Oral Health,Disability and Physical Function: Results From Studies of Older People in the United Kingdom and United States of America

ObjectivesStudies examining the associations between oral health and disability have limited oral health measures. We investigated the association of a range of objectively and subjectively assessed oral health markers with disability and physical function in older age.Design, Setting, and ParticipantsCross-sectional analyses were based on the British Regional Heart Study (BRHS) comprising men aged 71 to 92 years (n = 2147) from 24 British towns, and the Health, Aging, and Body Composition (HABC) Study comprising men and women aged 71 to 80 years (n = 3075) from the United States. Assessments included oral health (periodontal disease, tooth count, dry mouth, and self-rated oral health), disability, and physical function (grip strength, gait speed, and chair stand test).ResultsIn the BRHS, dry mouth, tooth loss, and cumulative oral health problems (≥3 problems) were associated with mobility limitations and problems with activities of daily living and instrumental activities of daily living; these remained significant after adjustment for confounding variables (for ≥3 dry mouth symptoms, odds ratio (OR) 2.68, 95% confidence interval (CI) 1.94–3.69; OR 1.76, 95% CI 1.15–2.69; OR 2.90, 95% CI 2.01, 4.18, respectively). Similar results were observed in the HABC Study. Dry mouth was associated with the slowest gait speed in the BRHS, and the weakest grip strength in the HABC Study (OR 1.75, 95% CI 1.22, 2.50; OR 2.43, 95% CI 1.47–4.01, respectively).Conclusions and ImplicationsMarkers of poor oral health, particularly dry mouth, poor self-rated oral health, and the presence of more than 1 oral health problem, were associated with disability and poor physical function in older populations. Prospective investigations of these associations and underlying pathways are needed.     

Characteristics of Emergency Department Visits by Older Versus Younger Homeless Adults in the United States

Objectives. We compared the characteristics of emergency department (ED) visits of older versus younger homeless adults.Methods. We analyzed 2005–2009 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of visits to hospitals and EDs, and used sampling weights, strata, and clustering variables to obtain nationally representative estimates.Results. The ED visits of homeless adults aged 50 years and older accounted for 36% of annual visits by homeless patients. Although demographic characteristics of ED visits were similar in older and younger homeless adults, clinical and health services characteristics differed. Older homeless adults had fewer discharge diagnoses related to psychiatric conditions (10% vs 20%; P = .002) and drug abuse (7% vs 15%; P = .003) but more diagnoses related to alcohol abuse (31% vs 23%; P = .03) and were more likely to arrive by ambulance (48% vs 36%; P = .02) and to be admitted to the hospital (20% vs 11%; P = .003).Conclusions. Older homeless adults’ patterns of ED care differ from those of younger homeless adults. Health care systems need to account for these differences to meet the needs of the aging homeless population.The average age of the US homeless population is increasing. Whereas 11% of the homeless population was aged 50 years or older in 1990, this percentage had increased to 32% by 20031 and has continued to rise since then.2 The median age of single homeless adults has increased from 37 years in 19901 to between 49 and 50 years today.2,3 This trend is thought to be because of the aging of individuals born in the second half of the baby boom generation (those born 1954–1965), who have a higher risk of homelessness than do other age cohorts.3 Most homeless adults aged 50 years and older are aged between 50 and 64 years, with adults aged 65 years and older making up less than 5% of the total homeless population.1,3In the general population, adults aged 50 to 64 years are considered middle aged and have lower rates of chronic conditions than do those considered elderly, adults aged 65 years and older.4,5 However, homeless adults aged 50 years and older have rates of chronic illnesses and geriatric conditions similar to or higher than those of housed adults 15 to 20 years older, including conditions often thought to be limited to the elderly, such as falls and memory loss.6,7 Because middle-aged homeless adults face the same geriatric problems as do elderly housed adults, experts consider them to be elderly when aged 50 years, despite their relatively younger age.6,8 Similar patterns of premature aging have been found in other vulnerable populations, including prisoners9 and patients with developmental disabilities.10Despite the growth of the older homeless population, relatively little is known about use of health services among older homeless adults. Homeless health services and research have focused on problems that are common among younger homeless adults, including infectious disease,11 substance use,12 and mental illness.13 The few studies that have focused on older homeless adults found that they have medical problems that differ from those of younger homeless adults, including higher rates of chronic illnesses6,14 and geriatric syndromes6 and lower rates of substance use.15 New frameworks for providing care to the vulnerable and growing older population are needed but cannot be developed until more is known about their use of health services.Homeless adults aged 50 years and older use the emergency department (ED) frequently and at rates nearly 4 times those of the general population.16–18 Knowledge about ED care that older homeless adults receive may allow researchers and clinicians to design interventions to reduce use of the ED and improve ED care for this vulnerable older population. Therefore, we have identified the demographic, clinical, and health services characteristics of ED visits in older versus younger homeless adults, using a nationally representative survey of US ED visits.     

