much-needed attention and resources. The disparity in smoking rates among persons with behavioral health issues relative to the general population will worsen over time if their needs remain unaddressed.ELIMINATING DISPARITIES IN health and health care is a major priority in the United States.1,2 Groups with health disparities are referred to as vulnerable or priority populations and can be defined by factors such as race/ethnicity, socioeconomic status, geography, gender, age, disability status, or sexual orientation.3 The sources of these disparities are complex, rooted in historic and social inequities.4 Cigarette smoking, the leading cause of preventable death, is listed as one of 21 conditions with ongoing health disparities that must be addressed.1 Indeed, as the American Legacy Foundation points out, tobacco is not an equal opportunity killer.5 The criteria organizations such as the Centers for Disease Control and Prevention use to designate a tobacco disparity group are that they experience disproportionate tobacco consumption, disproportionate consequences or health burden from tobacco use, disproportionate economic burden from tobacco use, or limited access to tobacco-related health care.1,6,7 These groups may also be targeted by the tobacco industry with special marketing.6 Increased tobacco consumption may stem from differences in risk for tobacco use initiation or progression, differences in tobacco use prevalence and rates of nicotine dependence, and differences in smoking cessation rates.Smokers with a co-occurring mental illness or substance use disorder (SUD) have historically been underserved.8–13 Persons with behavioral health conditions, a collective term whose use is increasing because it may reduce stigma, compose a significant subset of smokers in the United States. A recent study found that cigarette smoking prevalence was 37.8% among people with any anxiety disorder, 45.1% among those with any affective disorder, 63.6% among those with a substance use disorder, and only 21.3% among those with no mental disorder.14 Smoking rates have plateaued despite ongoing tobacco control efforts, and clinical data support the concern that public health techniques that have been largely successful in the past may have reduced impact with remaining smokers.15,16 Although population-level data are less consistent on this point, data from both the National Health Interview Survey17 and the National Survey of Drug Use and Health18 suggest that smokers with moderate to high levels of general psychological distress are less likely than those with lower levels to have quit smoking. These data raise the possibility that behavioral health comorbidity may contribute to existing concerns about the impact of current tobacco approaches on today’s smokers.Surprisingly, most tobacco control Web sites and organizations, such as the Centers for Disease Control and Prevention’s Office on Smoking and Health,19 Healthy People 2020,2 and the American Legacy Foundation,20 do not designate smokers with behavioral health comorbidity as a disparity group or priority population. Understanding and eliminating disparities are such high priorities that these larger organizations have sponsored dedicated spin-off groups, such the National Networks for Tobacco Control and Prevention (sponsored by the Centers for Disease Control and Prevention)21 and the Tobacco Research Network on Disparities (TReND; cosponsored by the National Cancer Institute and American Legacy Foundation).22 These groups have paid only cursory attention to smokers with behavioral health comorbidity.23 For example, these smokers are included on the TReND Web site with a long list of “other historically underserved groups” that includes lesbian, gay, bisexual, and transgender persons; people with disabilities; and the military. (Major tobacco control groups in the United States and their identified disparity populations are listed in Organization/ReportSourceRacial/Ethnic Minorities^aPersons With Low SES^bPregnant WomenLGBT PersonsGenderYouthsOlder AdultsMilitary PersonnelPersons With Mental Health and Substance Use DisordersCDC Office on Smoking and Healthhttp://www.cdc.gov/tobacco/basic_information/health_disparities/index.htmXXXXXXNational Networks for Tobacco Control and Prevention^chttp://www.tobaccopreventionnetworks.org/site/c.ksJPKXPFJpH/b.2588535/k.6D55/Eliminating_Disparities.htmXXXXSurgeon general’s reports (2000, 2001, 2004, and 2012)http://www.surgeongeneral.gov/library/index.htmlXXXHealthy People 2020http://healthypeople.gov/2020/LHI/tobacco.aspxXXXXXAmerican Legacy Foundationhttp://www.legacyforhealth.org/2165.aspxXXXXTobacco Research Network on Disparities^dhttp://www.tobaccodisparities.orgXXXXXXXXAmerican Lung Associationhttp://www.lung.org/stop-smoking/about-smoking/facts-figures/specific-populations.htmlXXXXXXXXTobacco Cessation Leadership Networkhttp://www.tcln.org/cessation/priority-populations.htmlXXXSociety for Research on Nicotine and Tobacco Tobacco Related Health Disparities Networkhttp://www.srnt.org/about/networks.cfmXSmoking Cessation Leadership Centerhttp://smokingcessationleadership.ucsf.edu/BehavioralHealth.htmXOpen in a separate windowNote. CDC = Centers for Disease Control and Prevention; LGBT = lesbian, gay, bisexual, transgender; SES = socioeconomic status.^aAfrican American, American Indian, Alaska Native, Asian American, Pacific Islander, and Hispanic.^bIndicated by poverty, low education level, unemployment.^cSponsored by CDC.^dCosponsored by the National Cancer Institute and American Legacy Foundation.     

