Diet-Beverage Consumption and Caloric Intake Among US Adults,Overall and by Body Weight

Objectives. We examined national patterns in adult diet-beverage consumption and caloric intake by body-weight status.Methods. We analyzed 24-hour dietary recall with National Health and Nutrition Examination Survey 1999–2010 data (adults aged ≥ 20 years; n = 23 965).Results. Overall, 11% of healthy-weight, 19% of overweight, and 22% of obese adults drink diet beverages. Total caloric intake was higher among adults consuming sugar-sweetened beverages (SSBs) compared with diet beverages (2351 kcal/day vs 2203 kcal/day; P = .005). However, the difference was only significant for healthy-weight adults (2302 kcal/day vs 2095 kcal/day; P < .001). Among overweight and obese adults, calories from solid-food consumption were higher among adults consuming diet beverages compared with SSBs (overweight: 1965 kcal/day vs 1874 kcal/day; P = .03; obese: 2058 kcal/day vs 1897 kcal/day; P < .001). The net increase in daily solid-food consumption associated with diet-beverage consumption was 88 kilocalories for overweight and 194 kilocalories for obese adults.Conclusions. Overweight and obese adults drink more diet beverages than healthy-weight adults and consume significantly more solid-food calories and a comparable total calories than overweight and obese adults who drink SSBs. Heavier US adults who drink diet beverages will need to reduce solid-food calorie consumption to lose weight.The trends and patterns of sugar-sweetened beverage (SSB) consumption have been well described in the literature,1,2 but less is known about consumption of diet beverages (artificially sweetened no-calorie drinks) among US adults. Available evidence focuses on broad temporal trends or changes among demographic groups suggesting that consumption of diet beverages has increased dramatically from about 3% of adults in 19653 to about 20% of adults today,4 and that diet-beverage drinkers are typically characterized as young to middle-age adults (aged 20–59 years), female, non-Hispanic White, and higher income.4To our knowledge, no studies to date have focused on national patterns in diet-beverage consumption and caloric intake by body-weight status. Understanding diet-beverage consumption by body weight is important as consuming these zero- or no-calorie drinks is a common weight-management strategy. Switching from SSBs to diet drinks has indeed been shown to be associated with weight loss because of differences in caloric content between the drinks.5 However, the evidence base is far from conclusive. Some studies, mostly cross-sectional in design, have shown that diet-beverage drinkers tend to be overweight,5,6 that they typically do not consume fewer calories on the days they consume diet beverages,7 and that high consumers (households purchasing more than 20 12-packs of diet soda annually) generally purchase more snack foods at the grocery store and more overall calories than consumers purchasing SSBs.8 The evidence from long-term studies is similarly mixed; some show the reduction in caloric intake promotes weight loss or maintenance, others show no effect, and some show weight gain.9 Evidence also suggests that diet drinkers have the same caloric intake and body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) as SSB drinkers10,11 and that consumption of diet drinks can be associated with significant weight gain.12The primary purpose of this study was to describe patterns in diet-beverage consumption and caloric intake (total, beverage, and solid-food calories) among US adults overall and among body-weight categories. In addition, we examined variations in dietary habits (i.e., snacking and calories per meal occasion) among adults consuming diet beverages. This analysis does not attempt to estimate the impact of diet-beverage intake on obesity incidence because of our reliance on cross-sectional data.     

High Alcohol Concentration Products Associated With Poverty and State Alcohol Policies

Objectives. We examined the associations among zip code demographics, the state alcohol policy environment, and the retail outlet availability of multiple fruit-flavored alcoholic drinks in a can (MFAC).Methods. In a nationally representative sample of zip codes (n = 872), we merged data from 4 sources: publicly available marketing information from 2 major MFAC producers, the US Census Bureau, state alcohol regulatory agencies, and recent research on state alcohol policies. We used zero-inflated negative binomial regression models to examine MFAC outlet availability in the United States.Results. More than 98% of MFAC outlets were off-premises alcohol establishments. After we controlled for population size and the number of licensed on- and off-premises alcohol outlets within zip codes, more families below the poverty line and weaker state alcohol control policies were associated with greater MFAC outlet availability.Conclusions. Economic conditions and alcohol policy environment appeared to be related to MFAC outlet availability, after adjusting for the general availability of alcohol. Research is needed to determine whether MFACs are disproportionately contributing to alcohol-related harm in socially and economically disadvantaged communities. Policies to better regulate the off-premises sale of alcohol are needed.In 2003, the first premixed caffeinated alcohol product was introduced in the United States, and by 2010 at least 8 brands of caffeinated alcohol were being sold.1,2 Released in August 2008, Four Loko became the most popular of these ready-to-drink products among underage drinkers.3,4 Anecdotal news and scientific reports linked Four Loko consumption to a number of dangerous drinking episodes, and as a result, questions were raised about its safety.5–7In addition to gaining the attention of the attorney generals of several states,8 by 2010, an emerging body of research began to show that caffeine–alcohol co-ingestion could produce elevated intoxication levels and reduce perceptions of impairment, and that drinkers could engage in riskier behaviors compared with the consumption of alcohol alone.9–14 Based on this research, the Federal Trade Commission and the Food and Drug Administration concluded that the combined high alcohol and high caffeine content of these premixed products was likely causing consumer harm.1,15 In response to pressure from the government, producers of products such as Four Loko and Joose voluntarily ceased production of these caffeinated drinks in November 2010.3 However, shortly thereafter, these producers began distributing reformulated products that no longer contained caffeine, guarine, and taurine.3,16,17Although the presence of a significant amount of caffeine likely played a role in producing injury and death, other characteristics of these products also likely contributed to hazardous alcohol consumption.18 Namely, their exceptionally high alcohol content, low price, fruit flavoring, colorful packaging, and targeted marketing may be responsible for attracting underage and lower socioeconomic consumers, and may continue to contribute to high-risk drinking among these groups.18,19 The combination of these product features led to Four Loko, Joose, and other similar beverages being labeled as multiple fruit-flavored alcoholic drinks in a can (MFAC) or supersized alcopops. Although alcopops contain similar fruit flavoring, MFACs are packaged in large, single-serving cans rather than in multiunit packs, they have higher alcohol content, and they cost less per standard drink, distinguishing them from alcopops.18 MFAC products are typically high in alcohol concentration (12%) and combined with large-sized containers (23.5 fluid ounces) result in that a single container, which is typically consumed immediately as 1 drink, actually contains 5 standard drinks.18 Moreover, the typical price is only $2.50 to $3.00, representing one of the lowest costs per dose of alcohol.18,19 There is limited research on MFAC products. Drug Abuse Warning Network data20 indicated that, in 2010, when Four Loko was primarily sold as a caffeinated product, there were an estimated 1242 hospital emergency department visits in the United States by persons who had consumed Four Loko (95% confidence interval = 332, 2152).21 However, in 2011, the first year Four Loko was sold without caffeine, the estimated Four Loko–related emergency department visits increased by nearly 4.5 times, to a total of 5492 (95% confidence interval = 2925, 8059).21 This substantial increase in emergency department visits suggests that Four Loko continues to be a health threat, despite the removal of caffeine. However, Four Loko was the only MFAC brand reported by the Drug Abuse Warning Network. Furthermore, a national survey conducted in 2012 found that approximately 6% of underaged drinkers consumed a Four Loko in the past 30 days, whereas consumption of other MFACs (e.g., Blast, Sparks, and Tilt) was less common.4Even less is known about the marketing and retail availability of MFAC products. One important question is whether the potential harms associated with MFAC consumption are borne evenly by all segments of society. The targeted marketing of potentially harmful products to vulnerable populations (e.g., low-income minority communities and communities with high proportions of youths) raises ethical concerns about social justice and corporate social responsibility.22Our purpose in this study was to test 2 hypotheses about MFAC outlet availability in the United States. First, we expected to find that zip code areas in states with stronger alcohol control environments (i.e., more laws, regulations, and practices designed to reduce excessive alcohol use and related harm) would have less MFAC availability. We expected this association because the combined effects of multiple concurrent alcohol policies in an overall alcohol policy environment helps shape local norms regarding alcohol use. For example, harsh penalties for supplying alcohol to underage drinkers or using or accepting fake identification may influence local alcohol marketing practices (i.e., products presumed to be higher risk might not be as heavily supplied or demanded in such areas). Second, we anticipated that zip code areas with greater poverty and a larger concentration of racial/ethnic minority persons would have greater MFAC outlet availability. The relatively low price of MFACs might make the products particularly appealing to economically disadvantaged communities.18,19 This notion was supported by previous research on malt liquor, another low-price, high-alcohol content, ready-to-drink product that was heavily marketed to and had greater retail availability in low-income minority communities.23–25 However, to date, there has been no systematic inquiry into these concerns with regard to MFAC products.     