Perceptions of Food Advertising and Association With Consumption of Energy-Dense Nutrient-Poor Foods Among Adolescents in the United States: Results From a National Survey

The advertising and marketing of energy-dense, nutrient-poor (EDNP) food and drink has been cited as one contributor to unhealthy eating behaviors in adolescents. The present study examines perceptions about and trust in food advertising and their association with consumption of EDNP foods and drinks among adolescents in the United States. Data (n = 1,384) come from the U.S. National Cancer Institute’s Family Life, Activity, Sun, Health, and Eating Survey. One way ANOVAs were conducted to assess differences between population subgroups in advertising perceptions. Bivariate and multivariable linear regression models were used to examine the associations between perceptions toward and trust in food advertising and consumption of EDNP foods and drinks, controlling for sociodemographic factors. Results show that there are significant differences between racial/ethnic groups on advertising perceptions (F = 16.32, p = < .0001). As positive perceptions toward food advertising increase among adolescents, there is an associated increase in daily frequency of consumption of EDNP foods and drinks (β = 0.10, p < .01). Similarly, the more adolescents agreed that they trusted food advertising, the higher the reported daily frequency of EDNP food and drink consumption (β = 0.08, p = .01). Targeting perceptions about food advertising may be a worthy intervention strategy to reduce the impact of food marketing and the consumption of heavily advertised EDNP foods and drinks among adolescents.     

Tobacco use transitions in the United States: The National Longitudinal Study of Adolescent Health

ObjectivesThe purpose of this study is to evaluate and describe transitions in cigarette and smokeless tobacco (ST) use, including dual use, prospectively from adolescence into young adulthood.MethodsThe current study utilizes four waves of the National Longitudinal Study of Adolescent Health (Add Health) to examine patterns of cigarette and ST use (within 30 days of survey) over time among a cohort in the United States beginning in 7th–12th grade (1995) into young adulthood (2008–2009). Transition probabilities were estimated using Markov modeling.ResultsAmong the cohort (N = 20,774), 48.7% reported using cigarettes, 12.8% reported using ST, and 7.2% reported dual use (cigarettes and ST in the same wave) in at least one wave. In general, the risk for transitioning between cigarettes and ST was higher for males and those who were older. Dual users exhibited a high probability (81%) of continuing dual use over time.ConclusionsFindings suggest that adolescents who use multiple tobacco products are likely to continue such use as they move into young adulthood. When addressing tobacco use among adolescents and young adults, multiple forms of tobacco use should be considered.     

Designing for Dissemination Among Public Health Researchers: Findings From a National Survey in the United States

Objectives. We have described the practice of designing for dissemination among researchers in the United States with the intent of identifying gaps and areas for improvement.Methods. In 2012, we conducted a cross-sectional study of 266 researchers using a search of the top 12 public health journals in PubMed and lists available from government-sponsored research. The sample involved scientists at universities, the National Institutes of Health, and the Centers for Disease Control and Prevention in the United States.Results. In the pooled sample, 73% of respondents estimated they spent less than 10% of their time on dissemination. About half of respondents (53%) had a person or team in their unit dedicated to dissemination. Seventeen percent of all respondents used a framework or theory to plan their dissemination activities. One third of respondents (34%) always or usually involved stakeholders in the research process.Conclusions. The current data and the existing literature suggest considerable room for improvement in designing for dissemination.The effective dissemination of information on priorities, health risks, and evidence-based interventions in public health is a formidable challenge.1,2 Dissemination is an active approach of spreading evidence-based information to the target audience via determined channels using planned strategies.3 Studies from both clinical and public health settings suggest that evidence-based practices are not being disseminated effectively.4–6 For example, in a study of US adults, only 55% of overall care received was based on what is recommended in the scientific literature.7 In a study of US public health departments, an estimated 58% of programs and policies were reported as “evidence-based.”8To illustrate the dissemination challenges and possible solutions, research on evidence-based interventions has now taught us several important lessons:

