Colorectal Cancer Screening Among the Homeless Population of New York City Shelter-Based Clinics

Objectives. We determined colorectal cancer (CRC) screening rates, predictors, and barriers in 2 major New York City shelter-based clinics.Methods. We extracted screening rates, sociodemographic characteristics, and factors associated with homelessness from medical records of domiciled and homeless patients aged 50 years and older (n = 443) with at least 3 clinic visits between 2010 and 2012.Results. The majority of patients were African American or Hispanic, 76% were male, and 60.7% were homeless (mean = 2.4 years; SD = 2.8 years). Domiciled patients were more likely than homeless patients to be screened (41.3% vs 19.7%; P < .001). Homeless and domiciled patients received equal provider counseling, but more homeless patients declined screening (P < .001). In logistic regression, gender, race, duration of homelessness, insurance status, substance and alcohol abuse, chronic diseases, and mental health were not associated with screening, but housing, provider counseling, and older age were.Conclusions. Proposed interventions to improve CRC screening include respite shelter rooms for colonoscopy prepping, patient navigators to help navigate the health system and accompany patients to and from the procedure, counseling at all clinical encounters, and tailored patient education to address misconceptions.Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer death in the Unites States, with 53 000 largely preventable deaths annually.1,2 CRC screening reduces morbidity and mortality by 60% and is considered the standard of care.3 The US Preventive Services Task Force (USPSTF) recommends CRC screening for all adults aged 50 to 75 years and for high-risk adults until age 85 years: a fecal occult blood test (FOBT) once per year, flexible sigmoidoscopy every 5 years with an FOBT every 3 years, or screening colonoscopy every 10 years.2 Despite recommendations, screening rates for CRC remain lower than for other types of cancer.1Little is known about CRC screening practices in the homeless population,4 but this population is expanding. An estimated 3.5 million Americans experience homelessness each year, and an estimated 633 782 people experience homelessness each night in the United States.5,6 More than 15% of these individuals are chronically homeless, and more than 18% of the homeless are older than 50 years.5,7 This population is aging and has a large component of persons born during the latter part of the baby boom era. Men aged 45 to 54 years are at the highest risk for homelessness, and many of them are veterans.8 These individual are entering their 50s and are due for CRC screening.2,9,10 New York State''s homeless population surpasses the national average, and the rate of chronic homelessness is rising.5 New York City is experiencing an all-time high of homelessness, with more than 28 000 adults sleeping each night in the municipal shelter system11 and approximately 3000 living on the streets.12Barriers to CRC screening include low rates of provider recommendation and patients’ lack of CRC knowledge,13–15 invasiveness, extensive preparation, discomfort, inability to pay for screening or follow-up care or lack of medical insurance,13 lack of trust in physicians, embarrassment, absence of symptoms, and fatalistic views about cancer.16 Screening rates are particularly low in minority and low-income populations, and these groups suffer higher rates of CRC mortality, in part because cancers are detected at a later stage.1,4 Other risk factors for never having or not being up-to-date with screening recommendations are Hispanic ethnicity, low education level, low income, recent immigration status, lack of a primary care physician, and no visit to a physician in the past year.17 Interventions implemented in primary care settings to improve CRC screening rates among racial and ethnic minorities have helped improve rates significantly.18Homeless persons are especially vulnerable and suffer worse health than domiciled ethnic and minority populations. The homeless have high rates of physical illness, mental illness, and substance abuse and are at increased risk for premature death.10,19 They are less likely to have a primary care provider and to adhere to medication regimens.10 Subsistence needs often take priority over health care that is not seen as urgent, such as preventive care. Furthermore, past experiences of discrimination in the health care setting decrease their likelihood of seeking health care again.16,19A considerable portion of nondomiciled Americans would likely benefit from CRC screening. We compared CRC screening rates among a New York City homeless population and an underserved population that used the same health facilities for adherence to USPSTF recommendations and identified predictors of and barriers to screening among the homeless population.     