Prenatal,Perinatal, Early Life,and Sociodemographic Factors Underlying Racial Differences in the Likelihood of High Body Mass Index in Early Childhood

Objectives. We investigated early childhood disparities in high body mass index (BMI) between Black and White US children.Methods. We compared differences in Black and White children’s prevalence of sociodemographic, prenatal, perinatal, and early life risk and protective factors; fit logistic regression models predicting high BMI (≥ 95th percentile) at age 4 to 5 years to 2 nationally representative samples followed from birth; and performed separate and pooled-survey estimations of these models.Results. After adjustment for sample design–related variables, models predicting high BMI in the 2 samples were statistically indistinguishable. In the pooled-survey models, Black children''s odds of high BMI were 59% higher than White children''s (odds ratio [OR] = 1.59; 95% confidence interval [CI]= 1.32, 1.92). Sociodemographic predictors reduced the racial disparity to 46% (OR = 1.46; 95% CI = 1.17, 1.81). Prenatal, perinatal, and early life predictors reduced the disparity to nonsignificance (OR = 1.18; 95% CI = 0.93, 1.49). Maternal prepregnancy obesity and short-duration or no breastfeeding were among predictors for which racial differences in children’s exposures most disadvantaged Black children.Conclusions. Racial disparities in early childhood high BMI were largely explained by potentially modifiable risk and protective factors.Over recent decades, as the prevalence of high body mass index (BMI; defined as at or above the Centers for Disease Control and Prevention 95th percentile1) has increased dramatically among all children,2,3 racial disparities have been documented in nationally representative samples of children at very young ages.4–7 Reviews and prevalence studies highlight the need for a better understanding of the predictors of these disparities in BMI and other indicators of childhood obesity,8,9 especially in early childhood.7Previous research on high BMI in early childhood with racially and ethnically diverse samples has identified risk and protective factors at multiple developmental stages. In the prenatal and perinatal period, risks include higher birth weight,10–13 maternal prepregnancy BMI,14 and maternal smoking during pregnancy.14,15 In infancy and early life, risks include maternal employment,11 especially among highly educated women,12,16 nonparent child care,13,17,18 and television viewing hours.12,19–21 Protective factors include breastfeeding10,12,14 and family meals.12,21,22Studies have shown that young racial/ethnic minority children are exposed to more of these risks and fewer of these protections.23,24 Nevertheless, in analyses of nationally representative samples, high BMI remains more common among Black than White children even after adjusting for sociodemographic characteristics and risk and protective factors.6,11,12,14,16 We suspect that the persistence of racial disparities in these studies might be attributable to omitted predictors or less detailed measurement of the age and duration of children’s exposures. This type of comprehensive assessment is methodologically challenging because of the number of variables and observations required to draw statistically valid inferences.We employed a novel 2-survey methodological design to overcome these challenges. We used data from 2 nationally representative samples of US children followed from birth to age 4 to 5 years in separate and pooled-survey analyses to identify prenatal, perinatal, early life, and sociodemographic factors that may explain Black–White disparities in early childhood high BMI. The separate analyses in 2 surveys that cover a historical period of more than 10 years increased the robustness of our findings to differences in sample design, measurement protocols, and period variability in unobserved confounders. The pooled-survey analyses enhanced the statistical power of our study and thereby strengthened our conclusions about which factors explain Black–White disparities in early childhood high BMI.     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.     

Higher Retail Prices of Sugar-Sweetened Beverages 3 Months After Implementation of an Excise Tax in Berkeley,California

Objectives. We assessed the short-term ability to increase retail prices of the first US 1-cent-per-ounce excise tax on the distribution of sugar-sweetened beverages (SSBs), which was implemented in March 2015 by Berkeley, California.Methods. In 2014 and 2015, we examined pre- to posttax price changes of SSBs and non-SSBs in a variety of retailers in Berkeley and in the comparison cities Oakland and San Francisco, California. We examined price changes by beverage, brand, size, and retailer type.Results. For smaller beverages (≤ 33.8 oz), price increases (cents/oz) in Berkeley relative to those in comparison cities were 0.69 (95% confidence interval [CI] = 0.36, 1.03) for soda, 0.47 (95% CI = 0.08, 0.87) for fruit-flavored beverages, and 0.47 (95% CI = 0.25, 0.69) for SSBs overall. For 2-liter bottles and multipacks of soda, relative price increases were 0.46 (95% CI = 0.03, 0.89) and 0.49 (95% CI = 0.21, 0.77). We observed no relative price increases for nontaxed beverages overall.Conclusions. Approximately 3 months after the tax was implemented, SSB retail prices increased more in Berkeley than in nearby cities, marking a step in the causal pathway between the tax and reduced SSB consumption.Consuming sugar-sweetened beverages (SSBs) increases the risk of obesity, diabetes, heart disease, and dental caries1–4 and has been linked to approximately 184 000 deaths per year worldwide.5 SSBs are also the largest source of added sugar in the US diet.6,7 Thus, reducing SSB consumption has been identified as important in preventing obesity and chronic disease.8–10Because of the success of tobacco taxation in reducing smoking prevalence and related diseases,11 public health experts, including the Institute of Medicine, have recommended taxing SSBs as a means to reduce SSB consumption.12–15 In 2013 and 2014, more than a dozen states and several cities proposed SSB tax legislation—so called soda taxes.16 Only 1 proposal passed. On November 4, 2014, Berkeley, California, passed a 1-cent-per-ounce specific excise tax on the distribution of SSBs (Measure D), becoming the first US city to levy such a tax.17Measure D is consistent with the type of tax public health experts have called for—an excise tax on SSBs.12 Unlike a sales tax, which is added at the register and paid directly by the consumer, an excise tax is levied before the point of purchase (e.g., on distributors). Specific excise taxes are levied per volume of a product, whereas, ad valorem excise taxes are levied as a proportion of product price.18 In response to an excise tax, distributors are expected to increase SSB prices for retailers, who, in turn, are expected to increase the shelf prices of SSBs paid by consumers. Excise taxes are thought to be more salient to consumers than are sales taxes because they result in higher shelf prices at the point of decision, thus deterring purchase.12 The effectiveness of an excise tax in reducing SSB consumption hinges partly on its “pass-through rate,” or the extent to which the tax is passed on to consumers through higher shelf prices.In perfectly competitive markets with perfectly inelastic demand (i.e., changing price does not change demand), economic theory predicts perfect pass-through (i.e., a 1-cent excise tax leads to a 1-cent retail price increase).19,20 However, research suggests that demand for SSBs is elastic21; thus, distributors or retailers may undershift the tax (increase prices by < 1 cent/oz), either by absorbing the costs or distributing costs across untaxed products (e.g., food or diet soda). In fact, concerns have been raised that businesses might undershift the tax and lower their profit margins to sustain sales (known as “strategic pricing”).22 Undershifting results in lower than expected price increases, potentially undermining the public health benefit of a tax.23 However, taxes may also be overshifted in monopolistic or oligopolistic markets.20 Empirically, there is evidence of both over- and undershifting of taxes on cigarettes,24–29 alcohol,30,31 and saturated fat.32 The few empirical studies on SSB excise taxes in other countries have found pass-through rates ranging from about 63% to more than 300%, depending on beverage type, brand, and retailer.33–35 Because Berkeley’s excise tax is the first of its kind in the nation, there is no empirical evidence on how such a tax will be passed-through to consumers in the United States.We have provided the first early details of the pass-through of Berkeley’s excise tax on SSBs. Using neighboring San Francisco and Oakland, California, as comparison cities, we estimated the effect of Berkeley’s tax on retail prices of SSBs. Additionally, we examined price changes by beverage, brand, size, and retailer type because research in other countries has found varying pass-through across these variables.     