1. dissemination generally does not occur spontaneously and naturally4;
2. passive approaches to dissemination are largely ineffective9,10;
3. single-source prevention messages are generally less effective than comprehensive, multilevel approaches11,12;
4. stakeholder involvement in the research or evaluation process is likely to enhance dissemination (so-called practice-based research)13–19;
5. theory and frameworks for dissemination are beneficial20,21; and
6. the process of dissemination needs to be tailored to specific audiences.22

The difficulty in dissemination is the result of differing priorities.23,24 For researchers, the priority is often on discovery (not application) of new knowledge, whereas for practitioners and policymakers, the priority is often on practical ways for applying these discoveries for their settings.25 The chasm between researchers and practitioners was illustrated in a “Designing for Dissemination” workshop sponsored by the US National Cancer Institute.26 In this workshop, all participants acknowledged the importance of dissemination. Researchers reported their role was to identify effective interventions, but that they were not responsible for dissemination of research findings. Similarly, practitioners did not believe they were responsible for dissemination.It has been recommended that researchers should identify dissemination partners before conducting discovery research, so that those who might adopt the discoveries will see the research process and results in a collaborative manner.24,27 Ultimately, we need to better understand how to design interventions with the elements most critical for external validity in mind,28–30 addressing these issues during early, developmental phases, and not near the end of a project.24,31 To date, few studies have evaluated the extent to which researchers are designing their studies for dissemination and how the design process may differ by researcher background and setting of research.In the present study, we described the practice of designing for dissemination (D4D) among researchers in the United States with the intent of identifying gaps and areas for improvement.     

Comparisons of Sarcopenia Defined by IWGS and EWGSOP Criteria Among Older People: Results From the I-Lan Longitudinal Aging Study

ObjectiveTo compare clinical characteristics of sarcopenia defined by the International Working Group on Sarcopenia (IWGS) and European Working Group on Sarcopenia in Older People (EWGSOP) criteria among older people in Taiwan.DesignA prospective population-based community study.SettingI-Lan County of Taiwan.ParticipantsA total of 100 young healthy volunteers and 408 elderly people.InterventionNone.MeasurementsAnthropometry, skeletal muscle mass measured by dual x-ray absorptiometry, relative appendicular skeletal muscle index (RASM), percentage skeletal muscle index (SMI), 6-meter walking speed, and handgrip strength.ResultsThe prevalence of sarcopenia was 5.8% to 14.9% in men and 4.1% to 16.6% in women according to IWGS and EWGSOP criteria by using RASM or SMI as the muscle mass indices. The agreement of sarcopenia diagnosed by IWGS and EWGSOP criteria was only fair by using either RASM or SMI (kappa = 0.448 by RASM, kappa = 0.471 by SMI). The prevalence of sarcopenia was lower by the IWGS definition than the EWGSOP definition, but it was remarkably lower by using RASM than SMI in both criteria. Overall, sarcopenic individuals defined by SMI were older, had a higher BMI but similar total skeletal muscle mass, and had poorer muscle strength and physical performance than nonsarcopenic individuals. However, by using RASM, sarcopenic individuals had less total skeletal muscle mass but similar BMI than nonsarcopenic individuals. Multivariable logistic regression showed that age was the strongest associative factor for sarcopenia in both IWGS and EWGSOP criteria. Obesity played a neutral role in sarcopenia when it is defined by using RASM, but significantly increased the risk of sarcopenia in both criteria by using SMI.ConclusionThe agreement of sarcopenia defined by IWGS and EWGSOP was only fair, and the prevalence varied largely by using different skeletal muscle mass indices. Proper selections for cutoff values of handgrip strength, walking speed, and skeletal muscle indices with full considerations of gender and ethnic differences were of critical importance to reach the universal diagnostic criteria for sarcopenia internationally.     