Health Outcomes of Obtaining Housing Among Older Homeless Adults

Objectives. We determined the impact of obtaining housing on geriatric conditions and acute care utilization among older homeless adults.Methods. We conducted a 12-month prospective cohort study of 250 older homeless adults recruited from shelters in Boston, Massachusetts, between January and June 2010. We determined housing status at follow-up, determined number of emergency department visits and hospitalizations over 12 months, and examined 4 measures of geriatric conditions at baseline and 12 months. Using multivariable regression models, we evaluated the association between obtaining housing and our outcomes of interest.Results. At 12-month follow-up, 41% of participants had obtained housing. Compared with participants who remained homeless, those with housing had fewer depressive symptoms. Other measures of health status did not differ by housing status. Participants who obtained housing had a lower rate of acute care use, with an adjusted annualized rate of acute care visits of 2.5 per year among participants who obtained housing and 5.3 per year among participants who remained homeless.Conclusions. Older homeless adults who obtained housing experienced improved depressive symptoms and reduced acute care utilization compared with those who remained homeless.Over the past 2 decades, the proportion of the homeless population aged 50 years and older has increased substantially. In 1990, only 11% of single homeless adults were aged 50 years and older, but this percentage increased to 32% by 20031 and is nearly 50% today.2 Homeless adults aged 50 years and older have health problems distinct from those of younger homeless adults, including higher rates of medical comorbidities3 and of geriatric conditions such as functional and cognitive impairment.4,5 Because homeless adults in their 50s develop medical and geriatric conditions at rates typical of adults 15 to 20 years older in the general population,4,5 experts consider homeless adults to be elderly at age 50 years, 15 years earlier than housed adults.4,6Among elderly adults who have geriatric conditions, environmental factors play a central role in maximizing and maintaining independence. Older adults who live in a stable housing environment may be able to adapt to geriatric impairments more easily and maintain their independence longer than those who lack these advantages.7,8 By contrast, older adults who live in shelters or on the street may encounter great difficulty in modifying their environment to accommodate functional impairments and other geriatric conditions.9 Moreover, adaptive equipment used to cope with impairments—such as glasses, hearing aids, or walkers—may be lost or stolen. This mismatch between older homeless people’s environment and their abilities may magnify the negative effect of geriatric conditions on their quality of life and ability to function independently, leading to the premature need for costly long-term care.9,10Experts have hypothesized that access to housing could ameliorate high rates of disability and other geriatric conditions among older homeless people and prevent or delay institutionalization.9 Studies of the adult homeless population have supported the putative health benefits of housing, having found decreased rates of acute care utilization after housing is received.11–13 However, little is known about the impact of housing on the unique health concerns of older homeless adults, including the geriatric conditions that play a key role in health and quality of life.Therefore, we conducted a prospective cohort study of 250 older homeless adults in Boston, Massachusetts. We previously described the high prevalence of geriatric conditions at baseline in this cohort.5 The goal of this study was to determine whether obtaining housing was associated with subsequent improvements in health status and geriatric conditions and decreased use of acute care.     