Impaired-Driving Prevalence Among US High School Students: Associations With Substance Use and Risky Driving Behaviors

Objectives. We examined the prevalence of impaired driving among US high school students and associations with substance use and risky driving behavior.Methods. We assessed driving while alcohol or drug impaired (DWI) and riding with alcohol- or drug-impaired drivers (RWI) in a nationally representative sample of 11th-grade US high school students (n = 2431). We examined associations with drinking and binge drinking, illicit drug use, risky driving, and demographic factors using multivariate sequential logistic regression analysis.Results. Thirteen percent of 11th-grade students reported DWI at least 1 of the past 30 days, and 24% reported RWI at least once in the past year. Risky driving was positively associated with DWI (odds ratio [OR] = 1.25; P < .001) and RWI (OR = 1.09; P < .05), controlling for binge drinking (DWI: OR = 3.17; P < .01; RWI: OR = 6.12; P < .001) and illicit drug use (DWI: OR = 5.91; P < .001; RWI: OR = 2.29; P = .05). DWI was higher for adolescents who drove after midnight (OR = 15.7), drove while sleepy or drowsy (OR = 8.6), read text messages (OR = 11.8), sent text messages (OR = 5.0), and made cell phone calls (OR = 3.2) while driving.Conclusions. Our findings suggest the need for comprehensive approaches to the prevention of DWI, RWI, and other risky driving behavior.Motor vehicle crashes are the leading cause of mortality for US adolescents.1 In general, alcohol and drug use impairs driving performance in proportion to the amount consumed and contributes significantly to motor vehicle crashes,2,3 particularly among younger drivers.4 In 2008, 31% of young drivers who were killed in motor vehicle crashes had been drinking5; in 2009, half of the child passengers who died in crashes involving alcohol were riding with an alcohol-impaired driver.6 Illicit drug use also contributes to a large portion of fatal motor vehicle crashes involving adolescents and adults.7–10 Despite downward trends among adolescents in rates of drinking and driving (from 17% in 1991 to 10% in 2009) and riding with drinking drivers (from 40% in 1991 to 28% in 2009), rates remain alarmingly high.11 Therefore, better understanding of the current prevalence, variability, and determinants of adolescent driving while intoxicated (DWI) and riding with alcohol- or drug-impaired drivers (RWI) is needed to guide the development of prevention strategies.Adolescence, the transition period from childhood to emerging adulthood, is a time of increased sensation seeking and risk behavior.12,13 During this transition, learning to drive and obtaining a license are major rites of passage for entering adulthood. However, adolescent drivers have high crash rates and tend to drive in a deliberately risky manner, typified by speeding, close following, sharp cornering, and hard stops.14–18 At the same time, drinking and drug use increase during adolescence, and vehicles become a primary means of transportation and provide a somewhat private place for adolescents to drink and use illicit drugs.19,20Previous research indicates that the prevalence of DWI and RWI among adolescents is higher for male than female adolescents and for Latinos than Whites.21–24 Concurrent and longitudinal research has shown that drinking, binge drinking, cigarette use, and marijuana use are associated with adolescent DWI and RWI.20,25–28 Similarly, drinking, drug use, and traffic violations are associated with adolescent risky driving.17,26 It has been shown in a few regional studies that risky driving covaries with other problem behaviors,17,26,29 but no national studies have reported associations between risky driving and DWI and RWI among adolescents.Using a national probability sample, we examined the following: (1) the variability in the prevalence of DWI and RWI among adolescents by demographic factors; (2) the association between risky driving and DWI and RWI; and (3) the independent contribution of binge drinking, illicit drug use, and risky driving to DWI and RWI.     

Racial Differences in Breast Cancer Stage at Diagnosis in the Mammography Era

Objectives. We assessed racial differences in breast cancer mortality by stage at diagnosis, since mammography became available.Methods. We calculated adjusted odds of distant (versus local or regional) tumors for 143 249 White and 13 571 Black women aged 50 to 69 years, diagnosed with breast cancer between 1982 and 2007 and living in a Surveillance, Epidemiology, and End Results region. We compared linear trends in stage at diagnosis before and after 1998.Results. Distant-stage cancer was diagnosed in 5.8% of White and 10.2% of Black participants. The Black–White disparity in distant tumors narrowed until 1998 (1998 adjusted difference = 0.65%), before increasing. Between 1982 and 1997, the proportion of distant tumors decreased for Blacks (adjusted odds ratio [AOR]/y = 0.973; 95% confidence interval [CI] = 0.960, 0.987) and Whites (AOR/y = 0.978; 95% CI = 0.973, 0.983), with no racial differences (P = .47). From 1998 to 2007, the odds of distant versus local or regional tumors increased for Blacks (AOR/y = 1.036; 95% CI = 1.013, 1.060) and Whites (AOR/y = 1.011; 95% CI = 1.002, 1.021); the rate of increase was greater for Blacks than Whites (P = .04).Conclusions. In the mammography era, racial disparities remain in stage at diagnosis.Despite a lower incidence of invasive breast cancer, Black women in the United States are more likely than are White women to die of the disease.1,2 Since 1992, although breast cancer deaths have declined in both White and Black women, the overall disparity in mortality has increased.3 Stage at diagnosis is the strongest predictor of survival in breast cancer,4–6 and Black women are more often diagnosed with advanced-stage disease than are White women.7–10Mammography is an important tool in the early detection of breast cancer.11–13 First introduced in the United States in the early 1980s,14 mammography was initially most prevalent among White women. Racial disparities in mammography rates narrowed by the mid-1990s,12,15 and Black women had rates equivalent to or greater than those of White women between 1996 and 2000.10,15,16 From 2000 to 2005, mammography use declined nationally in women aged 50 to 64 years (78.6% to 71.8%), with a slightly larger decrement for White (−4.0%) than Black (−3.3%) women.13The survival benefit of any screening program, including mammography, is related to its ability to detect tumors at earlier stages. Meta-analyses continue to find mortality benefit for mammography, although uncertainty remains regarding both the appropriate target population and the optimal screening interval.11,17,18 Consistent with the expected effect of screening, an observational cohort analysis found that improvements in screening rates for both Black and White women during the 1990s contributed to diagnosis at an earlier stage in both groups.10Nevertheless, despite generally equivalent rates of mammography for the past 15 years, the racial disparity in breast cancer mortality between Black and White women persists. Although previous meta-analyses suggested a mortality benefit for mammography, randomized controlled data regarding the efficacy of screening programs in minority populations are limited.18,19 Because stage at diagnosis is an important predictor of survival in breast cancer, we assessed temporal changes in the distribution of stage at diagnosis between 1982 and 2007, in both Black and White women, adjusting for covariates known to affect stage at diagnosis.     

Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

The Impact of a Free Older Persons’ Bus Pass on Active Travel and Regular Walking in England

Objectives. We assessed the potential public health benefit of the National Bus Pass, introduced in 2006, which permits free local bus travel for older adults (≥ 60 years) in England.Methods. We performed regression analyses with annual data from the 2005–2008 National Travel Survey. Models assessed associations between being a bus pass holder and active travel (walking, cycling, and use of public transport), use of buses, and walking 3 or more times per week.Results. Having a free pass was significantly associated with greater active travel among both disadvantaged (adjusted odds ratio [AOR] = 4.06; 95% confidence interval [CI] = 3.35, 4.86; P < .001) and advantaged groups (AOR = 4.72; 95% CI = 3.99, 5.59; P < .001); greater bus use in both disadvantaged and advantaged groups (AOR = 7.03; 95% CI = 5.53, 8.94; P < .001 and AOR = 7.11; 95% CI = 5.65, 8.94; P < .001, respectively); and greater likelihood of walking more frequently in the whole cohort (AOR = 1.15; 95% CI = 1.07, 1.12; P < .001).Conclusions. Public subsidies enabling free bus travel for older persons may confer significant population health benefits through increased incidental physical activity.Physical activity levels are decreasing globally.1 In 2008, 31% of people worldwide were insufficiently active contributing to 3.2 million deaths each year related to physical inactivity.2 Remaining physically active is as important in older as in younger adults because it reduces the risk of loss of mobility and muscle strength, falls, and fractures, and promotes social and mental well-being.3 Responding to this evidence, the US Surgeon General recommends regular moderate physical activity for older adults,4 and the UK Department of Health recommends at least 30 minutes of moderate exercise 5 times a week.3 Even lower activity levels may have significant benefits: the relative risk of disability is reduced by 7% for each additional hour of relatively gentle physical activity undertaken each week,5 and 15 minutes of moderate daily exercise is associated with a 12% decrease in all-cause mortality in persons older than 60 years.6Incidental physical activity may be defined as physical activity that is a byproduct of an activity with a different primary purpose. There is increasing interest in the promotion of incidental physical activity, including greater use of active transport—walking, cycling, and use of public transport.7–9 By swapping private vehicle travel for public transport—which may involve walking or cycling to transport access points or interchanges—physical activity levels are raised, offering significant health benefits, such as a reduced risk of obesity and cardiovascular ill health.10–12 Research from the United States finds that those commuting on public transport walk for an average of 19 minutes each day, and that nearly one third of commuters reach recommended daily physical activity levels just through active transport.13 In the United Kingdom, 19% of adults achieve recommended activity levels through active transport alone.14 Although commuting may not be as relevant to retired populations,15 incidental active travel may still have a key role to play in keeping older adults physically fit.16,17     

Directly Observed Antidepressant Medication Treatment and HIV Outcomes Among Homeless and Marginally Housed HIV-Positive Adults: A Randomized Controlled Trial

Objectives. We assessed whether directly observed fluoxetine treatment reduced depression symptom severity and improved HIV outcomes among homeless and marginally housed HIV-positive adults in San Francisco, California, from 2002 to 2008.Methods. We conducted a nonblinded, randomized controlled trial of once-weekly fluoxetine, directly observed for 24 weeks, then self-administered for 12 weeks (n = 137 persons with major or minor depressive disorder or dysthymia). Hamilton Depression Rating Scale score was the primary outcome. Response was a 50% reduction from baseline and remission a score below 8. Secondary measures were Beck Depression Inventory-II (BDI-II) score, antiretroviral uptake, antiretroviral adherence (measured by unannounced pill count), and HIV-1 RNA viral suppression (< 50 copies/mL).Results. The intervention reduced depression symptom severity (b = −1.97; 95% confidence interval [CI] = −0.85, −3.08; P < .001) and increased response (adjusted odds ratio [AOR] = 2.40; 95% CI = 1.86, 3.10; P < .001) and remission (AOR = 2.97; 95% CI = 1.29, 3.87; P < .001). BDI-II results were similar. We observed no statistically significant differences in secondary HIV outcomes.Conclusions. Directly observed fluoxetine may be an effective depression treatment strategy for HIV-positive homeless and marginally housed adults, a vulnerable population with multiple barriers to adherence.Depressive, pain, and substance use disorders are highly prevalent among persons living with HIV/AIDS1,2 and among the homeless and marginally housed.3–5 The triple diagnosis of depression, HIV, and substance use poses unique treatment challenges for clinicians: successful management of one condition is often dependent on successful management of the others, and the optimal sequencing of depression treatment, substance use treatment, and stabilization of psychosocial comorbidities remains unclear. Adherence to the entire continuum of HIV care is often hampered by depression6–8 and substance use.9,10 For homeless persons, the need to address subsistence concerns such as obtaining food and shelter may not only adversely affect mental well-being11 but may also divert attention away from medication adherence and regular clinic attendance.12 Timely and effective depression treatment is critical for HIV-positive persons, because depression has been associated with CD4⁺ T-lymphocyte cell count decline,13 progression to AIDS,14 and AIDS-related mortality.15 Yet depression remains pervasively underdiagnosed and undertreated among the homeless16–18 and among HIV-positive persons.19,20Depression treatment might be expected to improve virological or immunologic outcomes through improved adherence, but this has not been conclusively demonstrated.21–23 We therefore sought to determine whether treatment with once-weekly fluoxetine reduced depression symptom severity among homeless and marginally housed persons with comorbid depression and HIV. Because this population faces many psychosocial barriers to successful medication adherence,12,24 in addition to depression,25 we employed a directly observed treatment strategy similar to that used for treatment and management of patients with tuberculosis and HIV.26 This strategy reduced the potential for incomplete adherence to reduce the effectiveness of antidepressant treatment. A secondary aim was to determine whether depression treatment improved antiretroviral therapy (ART) uptake among persons eligible for treatment and ART adherence and viral suppression among treated persons.     