The Relationship of Oral Health with Progression of Physical Frailty among Older Adults: A Longitudinal Study Composed of Two Cohorts of Older Adults from the United Kingdom and United States

ObjectiveTo investigate the prospective associations between oral health and progression of physical frailty in older adults.DesignProspective analysis.Setting and ParticipantsData are from the British Regional Heart Study (BRHS) comprising 2137 men aged 71 to 92 years from 24 British towns and the Health, Aging, and Body Composition (HABC) Study of 3075 men and women aged 70 to 79 years.MethodsOral health markers included denture use, tooth count, periodontal disease, self-rated oral health, dry mouth, and perceived difficulty eating. Physical frailty progression after ∼8 years follow-up was determined based on 2 scoring tools: the Fried frailty phenotype (for physical frailty) and the Gill index (for severe frailty). Logistic regression models were conducted to examine the associations between oral health markers and progression to frailty and severe frailty, adjusted for sociodemographic, behavioral, and health-related factors.ResultsAfter full adjustment, progression to frailty was associated with dentition [per each additional tooth, odds ratio (OR) 0.97; 95% CI: 0.95–1.00], <21 teeth with (OR 1.74; 95% CI: 1.02–2.96) or without denture use (OR 2.45; 95% CI 1.15–5.21), and symptoms of dry mouth (OR ≥1.8; 95% CI ≥ 1.06–3.10) in the BRHS cohort. In the HABC Study, progression to frailty was associated with dry mouth (OR 2.62; 95% CI 1.05–6.55), self-reported difficulty eating (OR 2.12; 95% CI 1.28–3.50) and ≥2 cumulative oral health problems (OR 2.29; 95% CI 1.17–4.50). Progression to severe frailty was associated with edentulism (OR 4.44; 95% CI 1.39–14.15) and <21 teeth without dentures after full adjustment.Conclusions and ImplicationsThese findings indicate that oral health problems, particularly tooth loss and dry mouth, in older adults are associated with progression to frailty in later life. Additional research is needed to determine if interventions aimed at maintaining (or improving) oral health can contribute to reducing the risk, and worsening, of physical frailty in older adults.     

The Role of Communication Perceptions in the Mental Health of Older Adults: Views From Thailand and the United States

This study examines age ingroup and outgroup communication perceptions of older Thai and American adults to assess whether communication perceptions of self and others are associated with mental health outcomes such as personal self-esteem, collective self-esteem, and life satisfaction. Results suggest that more accommodation by same-age older others leads to greater personal self-esteem, greater group esteem, and greater life satisfaction, while more nonaccommodation by younger others leads to less life satisfaction for the Thais and Americans. More overaccommodation by younger others was found to lead to less personal self-esteem and less life satisfaction for the sample as a whole. Discriminant loadings show life satisfaction was the most important variable in distinguishing between the prototypical older Thai and American respondent. The overall profile shows the typical Thai older adult participants as perceiving members of their own age ingroup as communicatively avoidant and overaccommodating while also experiencing lower collective self-esteem and life satisfaction. Typical older Americans tended to be associated with higher collective self-esteem and life satisfaction.     

Stroke in Older Adults Living in Care Homes: Results From a National Data Linkage Study in Wales

ObjectivesTo determine the proportion of older people moving to care homes with a recent stroke, incidence of stroke after moving to a care home, mortality following stroke, and secondary stroke prevention management in older care home residents.DesignRetrospective cohort study using population-scale individual-level linked data sources between 2003 and 2018 in the Secure Anonymized Information Linkage (SAIL) Databank.Setting and ParticipantsPeople aged ≥65 years residing in long-term care homes in Wales.MethodsCompeting risk models and logistic regression models were used to examine the association between prior stroke, incident stroke, and mortality following stroke.ResultsOf 86,602 individuals, 7.0% (n = 6055) experienced a stroke in the 12 months prior to care home entry. The incidence of stroke within 12 months after entry to a care home was 26.2 per 1000 person-years [95% confidence interval (CI) 25.0, 27.5]. Previous stroke was associated with higher risk of incident stroke after moving to a care home (subdistribution hazard ratio 1.83, 95% CI 1.57, 2.13) and 30-day mortality following stroke (odds ratio 2.18, 95% CI 1.59, 2.98). Severe frailty was not significantly associated with risk of stroke or 30-day mortality following stroke. Secondary stroke prevention included statins (51.0%), antiplatelets (61.2%), anticoagulants (52.4% of those with atrial fibrillation), and antihypertensives (92.1% of those with hypertension).Conclusions and ImplicationsAt the time of care home entry, individuals with history of stroke in the previous 12 months are at a higher risk of incident stroke and mortality following an incident stroke. These individuals are frequently not prescribed medications for secondary stroke prevention. Further evidence is needed to determine the optimal care pathways for older people living in long-term care homes with history of stroke.     