Emergency Care for Homeless Patients: A French Multicenter Cohort Study

Objectives. To determine whether homeless patients experience suboptimal care in the emergency department (ED) by the provision of fewer health care resources.Methods. We conducted a prospective multicenter cohort study in 30 EDs in France. During 72 hours in March 2015, all homeless patients that visited the participating EDs were included in the study. The primary health care service measure was the order by the physician of a diagnostic investigation or provision of a treatment in the ED. Secondary measures of health care services included ED waiting time, number and type of investigations per patient, treatment in the ED, and discharge disposition.Results. A total of 254 homeless patients and 254 nonhomeless patients were included. After excluding homeless patients that attended the ED for the sole purpose of housing, we analyzed 214 homeless and 214 nonhomeless. We found no significant difference between the 2 groups in terms of health care resource consumption, and for our secondary endpoints.Conclusions. We did not find significant differences in the level of medical care delivered in French EDs to homeless patients compared with matched nonhomeless patients.On any given night in the European Union, 400 000 people are homeless.1,2 In France, the total number of homeless people increased by 44% between 2001 and 2012.2 These patients experience a high disease burden: it has been reported that there is a higher prevalence in the homeless population of various diseases such as mental illness, substance abuse, injuries, infectious diseases, and cardiovascular diseases than in the general population.1,3–7 Homeless patients seem to be admitted to hospital 10 to 15 years earlier than nonhomeless inpatients for the same diseases, and functional impairment occurs 20 years earlier than in nonhomeless patients.8–10 The all-cause mortality rate among homeless patients at any age is higher than in the general population, which in part is attributable to suicide and unintentional injuries.1,6,11,12Homeless patients often delay seeking medical care. Because they have difficulties in accessing health care, they have a lower rate of access to primary care than the general population.13,14 Their delayed health care can be attributed to a lack of medical insurance coverage, transportation barriers, or competing priorities (such as looking for food or shelter).15 However, homelessness is reported to be an independent risk factor for emergency department (ED) attendance and those patients are more likely to return to the ED after hospitalization.14,16–20 These ED frequent users are seen as prone to difficult behavior and little compliance to treatment.15,21 Some studies have shown that care providers may feel that homeless patients do not receive standard ED care.22–24Even though homeless patients are often frequent ED users, there is scarce literature on health care resource consumption from homeless people in the ED, especially in Europe. As it has been described in other frail populations (such as older patients25,26), we tested the hypothesis that homeless patients experience suboptimal care, by the provision of fewer health care resources.     

Influenza and Seasonal Patterns of Hospital Use by Older Adults in Long-Term Care and Community Settings in Ontario,Canada

Objectives. We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings.Methods. We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates.Results. Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%–20%) in LTC and 28% (27%–29%) in the community. Results for hospital admissions were comparable.Conclusions. We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.Influenza has been identified as among the top 10 infectious agents that are causes of health burden,1 and it continues to create significant morbidity and mortality among older adults. Individuals older than 65 years, in particular those with preexisting chronic conditions, are at increased risk for hospitalization2,3 and death4,5 associated with influenza. The Canadian province of Ontario first introduced universal influenza immunization in 2000, granting all provincial residents aged 6 months or older the option for annual immunization without out-of-pocket cost. Although immunization coverage in the general population remains relatively low, levels are highest among community-dwelling adults older than 65 years, with coverage exceeding 70%.6For residents of long-term care (LTC) facilities, also known as nursing homes, immunization coverage generally exceeds 90% in Ontario7 and 80% in other jurisdictions, mainly because of concerted efforts to reach this group.8,9 LTC residents are a particularly vulnerable segment of the older population, with an average age of 80 years, significant cognitive and physical impairments, and a high burden of complex chronic conditions, including cardiovascular and respiratory illnesses. Despite high immunization coverage in residents, influenza continues to cause significant burden. Influenza has been associated with increased rates of functional decline and pressure ulcers in this group.10 It is also among the most common reasons for transfer to the hospital and accounts for a significant proportion of mortality in this population.11–13A single study reported that rates of hospitalization for influenza were 3 times as high among LTC as among community residents, both during and before the identified influenza season.14 In addition to their heightened vulnerability, LTC residents face other risk factors for infection, including congregate living and shared bedrooms, that community residents do not experience. Because of this, LTC is targeted for strong infection prevention and control (IPC) measures, including staff immunization. Although evidence from Ontario suggests that LTC staff immunization rates are generally higher than 70%,7 well above that reported in hospitals, other evidence points to generally poor compliance with other IPC practices.15To date, little is known about the burden of influenza in LTC and how it compares to that in the community. Our objectives were to compare the burden of influenza, as measured by hospital use, both emergency department (ED) visits and inpatient admissions, among older adults in LTC and community settings.     