Lessons Learned From Evaluations of California's Statewide School Nutrition Standards

Objectives. We assessed the impact of legislation that established nutrition standards for foods and beverages that compete with reimbursable school meals in California.Methods. We used documentation of available foods and beverages, sales accounts, and surveys of and interviews with students and food service workers to conduct 3 studies measuring pre- and postlegislation food and beverage availability, sales, and student consumption at 99 schools.Results. Availability of nutrition standard–compliant foods and beverages increased. Availability of noncompliant items decreased, with the biggest reductions in sodas and other sweetened beverages, regular chips, and candy. At-school consumption of some noncompliant foods dropped; at-home consumption of selected noncompliant foods did not increase. Food and beverage sales decreased at most venues, and food service à la carte revenue losses were usually offset by increased meal program participation. Increased food service expenditures outpaced revenue increases.Conclusions. Regulation of competitive foods improved school food environments and student nutritional intake. Improvements were modest, partly because many compliant items are fat- and sugar-modified products of low nutritional value. Additional policies and actions are needed to achieve more substantive improvements in school nutrition environments and student nutrition and health.The current obesity epidemic in the United States has been associated with environmental factors such as the proliferation of unhealthy foods in schools and neighborhoods, as well as promotion of unhealthy foods in media environments.^1–4 An effective way to support children in being active and eating healthfully is to change institutional practices within schools by improving physical education and the nutritional value and quality of foods served.^5,6Schools participating in the federally reimbursed National School Lunch Program and School Breakfast Program serve meals that must meet federal nutrition guidelines. However, foods that are not part of the meal programs are only subject to minimal federal regulation, and these “competitive” foods have become increasingly widespread in schools over the last 40 years.⁷ Sold throughout schools in vending machines, school stores, snack bars, and at fundraisers, competitive foods and beverages are of lower nutritional quality and are typically high in added sugars, salt, and fat. Common examples of competitive foods include soft drinks and other sweetened beverages, potato chips, candy, cookies, and pastries.^8–11In an effort to combat childhood obesity, state and local policymakers have recently begun to regulate competitive school food offerings by enacting stricter school nutrition standards.¹² These efforts were reinforced by provisions in the Child Nutrition and WIC Reauthorization Act of 2004, which required school districts receiving federal meal program funding to enact wellness policies—including guidelines for all foods and beverages served—by the 2006–2007 school year.¹³The wellness policies of 92 out of 100 large school districts polled by the School Nutrition Association in 2007 included nutrition standards limiting times or offerings of competitive foods and beverages in school à la carte services, stores, and vending machines.¹⁴ Although the effects of state and local regulations of competitive foods are only beginning to be evaluated,¹⁵ emerging evidence suggests that school policies that decrease access to competitive foods of limited nutritional value are associated with less frequent student consumption of these foods during the school day.^16,17In California, Senate Bill 12 (SB 12), which applied nutrition standards to competitive foods sold in K–12 schools, took effect in July 2007. The law imposed the following limits on foods in secondary schools¹⁸:Individually sold snacks must contain no more than:

• 35% of calories from fat (with some exceptions, such as legumes, nuts, and eggs);
• 10% of calories from saturated fat (excluding eggs and cheese);
• 35% sugar by weight (excluding fruits and vegetables); and
• a total of 250 calories.