Developmental Trends in Sleep Duration in Adolescence and Young Adulthood: Evidence From a National United States Sample

PurposeTo present normative values of mean sleep duration from adolescence through young adulthood (ages 13–32 years), prevalence of short (<6 hours) and long (>10 hours) sleep durations, and differences in each by sex and race/ethnicity.MethodsMean sleep duration and prevalence of extremely short and long sleep were estimated using data from the United States National Longitudinal Study of Adolescent Health, Waves 1–4 (N = 15,701).ResultsSleep duration showed age-related trends, with decreases across the adolescent period from 8.5 hours per night at age 13 years to 7.3 hours at age 18 years, an increase through the emerging adulthood period to 8.5 hours at age 22, and a gradual decline across early adulthood to 7.7 hours at age 32 years. Prevalence of extremely long and short sleep followed similar developmental trends. Adolescent girls reported lower mean sleep duration than did boys, but women reported longer average sleep duration than did men from age 19 years onward. Short sleep duration was most common among African-Americans at all ages. Long sleep was most common among African-Americans in adolescence and emerging adulthood and among Hispanics in early adulthood.ConclusionsSleep duration is developmentally patterned from adolescence through early adulthood. Mean and extreme sleep durations vary systematically by sex and race/ethnicity as well as age. These normative data on sleep duration will inform studies of the role of sleep in the etiology of a wide range of health conditions affecting adolescents and young adults.     

HIV-Related Knowledge, Beliefs, and Behaviors Among High School Students in the United States: Results from a National Survey

The Secondary School Student Health Risk Survey measured the prevalence of sexual intercourse and illegal drug injection among a national probability sample of U.S. high school students and assessed their HIV-related knowledge and beliefs. Ninety-nine (81%) of the 122 selected schools and 8,098 (83%) of the eligible students participated. Nearly all high school students knew the major modes of HIV transmission. Three percent reported injecting illegal drugs, and 1% reported sharing needles used to inject drugs. In addition, 59% of students reported having sexual intercourse and, of students who reported having sexual intercourse, 40% reported having four or more sexual partners. HIV-related knowledge, beliefs, and behaviors among high school students suggest the need for school-based HIV education programs that help young people acquire the knowledge and skills to adopt and maintain behaviors that reduce risk of HIV infection and other related health problems.     

Current Tobacco Use Among Adults in the United States: Findings From the National Adult Tobacco Survey

Objectives. We assessed the prevalence and sociodemographic correlates of tobacco use among US adults.Methods. We used data from the 2009–2010 National Adult Tobacco Survey, a national landline and cell phone survey of adults aged 18 years and older, to estimate current use of any tobacco; cigarettes; cigars, cigarillos, or small cigars; chewing tobacco, snuff, or dip; water pipes; snus; and pipes. We stratified estimates by gender, age, race/ethnicity, education, income, sexual orientation, and US state.Results. National prevalence of current use was 25.2% for any tobacco; 19.5% for cigarettes; 6.6% for cigars, cigarillos, or small cigars; 3.4% for chewing tobacco, snuff, or dip; 1.5% for water pipes; 1.4% for snus; and 1.1% for pipes. Tobacco use was greatest among respondents who were male, younger, of non-Hispanic “other” race/ethnicity, less educated, less wealthy, and lesbian, gay, bisexual, or transgender. Prevalence ranged from 14.1% (Utah) to 37.4% (Kentucky).Conclusions. Tobacco use varies by geography and sociodemographic factors, but remains prevalent among US adults. Evidence-based prevention strategies are needed to decrease tobacco use and the health and economic burden of tobacco-related diseases.Tobacco use remains the single largest preventable cause of disease and premature death among both men and women in the United States.1 Health effects associated with tobacco use include heart disease, many types of cancer, pulmonary disease, adverse reproductive outcomes, and the exacerbation of multiple chronic health conditions.2 Cigarette smoking alone has been estimated to cause 443 000 deaths per year in the United States, including approximately 49 400 deaths attributed to secondhand smoke exposure.3 In addition, cigarette smoking has been estimated to cost the United States $96 billion in direct medical expenses and $97 billion in lost productivity per year.3 Despite significant progress over the past several decades,4 declines in the prevalence of cigarette smoking and the use of other tobacco products among US adults have stalled in recent years.5,6Monitoring the extent of the tobacco epidemic can assist in guiding decisions about tobacco control strategies for the overall population and high-risk subpopulations. The World Health Organization recognizes that monitoring tobacco use is an important and effective tobacco control approach in its MPOWER model and encourages the collection of data on tobacco use prevalence and consumption by demographic subdivisions, both nationally and regionally.7 In the United States, the report Key Outcome Indicators for Evaluating Comprehensive Tobacco Control Programs (KOI report) identified valid and reliable measures for tobacco-related indicators and provided a guide for tobacco control surveillance at the national, state, and local levels.8The National Adult Tobacco Survey (NATS) is the first adult tobacco use survey designed within the framework of the KOI report.9 NATS establishes a comprehensive standard for assessing the prevalence of tobacco use and the factors promoting and impeding tobacco use at both the national and state levels. We analyzed NATS data to determine the national prevalence and sociodemographic correlates of tobacco use among US adults, both overall and for multiple tobacco products. We also calculated state-specific estimates for overall tobacco use and for cigarette smoking.     