Impact of Health Insurance Status and a Diagnosis of Serious Mental Illness on Whether Chronically Homeless Individuals Engage in Primary Care

Objectives. We evaluated the impact of a diagnosis of serious mental illness on use of a primary care provider (vs the emergency department [ED]) as a source of care by people who were chronically homeless.Methods. We used data from 750 chronically homeless adults enrolled in the 11-site Collaborative Initiative to Help End Chronic Homelessness and identified demographic and clinical characteristics independently associated with using a primary care provider rather than an ED.Results. The factor most strongly associated with using the ED as a regular source of medical care was previous-year lack of health insurance. Despite high rates of serious mental illness, neither a diagnosis of serious mental illness nor increased severity of psychiatric symptoms was associated with such use.Conclusions. Findings suggest that people who are chronically homeless and have chronic medical illness would be more likely to access care if they had health insurance. Individual states’ deciding not to expand Medicaid coverage will likely have a tremendous impact on the health outcomes and health care costs associated with this and other vulnerable populations.On a typical night in 2010, approximately 650 000 people were homeless in the United States.1 Although most people are homeless for only a brief period of time, an estimated 10% have experienced chronic homelessness, defined as continuous homelessness for 1 year or more or at least 4 episodes of homelessness in the past 3 years.1 Most people experiencing chronic homelessness have chronic health problems and typically have multiple co-occurring conditions.2 Chronic homelessness has been associated with an increased risk of mortality, with reports of age-adjusted death rates of 2 to 4 times that of the general population3 and even higher mortality rates from trauma and suicide.4 Specific chronic medical conditions (HIV, liver disease, and arrhythmia) have been associated with the greatest risk of death.5For many chronically homeless individuals, competing demands for shelter, food, and safety supersede the subjective need for primary medical care.6 This issue is of critical importance, given recent evidence that improved access to primary care reduces mortality7 and that individuals without a primary care provider (PCP) are less likely to receive recommended preventive care8 and more likely to have poor health outcomes, such as diabetic ketoacidosis9 or severe uncontrolled hypertension.10 Homeless people are less likely than domiciled individuals to use ambulatory care services,11 relying to a greater extent on emergency department (ED) visits and costly inpatient hospitalizations.12 The cost of inpatient services for people who are homeless may substantially affect the health care system because almost one quarter of homeless people in the United States report a hospitalization within the previous year.13 Homeless patients on medical and surgical services remain hospitalized longer than housed patients, resulting in substantial excess costs.14Homeless individuals are 3 times more likely to use the ED than are nonhomeless people.15 A recent large national study of ED use demonstrated that homeless people who seek care in urban EDs come by ambulance, are more likely to lack medical insurance, and have psychiatric and substance use diagnoses than are people who are not homeless.16 Homeless individuals also appear to use the ED for routine, nonemergency medical needs,16,17 often for preventable medical problems.18Previous research has attempted to determine rates and predictors of medical service use among homeless samples.11,19–22 The behavioral model for vulnerable populations is a conceptual model for health service use and medical outcomes of people such as those who are chronically homeless.23 This model predicts the use of health services on the basis of predisposing, enabling, and need factors and identifies the particular challenges vulnerable groups face in obtaining necessary services. This model has been applied to homeless populations, and findings from these studies have suggested that among homeless individuals, drug use increases the risk of medical hospitalization, and psychological distress (self-report of mood over the past 4 weeks) is associated with barriers to obtaining outpatient medical care.24The impact of serious psychiatric illness and psychiatric symptom severity on engagement in primary care has not previously been specifically evaluated among chronically homeless individuals. Serious mental illness (schizophrenia or bipolar disorder) may be a more important determinant of underuse of PCPs among homeless people than are logistical barriers such as lack of insurance. Compared with the general population, people who are homeless have substantially higher rates of psychiatric and substance use disorders.25,26 Evidence has also shown that individuals with serious mental illness underuse primary care even after accounting for their medical need27 and that severity of psychiatric illness might increase the risk of frequent ED use.28 In the current study, we identified factors associated with having a regular PCP, as contrasted with relying on ED services as a usual source of care, in a national sample of chronically homeless individuals. In particular, we evaluated the impact of a diagnosis of serious mental illness and psychiatric symptom severity on having a regular source of care.     