e-Cigarette Awareness,Use, and Harm Perceptions in US Adults

Objectives. We estimated e-cigarette (electronic nicotine delivery system) awareness, use, and harm perceptions among US adults.Methods. We drew data from 2 surveys conducted in 2010: a national online study (n = 2649) and the Legacy Longitudinal Smoker Cohort (n = 3658). We used multivariable models to examine e-cigarette awareness, use, and harm perceptions.Results. In the online survey, 40.2% (95% confidence interval [CI] = 37.3, 43.1) had heard of e-cigarettes, with awareness highest among current smokers. Utilization was higher among current smokers (11.4%; 95% CI = 9.3, 14.0) than in the total population (3.4%; 95% CI = 2.6, 4.2), with 2.0% (95% CI = 1.0, 3.8) of former smokers and 0.8% (95% CI = 0.35, 1.7) of never-smokers ever using e-cigarettes. In both surveys, non-Hispanic Whites, current smokers, young adults, and those with at least a high-school diploma were most likely to perceive e-cigarettes as less harmful than regular cigarettes.Conclusions. Awareness of e-cigarettes is high, and use among current and former smokers is evident. We recommend product regulation and careful surveillance to monitor public health impact and emerging utilization patterns, and to ascertain why, how, and under what conditions e-cigarettes are being used.A heterogeneous collection of battery-driven nicotine inhalers—“e-cigarettes” or electronic nicotine delivery systems (ENDS)—are emerging products receiving considerable advocacy, policy, and media attention.1 ENDS have been marketed as harm-reducing alternatives to smoking and used as cessation aids, though the US Food and Drug Administration (FDA) has not reviewed these claims or devices.2,3 Independent testing of ENDS has demonstrated poor quality control,2,4 low-level toxic contaminants,5 variable nicotine delivery,2,6,7 and insufficient evidence of overall public health benefit.8 Packaging and Web sites for ENDS reveal unsubstantiated health claims and erroneous nicotine content labeling.4 In addition, their wide combination of flavorings and “high-tech” image are potentially attractive to youths and young adults.2,4 In 2010, the World Health Organization recommended that ENDS products be regulated as combination drug and medical devices.1 Consistent with this recommendation, several countries, such as Australia and Canada, restricted or banned ENDS until reviewed by their regulatory agencies.9,10 A 2009 court decision (Sottera Inc v. Food and Drug Administration)11 blocked the FDA from regulating ENDS as drug delivery devices in the United States, ruling that products containing nicotine derived from tobacco are “tobacco products” under the 2009 Family Smoking Prevention and Tobacco Control Act unless they are sold as therapeutic aids for cessation.12 In keeping with this ruling, on April 25, 2011, the FDA announced its intention to regulate ENDS as tobacco products. The nature of the FDA’s ENDS regulation procedure has yet to be determined; until that time, ENDS will likely continue to be sold to consumers without regulation, raising serious concerns for public health.Although variations of ENDS have been on the market since at least 2007,13 little is known about the population prevalence of ENDS use in representative samples. One study examined Google searches and reported a sharp increase from 2008 to 2010 in queries, with ENDS search terms receiving more hits than nicotine patches and snus.14 Although this suggests relative increased interest, the denominators are unknown. In a European study, Etter et al.15 posted a survey in French for 34 days on a cessation Web site (http://www.stop-tabac.ch), which typically obtains about 120 000 visitors a month. Of 214 respondents, 81 eligible ENDS users reported mainly using ENDS for cessation or to avoid disturbing others; some were concerned about potential ENDS toxicity.16 Another online survey17 of first-time ENDS purchasers yielded a response proportion of only 4.5%; considering this low percentage, participants are not likely representative of ENDS purchasers and results are difficult to interpret. In a 2009 Zogby opinion poll, 59% of Americans supported FDA regulation of ENDS, with almost half (47%) saying that ENDS should be made available for people who want to quit smoking.18There are several widely cited and as yet unaddressed concerns regarding the effect of ENDS on public health. First is the concern that ENDS could act as a starter product for combustible cigarettes, especially among youths or young adults who may be attracted to their “tech” image or flavorings.3,19 Other concerns include that ENDS may lure former smokers to return to nicotine dependence, delay cessation among current smokers,2,3 serve as a dual-use product, or enable individuals to avoid smoking restrictions.19 Despite these gaps in our knowledge, there are no reliable national estimates of ENDS awareness, utilization, or harm perceptions in the peer-reviewed literature. Furthermore, other than the 2009 Zogby poll, no investigation of ENDS among nonsmokers is evident.18 This study makes an initial contribution to address some of these pressing knowledge gaps by using cross-sectional data from 2 separate surveys conducted in 2010, 1 nationally representative and 1 from the follow-up of a large cohort of current smokers and recent former smokers, to estimate ENDS awareness, use, and harm perceptions in the adult US population.     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Impact of Rurality,Broiler Operations,and Community Socioeconomic Factors on the Risk of Campylobacteriosis in Maryland

Objectives. We evaluated the combined impact of community-level environmental and socioeconomic factors on the risk of campylobacteriosis.Methods. We obtained Campylobacter case data (2002–2010; n = 3694) from the Maryland Foodborne Diseases Active Surveillance Network. We obtained community-level socioeconomic and environmental data from the 2000 US Census and the 2007 US Census of Agriculture. We linked data by zip code. We derived incidence rate ratios by Poisson regressions. We mapped a subset of zip code–level characteristics.Results. In zip codes that were 100% rural, incidence rate ratios (IRRs) of campylobacteriosis were 6 times (IRR = 6.18; 95% confidence interval [CI] = 3.19, 11.97) greater than those in urban zip codes. In zip codes with broiler chicken operations, incidence rates were 1.45 times greater than those in zip codes without broilers (IRR = 1.45; 95% CI = 1.34, 1.58). We also observed higher rates in zip codes whose populations were predominantly White and had high median incomes.Conclusions. The community and environment in which one lives may significantly influence the risk of campylobacteriosis.Campylobacter is a leading cause of bacterial gastroenteritis in much of the developed and developing world.1,2 In addition to the diarrhea and vomiting associated with gastroenteritis, infection with Campylobacter can lead to more serious sequelae, such as Guillain-Barré syndrome, a demyelinating autoimmune disorder that can sometimes lead to death.3 Scallan et al.4 estimated that Campylobacter causes approximately 845 000 domestically acquired illnesses in the United States each year, along with 8463 hospitalizations and 76 deaths. Although the majority of these illnesses are estimated to be foodborne,4 attributing specific infections to specific sources has been challenging.Commonly reported risk factors for Campylobacter outbreaks include exposure to undercooked poultry,5 unpasteurized milk,6,7 and contaminated water.8 Eating in restaurants,9 not observing proper food preparation practices,10 and traveling abroad9,11 have also been associated with both outbreaks and sporadic (nonoutbreak) cases of campylobacteriosis. Additional risk factors for sporadic infections include contact with pets,5,12 contact with farm animals and livestock,13,14 and contact with animal feces.15 Significant associations of living in rural areas with risk of campylobacteriosis also have been identified in Europe and Canada.16–18 Moreover, a specific feature of rural environments—animal density—has been identified as a significant predictor of Campylobacter incidence in Canada and New Zealand.16,17Several sociodemographic risk factors for campylobacteriosis have also been identified, the 2 most consistent being gender (males) and age (< 5 years).8,16–19 Previous studies have also evaluated socioeconomic factors associated with the incidence of Campylobacter infection, and the findings suggest that these infections may occur more frequently among individuals characterized by higher socioeconomic status.16,20 Moreover, Samuel et al.21 reported that the incidence of campylobacteriosis among African Americans was lower than that among other ethnic groups across multiple sites in the United States, although hospitalization rates for this group were higher. These findings, however, may be influenced by differentials in illness reporting among varying races and ethnic groups.Nonetheless, these previous reports have largely resulted from population-based case–control studies focused on individual-level data. To our knowledge, no US study has examined the combined effect of community-level environmental and socioeconomic risk factors on the risk of campylobacteriosis. Such an analysis can be useful in (1) identifying (and possibly predicting) “hot spot” communities that bear high burdens of this illness, and (2) addressing significant research gaps concerning potential health disparities in the risk of infectious diseases.22 We linked Maryland Foodborne Diseases Active Surveillance (FoodNet) data to US Census data and US Department of Agriculture Census of Agriculture data at the zip code level to evaluate associations between community-level environmental and socioeconomic risk factors and the incidence of Campylobacter infections in Maryland.     

Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

Objectives. We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors.Methods. In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up.Results. Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctor’s recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003).Conclusions. Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.Quadrivalent human papillomavirus (HPV) vaccine against types 6, 11, 16, and 18 is approved to protect against genital warts (caused mostly by HPV types 6 and 111) and anal cancer (caused mostly by HPV types 16 and 182) in males.3 About 4% of men in the United States report a previous diagnosis of genital warts,4 and about 2250 new cases of anal cancer occur annually among males in the United States.5 Given the high levels of HPV concordance among sexual partners,6 vaccinating males may also have indirect health benefits for their partners.7 United States guidelines began including HPV vaccine for males in October 2009.8 The Advisory Committee on Immunization Practices first provided a permissive recommendation, recommending the 3-dose quadrivalent vaccine series for males aged 9 to 26 years but not making it part of their routine vaccination schedule.8 In October 2011, the Advisory Committee on Immunization Practices updated its stance on HPV vaccine for males and recommended routine vaccination of boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.9 The updated recommendation continues to allow HPV vaccine to be given to males aged as young as 9 years and up to 26 years.9Although numerous studies have examined HPV vaccine uptake among females,10 data on HPV vaccine uptake among males are sparse. Despite mostly encouraging early levels of parental acceptability of the vaccine for males,11–13 initial estimates found that only about 2% of male adolescents in the United States had received any doses of HPV vaccine by the end of 2010.14,15 Recent data suggest that this increased to about 8% by the end of 2011.16 We are not aware of any studies that have examined predictors of vaccine uptake among males.Our study addresses several important gaps in the existing literature. We provide the first longitudinal examination of HPV vaccination among males and identify predictors of vaccine uptake. In doing so, we used data from both parents and their adolescent sons because many adolescents are involved in vaccination decisions.17 We also examined longitudinal changes in vaccine acceptability among parents and sons and parents’ reasons for not getting their sons HPV vaccine, because these data may provide valuable insight about future HPV vaccine uptake among males.     

Self-Reported Health Among Recently Incarcerated Mothers

Objectives. We examined self-reported health among formerly incarcerated mothers.Methods. We used data from the Fragile Families and Child Wellbeing Study (n = 4096), a longitudinal survey of mostly unmarried parents in urban areas, to estimate the association between recent incarceration (measured as any incarceration in the past 4 years) and 5 self-reported health conditions (depression, illicit drug use, heavy drinking, fair or poor health, and health limitations), net of covariates including health before incarceration.Results. In adjusted logistic regression models, recently incarcerated mothers, compared with their counterparts, have an increased likelihood of depression (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.18, 2.17), heavy drinking (OR = 1.79; 95% CI = 1.19, 2.68), fair or poor health (OR = 1.49; 95% CI = 1.08, 2.06), and health limitations (OR = 1.78; 95% CI = 1.27, 2.50). This association is similar across racial/ethnic subgroups and is larger among mothers who share children with fathers who have not been recently incarcerated.Conclusions. Recently incarcerated mothers struggle with even more health conditions than expected given the disadvantages they experience before incarceration. Furthermore, because incarceration is concentrated among those who are most disadvantaged, incarceration may increase inequalities in population health.The US incarceration rate, though recently stabilized, has increased rapidly over the past 4 decades. Accordingly, researchers have become acutely aware of the sheer number of individuals who experience incarceration and the vulnerabilities these individuals face before, during, and after incarceration.1 In particular, a growing literature has documented the consequences of mass incarceration, defined as the historically and comparatively extreme rates of incarceration in the United States, for population health.2–5 Formerly incarcerated individuals, compared with their counterparts, have elevated rates of mortality,6 infectious diseases,7 cardiovascular diseases,8 and disability,9 as well as an array of mental health problems including depression,10 anxiety,9 and life dissatisfaction.11Despite the fact that, since the early 1980s, women’s incarceration rates have increased faster than men’s incarceration rates,12,13 very little research has explicitly considered the health of formerly incarcerated women. Instead, research on incarcerated women often focuses on the consequences of incarceration for their families and children.14–19 The dearth of research on formerly incarcerated women’s health is an important oversight because these women are an extremely vulnerable population and present a pressing public health concern. Formerly incarcerated mothers are an especially important group because poor physical and mental health among mothers may have deleterious consequences for their children.20–23We used data from the Fragile Families and Child Wellbeing Study, a longitudinal study of mostly unmarried parents living in urban areas, to provide the first examination of the relationship between recent incarceration, measured as any incarceration experience in the past 4 years, and 5 self-reported health conditions among mothers: depression, illicit drug use, heavy drinking, fair or poor health, and health limitations. First, we estimated the association between recent incarceration and self-reported health. We then estimated this association by race/ethnicity and by romantic partner’s incarceration history. Our analyses adjusted for a large number of individual characteristics that may render the association between recent incarceration and health conditions spurious (including health before incarceration). Adjusting for these characteristics is especially important because incarcerated mothers are at risk for poor physical and mental health before incarceration.5,24–26     

Gender-Equitable Attitudes,Bystander Behavior,and Recent Abuse Perpetration Against Heterosexual Dating Partners of Male High School Athletes

Objectives. We assessed the relationship between gender attitudes, identified as a critical component of violence prevention, and abuse toward dating partners among adolescent male athletes.Methods. Our sample comprised 1699 athletes from 16 high schools in northern California who were surveyed between December 2009 and October 2010 in the larger Coaching Boys Into Men trial. We used logistic regression to assess the association between gender-equitable attitudes, bystander behavior, and recent abuse incidents.Results. Athletes with more gender-equitable attitudes and greater intention to intervene were less likely (adjusted odds ratio [AOR] = 0.36; 95% confidence interval [CI] = 0.28, 0.46; and AOR = 0.60; 95% CI = 0.48, 0.75, respectively) and athletes who engaged in negative bystander behavior were more likely (AOR = 1.22, 95% CI = 1.10, 1.35) to perpetrate abuse against their female dating partners.Conclusions. Despite the shift among bystander intervention programs toward gender neutrality, our findings suggest a strong association between gender attitudes and dating violence. Programs designed for adolescents should include discussion of gender attitudes and target bystander behavior, because these components may operate on related but distinct pathways to reduce abuse.Adolescent relationship abuse among heterosexual youths is common, with 20% to 25% of adolescents reporting this exposure.1,2 Adolescent relationship abuse is a gendered exposure. Although adolescent boys report experiencing aggression or physical violence from their female dating partners,3 women and girls are more likely to experience such violence, particularly sexual assault, and to experience poor health as a result.4,5 This disparity has been attributed to social norms supportive of male dominance in sexual and dating relationships, normalization of the use of violence as a means of conflict resolution, and the perception that peers support aggressive and abusive behavior.6,7Gender-equitable norms (socially prescribed definitions of masculinity and equitable power in sexual relationships) have been recognized by the global health community as a critical component of violence prevention.8,9 A small body of literature has empirically tested the association of such attitudes with adolescent relationship abuse10,11 and adult intimate partner violence.12 Although attitudes that degrade women and legitimize violence have been shown to be modifiable in men,12–16 limited attention has been paid to addressing norms in the context of dating violence among adolescents.Recent work in the field has focused on the social context of violence by attempting to alter the behavior of men and boys when they witness peers perpetrating physical–sexual abuse, rather than targeting the behavior of individual perpetrators. This bystander intervention approach aims to help witnesses better recognize abusive behaviors and take responsibility to stop them.17–19 Early bystander intervention programs incorporated conversations about masculinity and power into their curricula, the most notable of which was designed for male high school and college athletes.20 The athletic context provided a unique opportunity to implement gender-transformative programming within a culture influenced by discourses of masculinity and power, and the program encouraged athletes to model respectful behavior for peers in the greater school community. Today, discussions of gender norms are largely absent from bystander intervention programs so as not to target individual perpetrators.20 Such gender-neutral programs consider the impact of power imbalances on violence, but the underlying causes of these imbalances are less clearly articulated.In light of the shift in bystander intervention programs toward gender neutrality,20 despite evidence that sexual violence and harassment are influenced by social norms regarding relationships and masculinity,21 we empirically examined the relationships between gender-equitable attitudes, bystander behavior, and abuse toward heterosexual dating partners among a sample of male high school athletes.     