Individually sold entrées must contain no more than 36% of calories from fat and 400 calories per entrée.At elementary schools, the only competitive foods allowed are individually sold portions of nuts, nut butters, seeds, eggs, cheese packaged for individual sale, fruit, vegetables that have not been deep-fried, legumes, and dairy or whole-grain foods that meet the nutrient limits described previously and contain no more than 175 calories.A second law, SB 965, limited the competitive beverages that could be offered during the school day.¹⁸ The limits went into full effect in July 2007 for elementary and middle schools; at high schools, 50% of beverages had to comply by July 2007, and 100% of beverages had to comply by July 2009. The law limits competitive beverages to the following:

• fruit-based and vegetable-based drinks that are at least 50% fruit juice without added sweeteners;
• drinking water without added sweeteners;
• milk products and nondairy milks that have no more than 2% fat and 28 g of total sugars per 8 oz; and
• electrolyte replacement beverages with no caffeine and no more than 42 g of added sweetener per 20 oz (not allowed at elementary schools).

Three studies—the Healthy Eating, Active Communities study (HEAC), the High School Study (HSS), and the School Wellness Study (SWS), all conducted by the authors of this article, assessed different aspects of the implementation and impact of California''s school nutrition standards in diverse settings (Data Collection Dates

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Data Collection MethodologyPurposeStudies IncludedNo.PrelegislationPostlegislation^aOn-site observations: One-day site visits were made to each school. Information on all competitive foods and beverages available for sale was documented by trained staff who used standardized forms. We determined the nutrient profile of each item by using a validated nutrient composition database or information obtained from packaging, recipes, or manufacturer Web sites.To assess changes made to foods and beverages offered and to quantify change in degree of compliance with the nutrition standards.HEAC6 elementary schools, 6 middle schools, 6 high schools, 1 K-12 schoolSpring 2005Spring 2008HSS56 high schoolsSpring 2007Spring 2008SWS8 elementary schools, 8 middle schools, 8 high schoolsFall 2007Spring 2009Student survey: Paper questionnaires—proctored on-site by trained research staff—were completed by seventh- and ninth-grade students.To understand the impact on student dietary intake and food and beverage purchases.HEAC3527 students prelegislation; 3828 students postlegislationSpring 2006Spring 2008Food and beverage sales: Information was provided by school food service and school administration and entered onto standardized forms.To determine the financial impact of implementing the nutrition standards.HEAC6 elementary schools, 6 middle schools, 6 high schools2004–20052007–2008Food service survey: Interactive PDF questionnaire was sent electronically and was completed by school food service directors or supervisors (1 per school).To ascertain the perceived benefits of and challenges to implementation of the standards.HSS56 high schoolsSpring 2007Spring 2008School wellness team interviews: One on-site group interview with school wellness personnel was conducted by trained research staff at each school.To ascertain the perceived benefits of and challenges to implementation of the standards.SWS8 elementary schools, 8 middle schools, 8 high schoolsFall 2007Spring 2009Open in a separate window^aHEAC postlegislation data were collected at the midpoint of the project. HEAC endpoint data were collected in spring of 2010 and were not yet available for inclusion in this article at press time.

• To what extent did schools comply with nutrition standards?
• What changes did schools make in foods and beverages offered?
• What was the impact on student dietary intake?
• What was the impact on food and beverage sales?
• What were the benefits of and challenges to implementation?