Environmental Factors Associated With Social Participation of Older Adults Living in Metropolitan,Urban, and Rural Areas: The NuAge Study

Objectives. We compared the social participation of older adults living in metropolitan, urban, and rural areas, and identified associated environmental factors.Methods. From 2004 to 2006, we conducted a cross-sectional study using an age-, gender-, and area-stratified random sample of 1198 adults (aged 67–82 years). We collected data via interviewer-administered questionnaires and derived from Canadian censuses.Results. Social participation did not differ across living areas (P = .09), but after controlling for potential confounding variables, we identified associated area-specific environmental variables. In metropolitan areas, higher social participation was associated with greater proximity to neighborhood resources, having a driver’s license, transit use, and better quality social network (R² = 0.18). In urban areas, higher social participation was associated with greater proximity to neighborhood resources and having a driver’s license (R² = 0.11). Finally, in rural areas, higher social participation was associated with greater accessibility to key resources, having a driver’s license, children living in the neighborhood, and more years lived in the current dwelling (R² = 0.18).Conclusions. To enhance social participation of older adults, public health interventions need to address different environmental factors according to living areas.Social participation, which is defined as the involvement of the person in activities that provide interactions with others in the community,1 is a key element of successful2 and healthy3,4 aging that ensures survival and development of people in society throughout their existence.5 As a modifiable target of health interventions, social participation is conceptualized by the Human Development Model and Disability Creation Process to be the result of bidirectional interaction between personal and environmental factors.5 Some personal factors,6 including age, gender, and health, are recognized as being related to social participation.2 Environmental factors (i.e., aspects that are extrinsic to individuals and generate a reaction from them)7 relate to the immediate social and physical environment to which individuals, especially older adults, are exposed. Environmental factors may act as facilitators or barriers to the accomplishment of social and community activities.5 Environmental factors are also important because interventions targeting the environment may have a greater impact on an individual’s social participation than those targeting individual factors.8To date, some theoretical and empirical evidence supports associations between specific environmental factors and social participation.9 For example, the Human Development Model and Disability Creation Process showed that support, attitude, services, systems, policies, and accessibility of the physical environment can be associated with social participation.5 Another study demonstrated that user-friendliness of the physical environment and access to transport facilities promote older adults’ social participation in both urban and rural areas.10 Favorable characteristics, such as proximity to resources and services, including access to food shopping, health services, banking, and social or sports clubs, are also important factors.11,12 Moreover, independently of individual demographic and socioeconomic characteristics, older adults living in affluent areas are less likely to have lower social participation.13 Support from the social environment14 and resource accessibility in the physical environment11 may be seen as imperatives to help individuals with disabilities living in the community.15 The presence of local resources may have an impact on the likelihood of initiating and maintaining social links with community members.16 However, little is known about which environmental factors are associated with social participation of older adults according to living area. Living in metropolitan, urban, or rural areas can have an impact on many personal factors, such as health and well-being, as well as on several environmental factors (e.g., neighborhood socioeconomic status or access to services and transportation). For example, access to public transport for people living in rural areas may be limited, which can be a challenge.17 To our knowledge, only 1 study18 compared social participation of older people living in metropolitan, urban, and rural areas. Despite area differences in income, access to public transportation, services and resources, automobile use, satisfaction with social support, and sense of security, no significant difference was found in social participation and its associated factors.18 In our study, which involved 350 older adults, we operationalized social participation by the level of difficulty and assistance required in targeted daily activities and social roles. Because having a better understanding of older adults’ social participation according to their living environment could improve the development of public health services, further studies operationalizing social participation by the frequency of involvement in social activities and considering other environmental factors are needed. We aimed to compare social participation of older adults living in metropolitan, urban and rural areas, and identified associated environmental factors.     