Intimate Partner Violence and Socioeconomic Deprivation in England: Findings From a National Cross-Sectional Survey

Objectives. We examined the prevalence of intimate partner violence (IPV) and its association with social deprivation in England.Methods. We used multivariable logistic regression to investigate IPV correlates among 21 226 men and women aged 16 to 59 years in the 2008 nationally representative cross-sectional British Crime Survey.Results. Lifetime IPV was reported by 23.8% of women and 11.5% of men. Physical IPV was reported by 16.8% and 7.0%, respectively; emotional-only IPV was reported by 5.8% and 4.2%, respectively. After adjustment for demographic confounders, lifetime physical IPV experienced by women was associated with social housing tenure (odds ratio [OR] = 2.3; 95% confidence interval [CI] = 2.0, 2.7), low household income (OR = 2.2; 95% CI = 1.8, 2.7), poor educational attainment (OR = 1.2; 95% CI = 1.0, 1.5), low social class (OR = 1.5; 95% CI = 0.3, 1.7), and living in a multiply deprived area (OR = 1.4; 95% CI = 1.1, 1.7). Physical IPV experienced by men and emotional IPV experienced by either gender were generally not associated with deprivation factors.Conclusions. Physical and emotional IPV are very common among adults in England. Emotional IPV prevention policies may be appropriate across the social spectrum; those for physical IPV should be particularly accessible to disadvantaged women.The World Health Organization highlights intimate partner violence (IPV) as a pressing public health and human rights issue.1 The World Health Organization defines IPV as physical or sexual violence, emotional abuse, or controlling behavior by a current or former intimate partner.2 In nearly 50 populationwide surveys globally some 10% to 69% of women report having ever experienced physical abuse by an intimate partner.2 In the United Kingdom, a 2009 review found that the prevalence of lifetime IPV against women was 13% to 31% in community studies, and 13% to 41% in clinical populations.3 The health impact of IPV extends beyond mortality and direct injury4 to poor overall self-rated health, mental health problems, and gynecological and sexual health problems.5,6 The annual UK domestic violence cost was estimated at £ 16 billion in 2008.7Often, IPV is seen in terms of physical or sexual violence perpetrated by men against women.1 As a consequence, most UK and international IPV prevention policies are targeted at women.1,8 However, some recent national surveys found a near-equal prevalence of physical IPV reported by men and women, mainly in North America and New Zealand, and there are calls for more services for male victims.9,10 Many have argued that this finding reflects measurement artifact, ignoring important differences in the nature and context of abuse.11 Further detailed examination of IPV as reported by both genders in national studies is needed to inform this debate.Policies for prevention of IPV also tend to emphasize that all women are at risk, regardless of their socioeconomic background.1,12 This is perhaps in an effort to decrease stigma associated with IPV. However, many studies show that both male perpetrators and female victims of physical IPV are more likely to come from disadvantaged backgrounds.13–15 The association with social deprivation depends on the broader social context, with more empowered women being at higher risk in some settings.16 There is little evidence on the socioeconomic profile of male victims. Finally, although central to the World Health Organization’s definition of IPV, emotional abuse is not well-described in the current literature among either gender. This is an important knowledge gap, as emotional abuse has a significant public health impact that can be as great as that of physical abuse.17,18 Understanding how social deprivation is associated with different types of abuse in both sexes will inform the need for targeted versus universal interventions.The British Crime Survey (BCS), a large national victimization survey in England and Wales, provides a detailed assessment of IPV. Home Office BCS reports examined associations between social deprivation and IPV victimization during the past year,19–21 but did not examine associations with lifetime IPV or IPV subtypes. To our knowledge there are no IPV studies using BCS data in the peer-reviewed scientific or public health literature, and only 1 UK national study using data other than the BCS, focusing on physical IPV.3,22 We used BCS data to describe the prevalence of both recent and lifetime IPV among men and women in England, and to explore whether different types of lifetime IPV were associated with social deprivation among either gender.To facilitate interpretation of our empirical findings we generated hypotheses in advance, following our review of theoretical and empirical literature. We expected to find that (1) women would report a higher prevalence of all types of IPV than men, particularly severe, prolonged, and controlling types of abuse11,23; (2) social deprivation would be associated with being a victim of lifetime IPV in both men and women13,15; and (3) social deprivation would be more strongly associated with being a victim of physical than of emotional lifetime IPV.17,24     

Trust,Medication Adherence,and Hypertension Control in Southern African American Men

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively).Trust remains an important issue with African Americans (AAs), particularly in the South where its history of mistreatment and racial discrimination at times were highly prevalent.1 Racial and ethnic minorities are more prone than are Whites to distrust the health care establishment, and historically, minority men have had less access to culturally competent providers.2–4 Southern AAs are more likely than are Whites to report perceived racial barriers to care,5 and AA men are more likely than are AA women to report perceived discrimination.6–10 Perceived discrimination and mistreatment are associated with poorer medical adherence and delays in seeking health care.11–14 In addition, higher levels of trust in the health care system are associated with better adherence to recommended care, greater patient satisfaction, and better outcomes.15–18 This has significant implications considering that AA men develop hypertension (HTN) at an earlier age, have higher rates of advanced (stage 3) HTN, are more likely to experience HTN complications, and are less likely to achieve HTN-control compared with White men.19–21 The rates of HTN are even higher in the South for AA men, accounting, in part, for higher stroke (80% higher) and cardiovascular mortality (50% higher) in this subpopulation compared with other groups in other regions.21–23The goal of this brief study was to assess the relationship between trust in the medical, medication adherence,24 and HTN control25 among Southern AA men. Other covariates were perceived discrimination, perceived racism, self-efficacy, and participation in medical decision-making. This study is based on the Race and Health Outcomes Model developed by Williams et al.26     

Work Safety Climate,Safety Behaviors,and Occupational Injuries of Youth Farmworkers in North Carolina