Psychosocial Correlates of Dietary Supplement Use: Results from the National Survey of Midlife Development in the United States

Drawing on data gathered in the National Survey of Midlife Development in the United States, this study examined internal and external locus of control, self-esteem, neuroticism, perceived health status, uniqueness, and somatic amplification as correlates of dietary supplement use. With sex, race, and age measures also included in the study, bivariate analyses showed greater supplement use among women and older respondents as well as those scoring higher on internal locus of control, self-esteem, perceived health status, and somatic amplification. Regression analyses identified sex and internal locus of control as the strongest predictors. Interactions between age and external locus of control also emerged.     

Attachment to Conventional Institutions and Adolescent Rapid Repeat Pregnancy: A Longitudinal National Study Among Adolescents in the United States

Introduction There is limited research on rapid repeat pregnancies (RRP) among adolescents, especially using nationally representative samples. We examine distal factors—school, family, peers, and public/private religious ties—and their associations with RRP among adolescent mothers. Methods Guided by social development theory, we conducted multivariate logistic regression analyses, adjusted for sociodemographic characteristics, to examine associations between RRP and attachment to school, family, peers, and religion among 1158 female respondents from the National Longitudinal Study of Adolescent to Adult Health (Add Health) who reported at least one live birth before age 20. Results Attachments to conventional institutions were associated with lower likelihood of RRP. Adolescent mothers who had a stronger relationship with their parents had reduced odds of RRP (adjusted odds ratio [aOR] 0.83, 95 % CI 0.71–0.99). Increased odds of RRP were associated with anticipating fewer negative social consequences of sex (aOR 1.18, 95 % CI 1.02–1.35), never praying (versus praying daily; aOR 1.47, 95 % CI 1.10–1.96), and never participating in church-related youth activities (versus participating once a week; 1.04, 95 % CI 1.01–1.07). Discussion After an adolescent birth, social support from family, peers, and the community can benefit young mothers. Private aspects of religiosity may be especially important. Understanding the processes by which these distal factors are linked to the likelihood of RRP is needed to create multifaceted intervention programs that provide diverse methods of support customized to specific circumstances of adolescent mothers.     

Smoking Initiation Associated With Specific Periods in the Life Course From Birth to Young Adulthood: Data From the National Longitudinal Survey of Youth 1997