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.     

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.     

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.     

Prevalence of Undiagnosed Acute and Chronic HIV in a Lower-Prevalence Urban Emergency Department

Objectives. We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of emergency department (ED) patients from a region of the United States with low-to-moderate HIV prevalence.Methods. This cross-sectional seroprevalence study consecutively enrolled patients aged 18 to 64 years within randomly selected sampling blocks in a Midwestern urban ED in a region of lower HIV prevalence in 2008 to 2009. Participants were compensated for providing a blood sample and health information. After de-identification, we assayed samples for HIV antibody and nucleic acid.Results. There were 926 participants who consented and enrolled. Overall, prevalence of undiagnosed HIV was 0.76% (95% confidence interval [CI] = 0.30%, 1.56%). Three participants (0.32%; 95% CI = 0.09%, 0.86%) were nucleic acid–positive but antibody-negative and 4 (0.43%; 95% CI = 0.15%, 1.02%) were antibody-positive.Conclusions. Even when the absolute prevalence is low, a considerable proportion of undetected HIV cases in an ED population are acute. Identification of acute HIV in ED settings should receive increased priority.HIV screening is recommended by the US Centers for Disease Control and Prevention as an essential component of the nation’s HIV prevention effort.1,2 Emergency departments (EDs) are particularly emphasized as venues for HIV screening.3–5 Emergency departments serve more than 100 million patients annually, readily accessing vulnerable populations with a high prevalence of undetected HIV.1,4–8To date, most attention has been focused on detection of HIV in the chronic phase, after seroconversion, by assay for antibodies. Yet identification of patients during acute HIV infection could have a significant impact on further transmission.9,10 Testing for acute HIV infection is accomplished by assays that detect viral proteins or viral genetic material before antibody detection is possible. This testing is more expensive, complex, or may delay results compared with antibody testing.9,11,12 Despite these disadvantages, screening for acute HIV is increasingly suggested by various authors.9,13–19 Acute HIV infection is thought to contribute disproportionately to HIV incidence because of high viral replication and increased infectiousness during this phase.15,20–22 Diagnosis prompts many individuals to reduce transmission behaviors,23 and partner notification efforts may be more successful.24 There is also renewed interest in treatment during acute HIV infection, to lower infectiousness and improve long-term patient health outcomes.21,25–27 In light of these benefits, screening for acute HIV infection may ultimately be cost-effective and worthy of increased logistical challenges.9,28Unfortunately, the controversies and implementation barriers in HIV screening have yet to be fully resolved,29–35 particularly in ED settings where patient volumes exceed capacity and acute stabilization takes precedence over preventive health.36–38 Screening in the ED for acute HIV infection will be even more challenging than screening for chronic HIV if it entails additional complexity and expense. Motivation to surmount such barriers is likely to be less in regions of lower HIV prevalence, in which disease incidence would also be presumed lower. Improving our understanding of acute HIV epidemiology in ED settings is fundamental for guiding potential implementation of ED screening interventions targeting acute HIV infection. We estimated the seroprevalence of both acute and chronic HIV infection by using a random sample of ED patients from a low-to-moderate HIV prevalence region of the United States.     