     

The Enduring Effects of Smoking in Latin America

Objectives. We estimated smoking-attributable mortality, assessed the impact of past smoking on recent mortality, and computed expected future losses in life expectancy caused by past and current smoking behavior in Latin America and the Caribbean.Methods. We used a regression-based procedure to estimate smoking-attributable mortality and information for 6 countries (Argentina, Brazil, Chile, Cuba, Mexico, and Uruguay) for the years 1980 through 2009 contained in the Latin American Mortality Database (LAMBdA). These countries jointly comprise more than two thirds of the adult population in Latin America and the Caribbean and have the region’s highest rates of smoking prevalence.Results. During the last 10 years, the impact of smoking was equivalent to losses in male (aged ≥ 50 years) life expectancy of about 2 to 6 years. These effects are likely to increase, particularly for females, both in the study countries and in those that joined the epidemic at later dates.Conclusions. Unless innovations in the detection and treatment of chronic diseases are introduced soon, continued gains in adult survival in Latin America and the Caribbean region may slow down considerably.Continuous progress in the remarkable mortality decline in Latin America and the Caribbean region1 may be difficult to sustain. This possibility is foreshadowed in a recent report showing that cancers of the respiratory tract, particularly lung cancers, are among the 3 most important forms of cancer in the region and are primary causes of adult mortality.2 It is known that these chronic illnesses are closely connected to smoking, but less is known about the actual contribution of past smoking on current and future adult mortality in these countries. It could well be that, if pervasive enough, past (and future) smoking behavior trumps long-term trends in adult mortality.In response to the increasing vigilance and massive public health campaigns against tobacco consumption that began in the United States after the mid-1960s, the tobacco industry initiated an aggressive program to open new markets in Europe, Asia, and Latin America.3–5 A number of sociodemographic factors contributed to the higher numbers of potential smokers in Latin America and the Caribbean region beginning in the 1950s: the explosive growth in the populations of adolescents and young adults, who are at highest risk for smoking initiation; the spread of an urban lifestyle and the accelerated growth of cities; greater access to education; and the entry of women into the labor market.6,7 Increasing cigarette affordability,8–10 widespread legislative maneuvers,6,11–13 and a sophisticated publicity machine8,12–14 contributed to a massive market expansion for tobacco in all forms and cigarettes in particular. As a result, cigarette consumption increased first in countries in the vanguard of mortality decline (Argentina, Uruguay, Cuba, and Chile) and then in Mexico, Brazil, Colombia, Costa Rica, and Panama.3,15 Countries with higher mortality, such as, Peru, Ecuador, Bolivia, Paraguay, and Guatemala, still have low levels of smoking, but some of them (e.g., Bolivia) are catching up rapidly. The spread of smoking is known in public health circles as the “smoking epidemic”—a term we adopt here.16,17According to a useful typology,18 countries in Latin America and the Caribbean span a broad range of experiences in the smoking epidemic, from those in the late stages (Argentina, Chile, Cuba, and Uruguay) to those of more recent onset (Mexico and Brazil).19 24 Males in 4 countries—Argentina, Cuba, Chile, and Uruguay—have higher rates of smoking than do US males, whereas the rates are lower in Brazil and Mexico. As we will show, Cuba’s unique position at the top of the ranking of smoking prevalence translates into the highest estimated excess adult mortality. Female rates lag behind male rates everywhere, but they have reached levels of around 20% in Argentina and Chile. Age-specific smoking prevalence rates for the 6 countries in this study (data available as a supplement to the online version of this article at http://www.ajph.org) display a high degree of heterogeneity and reflect characteristics typical of different stages of the epidemic. These age patterns reveal telling anomalies: an exceptionally high prevalence among the population younger than 25 years in Chile, signs of a recrudescence of the smoking epidemic, and unexpectedly low levels of adolescent smoking in Brazil, an indication of successful antismoking campaigns.19,26

TABLE 1—

Characteristics of the Smoking Epidemic Among Adults Aged 20–80 Years: Argentina, Brazil, Chile, Cuba, Mexico, Uruguay, and United States; 2005–2009