Objectives. Guided by the life-course perspective, we examined whether there were subgroups with different likelihood curves of smoking onset associated with specific developmental periods.Methods. Using 12 waves of panel data from 4088 participants in the National Longitudinal Survey of Youth 1997, we detected subgroups with distinctive risk patterns by employing developmental trajectory modeling analysis.Results. From birth to age 29 years, 72% of female and 74% of US males initiated smoking. We detected 4 exclusive groups with distinctive risk patterns for both genders: the Pre-Teen Risk Group initiated smoking by age 12 years, the Teenage Risk Group initiated smoking by age 18 years, the Young Adult Risk Group initiated smoking by age 25 years, and the Low Risk Group experienced little or no risk over time. Groups differed on several etiological and outcome variables.Conclusions. The process of smoking initiation from birth to young adulthood is nonhomogeneous, with distinct subgroups whose risk of smoking onset is linked to specific stages in the life course.Studies suggest that there have been recent increases in adolescent smoking in the United States.1,2 More effective prevention requires further understanding of tobacco use etiology. Numerous researchers have documented the timing and risk of early onset of tobacco use.3–8 Although children as young as 4 to 5 years have reported smoking,3,4 the hazard of smoking onset (defined as the probability for a never-smoker to initiate smoking during a 1-year period) is relatively low (0%–3%) before age 10 years.3–6 The risk then increases rapidly to peak at around age 14 to 16 years, with initiation rates ranging from 5% to 15%, depending on study population and time of measurement, before it declines.3–6 The risk of smoking initiation in later adolescence and early adulthood remains at less than 10%.9–13Despite this general age pattern of the risk of smoking onset, it remains unclear whether there are actual subgroups with unique risk curves associated with different developmental periods. Most studies of smoking risk trajectories are based, either implicitly or explicitly, on the assumption that 1 probability curve quantifies the risk of smoking onset for all individuals across ages and developmental periods, which may not be the case. An additional limitation of the current literature is that much of the previous research has relied on cross-sectional or brief longitudinal samples of adolescents rather following adolescents through young adulthood.According to the life-course perspective,14–16 the interplay of intrapersonal factors and environmental factors determines who is at risk for smoking initiation at what time periods (i.e., ages). Such influential factors may include age- and development-related differences in individual vulnerability to tobacco use17 and external influences such as peer pressure, parental monitoring, and social support.11,18–20 Therefore, the process of smoking onset may not be homogeneous but diverse, involving subgroups of individuals with unique time patterns corresponding to different developmental periods in the life span.In general, very young children and adolescents are less likely than older adolescents to be self-motivated to smoke.21 Rather, children are likely to be influenced by external factors, such as parents and peers.22–24 For example, some young adolescents may be left home alone around friends who smoke; they may mimic others and simply pick up a cigarette. Those who pass through preadolescence without smoking may face new risks in high school. Most youths have more freedom from their parents in high school than they did previously. The increased unsupervised time allows adolescents more opportunities to start smoking when they feel the need, such as being with other smokers or feeling stressed or depressed.25,26 Research among young adults (primarily college students) indicates that lack of self-efficacy, being more rebellious, and previous use of other substances are among the most influential factors for smoking onset in this period.10,11,18Further support for the existence of subgroups for smoking initiation is the research finding of subgroups with different trajectories in frequency and amount of tobacco use.27–38 Labels vary, but typical subgroups reported by these studies include nonsmokers, occasional smokers, early and late stable smokers, escalators, and quitters. Although not linked to specific developmental periods, each subgroup has its own risk curve across the age span from adolescence to young adulthood. Additionally, researchers have found significant differences in a variety of factors among trajectory subgroups, including gender, race/ethnicity, mental health, and parental monitoring.27–38 A landmark longitudinal study found that early stable smokers had more smoking friends than experimenters, abstainers, late stable smokers, and quitters; abstainers were more likely than early and late stable smokers to have enrolled in college; and late stable smokers were least likely to be married.31We are not aware of other research examining subgroups with time patterns of smoking onset risk that are directly linked to specific periods in the life span, which has direct implications for smoking prevention. Guided by the life-course perspective, we used 12 rounds of panel data from a nationally representative sample. Our goals were to detect subgroups with distinctive time patterns regarding likelihood of smoking initiation and then to determine whether the detected subgroups varied systematically by established risk factors in adolescence and outcome measures in young adulthood.     

Media images of physicians and nurses in the United States

This paper analyzes images of physicians and nurses presented in advertisements in the medical and nursing journals JAMA (Journal of the American Medical Association) and AJN (American Journal of Nursing). Advertisements are viewed as hyper-ritualized displays of symbols and rituals associated with medical and nursing practice, both reflecting and reaffirming stereotypes and beliefs that are widely held in the society at large. Trends over the past few decades show that medical advertisements are dropping some traditional symbols (such as the white coat and stethoscope) in favor of depicting science-in-action and high technology. Nursing advertisements, however, are more frequently utilizing the symbols formerly reserved for physicians. Both physicians and nurses are depicted in their respective journals as existing largely independent of one another. While these advertisements clearly do not depict social reality, they present a fictionalized version which reflects and reproduces some of the expressed ideals in medical and nursing practice.