Diverging Trends in the Incidence of Occupational and Nonoccupational Injury in Ontario, 2004–2011

Objectives. We describe trends in occupational and nonoccupational injury among working-age adults in Ontario.Methods. We conducted an observational study of adults aged 15 to 64 over the period 2004 through 2011, estimating the incidence of occupational and nonoccupational injury from emergency department (ED) records and, separately, from survey responses to 5 waves of a national health interview survey.Results. Over the observation period, the annual percentage change (APC) in the incidence of work-related injury was −5.9% (95% confidence interval [CI] = −7.3, −4.6) in ED records and −7.4% (95% CI = −11.1, −3.5) among survey participants. In contrast, the APC in the incidence of nonoccupational injury was −0.3% (95% CI = −0.4, 0.0) in ED records and 1.0% (95% CI = 0.4, 1.6) among survey participants. Among working-age adults, the percentage of all injuries attributed to work exposures declined from 20.0% in 2004 to 15.2% in 2011 in ED records and from 27.7% in 2001 to 16.9% in 2010 among survey participants.Conclusions. Among working-age adults in Ontario, nearly all of the observed decline in injury incidence over the period 2004 through 2011 is attributed to reductions in occupational injury.Although most developed countries have made progress in improving population health over the past 2 decades, reductions in the burden of mortality, morbidity, and disability attributed to injury have been uneven.1 In the United States, the age-standardized death rate from motor vehicle collisions declined by 30% between 1990 and 2010. By contrast, the age-standardized death rate from falls and poisonings increased by 71% and 128%, respectively, over the period 2000 through 2009.2 A recent surveillance report on injury mortality in Canada found that the share of all-cause mortality attributed to injury increased over the period 2001 through 2007.3 Injury remains the leading cause of death among persons aged younger than 45.4The burden of injury among working-age adults arises from occupational and nonoccupational exposures. Although the reduction in hazardous exposures arising from work has been listed as among the 10 most important public health contributions to the improvement in population health over the past 100 years,5 work exposures continue to cause a large fraction of injury morbidity, responsible for as much as 25% of the burden of injury in working-age adults.6The objective of surveillance in public health and occupational health is the systematic and ongoing assessment of population health status, based on the timely collection, analysis, and dissemination of information on health status and health risks.7 Over the past 2 decades, the population surveillance of injury morbidity has made strengthened use of health interview surveys6,8,9 and administrative records of health care utilization, particularly emergency department (ED) records.10–17 These data sources can be used effectively to identify important trends in injury incidence and, if well-designed, can document occupational and nonoccupational injury causation.We estimated trends in the incidence of occupational and nonoccupational injury in Ontario over the period 2004 through 2011 for adults aged 15 to 64, drawing on a census of ED records and participants in national health interview surveys.     

Gender-Stratified Models to Examine the Relationship Between Financial Hardship and Self-Reported Oral Health for Older US Men and Women