Objectives. The aims of this project were to describe the work safety climate and the association between occupational safety behaviors and injuries among hired youth farmworkers in North Carolina (n = 87).Methods. We conducted personal interviews among a cross-sectional sample of youth farmworkers aged 10 to 17 years.Results. The majority of youths reported that work safety practices were very important to management, yet 38% stated that supervisors were only interested in “doing the job quickly and cheaply.” Few youths reported appropriate work safety behavior, and 14% experienced an injury within the past 12 months. In bivariate analysis, perceptions of work safety climate were significantly associated with pesticide exposure risk factors for rewearing wet shoes (P = .01), wet clothes (P = .01), and shorts (P = .03).Conclusions. Youth farmworkers perceived their work safety climate as being poor. Although additional research is needed to support these findings, these results strengthen the need to increase employer awareness to improve the safety climate for protecting youth farmworkers from harmful exposures and injuries.Agriculture is one of the most dangerous industries in the United States, with the highest prevalence of potentially hazardous workplace exposures.1 Despite a decline in the number of total work-related fatalities and work injuries over the past 2 years, the agriculture sector recorded the highest fatality rate of any industry sector in 2012 at rate of 22.1 (per 100 000 full-time employees).2 Statistics on the number of youth farmworker injuries and fatalities are not publicly available. However, work-related fatal injuries disproportionally affect youths in agriculture. From 1998 to 2002, the US Department of Labor reported that the overall number of work fatalities declined for other age groups, yet fatal work injuries involving youths younger than 16 years nearly doubled, with the majority of deaths occurring among youths employed as agricultural workers.2,3Regulations in the United States governing working conditions for minors provide less protection for children employed in agricultural than for those employed in nonagricultural industries.4,5 Under the Fair Labor Standards Act of 1938, minors who are at least 16 years old are allowed to perform any job on the farm including hazardous duties (e.g., operating a tractor, feed grinder, chain saw, and earthmoving equipment); youths aged 12 and 13 years can be employed outside school hours and, in some cases, children aged as young as 10 years can hand-harvest crops with parental consent.5 Latino farmworker youths have been reported to begin working in agriculture in early adolescence,6 even though some reports have observed children aged as young as 4 or 5 years working with their parents.7,8 The number of youth farmworkers in the United States is difficult to establish. In 1998, the US General Accounting Office reported an estimated 169 000 to 200 000 youths working in migrant agricultural jobs.6,9 However, undocumented estimates as high as 500 000 youth agricultural workers have been reported.10,11Youth farmworkers represent a vulnerable work group. Many are exposed to dangerous work conditions, receive little pay, migrate from place to place looking for work, and often perform duties similar to those of their farmworker parents.12 For 2001 to 2002, the National Agricultural Worker Study reported that farmworker youths made up approximately 7% of all farmworkers, were predominately male, were aged between 14 and 17 years, and lived in poverty.13 Agricultural occupational exposures that youth farmworkers commonly encounter include physical hazards, such as working with sharp tools, equipment, machinery and transportation; environmental exposure hazards, such as pesticides, heat and sun exposure, insect bites, and poisonous plants; and ergonomic hazards, including heavy lifting, awkward positions, and repetitive motions.14 In addition, psychological stress hazards include pressure to work fast without breaks, sexual harassment, and lack of job control.15–17     

Latent Tuberculosis Infection Screening in Foreign-Born Populations: A Successful Mobile Clinic Outreach Model

Objectives. We evaluated the efficacy of a mobile medical clinic (MMC) screening program for detecting latent tuberculosis infection (LTBI) and active tuberculosis.Methods. A LTBI screening program in a MMC in New Haven, Connecticut, used medical surveys to examine risk factors and tuberculin skin test (TST) screening eligibility. We assessed clinically relevant correlates of total (prevalent; n = 4650) and newly diagnosed (incident; n = 4159) LTBI from 2003 to 2011.Results. Among 8322 individuals, 4159 (55.6%) met TST screening eligibility criteria, of which 1325 (31.9%) had TST assessed. Similar to LTBI prevalence (16.8%; 779 of 4650), newly diagnosed LTBI (25.6%; 339 of 1325) was independently correlated with being foreign-born (adjusted odds ratio [AOR] = 8.49; 95% confidence interval [CI] = 5.54, 13.02), Hispanic (AOR = 3.12; 95% CI = 1.88, 5.20), Black (AOR = 2.16; 95% CI = 1.31, 3.55), employed (AOR = 1.61; 95% CI = 1.14, 2.28), and of increased age (AOR = 1.04; 95% CI = 1.02, 1.05). Unstable housing (AOR = 4.95; 95% CI = 3.43, 7.14) and marijuana use (AOR = 1.57; 95% CI = 1.05, 2.37) were significantly correlated with incident LTBI, and being male, heroin use, interpersonal violence, employment, not having health insurance, and not completing high school were significantly correlated with prevalent LTBI.Conclusions. Screening for TST in MMCs successfully identifies high-risk foreign-born, Hispanic, working, and uninsured populations and innovatively identifies LTBI in urban settings.Foreign-born populations are at greatest risk for having both latent tuberculosis infection (LTBI) and developing tuberculosis (TB) disease within high-income countries and, in 2012, accounted for 63.0% of the 9951 TB cases in the United States.1 Newly diagnosed and reactivated TB infection among foreign-born individuals in the United States is currently 12 times greater (15.8 vs 1.4 cases per 100 000 population) than among US-born persons.1 Among foreign-born individuals, LTBI often reactivates within 5 to 10 years after arrival to the United States.2,3 Undocumented migrants and visitors from high-TB-prevalence countries, however, do not undergo routine LTBI screening and thus remain outside traditional health care screening and treatment programs in primary or specialty care settings except when they are acutely ill.3,4 Thus, identifying and treating LTBI cases among these high-risk populations before transforming to TB disease and resultant transmission to others is crucial to ending the cycle of ongoing TB infection within the United States.Workplace screening,4,5 mandatory criminal justice system screening,6–8 screening for entry into medication-assisted therapy and drug treatment programs,9 and refugee and naturalization programs10,11 have been successful for reaching legal and domestic populations, but innovative options are needed to target foreign-born populations that are not yet integrated into mainstream care.Culturally and geographically isolated foreign-born groups may be overlooked especially if there is low self-perception of tuberculosis risk.12 Tuberculin skin testing (TST), though imperfect, is internationally recognized and has been shown to be a reasonably accurate assessment of LTBI status in immunocompetent adults, despite receiving previous Bacillus Calmette-Guérin vaccine.13 Whereas other studies have focused on traditional clinics or statewide programs,14 we present an innovative mobile medical clinic (MMC) as a model to target “hidden” foreign-born populations for LTBI screening.New Haven, Connecticut, the country’s fourth poorest city for its size, with a census of 130 000, is a medium-sized urban setting in New England that has experienced extraordinary social and medical disparities including a high prevalence of poverty, drug addiction, HIV/AIDS, and unemployment and is disproportionately comprised of people of color, including 35.4% and 27.4% being Black or Hispanic, respectively.15 As New Haven is an industrial city with low-paying jobs, there has been an influx of foreign-born people, now officially comprising 11.6% of the population, with many having an undocumented residency status. Health care access for this group is absent unless individuals pay directly for fee-for-service, and concern for deportation and arrest further hinders willingness to seek care.16The Community Health Care Van (CHCV) is an MMC that provides free health care 5 days per week in 4 impoverished neighborhoods in New Haven. Though at inception the program was linked to the needle and syringe exchange program,17 it has since expanded over 20 years to become a vital bridge to a diverse array of health and addiction treatment services that includes services for medically underserved populations, including directly administered antiretroviral therapy to treat HIV,18–21 buprenorphine maintenance therapy,22–25 community transitional programs from the criminal justice system,26–33 hepatitis B vaccination,34 rapid hepatitis C screening,35 and other ongoing primary health care programs such as screening and monitoring of sexually transmitted infections,36 diabetes, and hypertension. In addition, the CHCV provides outreach and intensive case management services.37 Screening for LTBI and TB disease began in 2003 to target high-risk undocumented and foreign-born clients, as well as clients entering drug treatment programs or homeless shelters, who were concerned about TB infection yet were reluctant to seek care in traditional health care settings for fear of deportation, prohibitive cost, or language barriers. The LTBI screening program shortly thereafter became successfully incorporated into the country’s first mobile buprenorphine maintenance therapy program.9