Objectives. We evaluated the relationship between financial hardship and self-reported oral health for older men and women.Methods. We focused on adults in the 2008 Health and Retirement Study (n = 1359). The predictor variables were 4 financial hardship indicators. We used Poisson regression models to estimate the prevalence ratio of poor self-reported oral health.Results. In the non–gender-stratified model, number of financial hardships was not significantly associated with self-reported oral health. Food insecurity was associated with a 12% greater prevalence of poor self-reported oral health (95% confidence interval [CI] = 1.04, 1.21). In the gender-stratified models, women with 3 or more financial hardships had a 24% greater prevalence of poor self-reported oral health than women with zero (95% CI = 1.09, 1.40). Number of hardships was not associated with self-reported oral health for men. For men, skipping medications was associated with 50% lower prevalence of poor self-reported oral health (95% CI = 0.32, 0.76).Conclusions. Number of financial hardships was differentially associated with self-reported oral health for older men and women. Most financial hardship indicators affected both genders similarly. Future interventions to improve vulnerable older adults’ oral health should account for gender-based heterogeneity in financial hardship experiences.The Institute of Medicine’s 1998 publication Gender Differences in Susceptibility of Environmental Factors called attention to how socioeconomic factors differentially affect health outcomes for men and women.1 Gender-based health disparities are pronounced among older adults.2,3 In 2010, 25% of the US population was aged 55 years or older, a 15% increase from 2000.4 Advances in chronic disease management have improved adult life expectancy,5–12 making older adults the fastest growing subgroup in the United States. The close relationship between oral and systemic health13–15 has motivated interest in addressing oral health disparities in older adults, particularly among those who are financially vulnerable.16Poverty and low socioeconomic status (SES) are associated with tooth decay, gum diseases, and oral cancers—all of which are indicators of poor oral health.17–28 Older men and women are at differential risk for dental diseases and conditions.29,30 For instance, older men are more likely to have untreated tooth decay,31,32 gum disease,33 and oropharyngeal cancer34 whereas older women are more likely to have missing teeth and to be edentulous.29 Dental care use by women partially explains this heterogeneity in disease risk35 although the mechanisms underlying gender-based differences have not been elucidated. Differential risk for dental disease may translate to differences in self-reported oral health. Based on 1999–2004 US National Health and Nutrition Examination Survey data, a larger proportion of men aged 65 years and older reported fair or poor oral health compared with women (40.1% and 36.9%, respectively).29 Although 2 studies suggest that self-reported oral health measures are weakly associated with dental disease status as assessed by a dentist,36,37 most studies have concluded that self-reported oral health is a valid and reliable measure of clinical oral health.38–41There is a growing body of literature on gender, socioeconomic inequality, and health disparities.42–45 Most studies have focused on traditional measures of SES such as education, income, or occupation.46–48 However, these measures do not adequately capture the multiple pathways by which socioeconomic and financial circumstances influence health.49–53 For example, focusing on income alone may not fully capture an individual’s ability to garner resources to meet financial obligations.54 Alternative SES measures such as financial hardship have been shown to have an impact on health over and above traditional measures of SES.55,56 Furthermore, recent studies suggest that alternative SES measures, which account for economic resources, assets, and household material conditions, are moderated by gender on outcomes such as self-rated health, psychological distress, musculoskeletal disorders, and mortality.55–58 This interaction is particularly relevant for older adults, many of whom are retired or are preparing to exit the workforce.59Currently, there is little understanding of how gender and financial hardship interact on oral health outcome measures. In addition, the studies relevant to adult oral health have 2 limitations: (1) the inclusion of both younger and older adults in the same models, which assumes that the relationship between socioeconomic indicators and oral health is homogeneous across the adult life span20,22,27,47; and (2) the lack of gender-stratified models,28 which treats gender as a confounder rather than as an effect modifier.The aim of the present study was to test the hypothesis that the association between financial hardship and self-reported oral health is different for women and men. This research continues the line of work aimed at identifying ways to improve the oral health of vulnerable older adults, and has important implications in the development of interventions and policies that address gender-based disparities in adult oral health.60,61     

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.     

The Next Generation of Users: Prevalence and Longitudinal Patterns of Tobacco Use Among US Young Adults

Objectives. We monitored the prevalence and patterns of use of the array of tobacco products available to young adults, who are at risk for initiation and progression to established tobacco use.Methods. We used data from waves 1 to 3 of GfK’s KnowledgePanel (2011–2012), a nationally representative cohort of young adults aged 18 to 34 years (n = 2144). We examined prevalence and patterns of tobacco product use over time, associated demographics, and state-level tobacco policy. We used multivariable logistic regression to determine predictors of initiation of cigarettes as well as noncombustible and other combustible products.Results. The prevalence of ever tobacco use rose from 57.28% at wave 1 to 67.43% at wave 3. Use of multiple products was the most common pattern (66.39% of tobacco users by wave 3). Predictors of initiation differed by product type and included age, race/ethnicity, policy, and use of other tobacco products.Conclusions. Tobacco use is high among young adults and many are using multiple products. Efforts to implement policy and educate young adults about the risks associated with new and emerging products are critical to prevent increased initiation of tobacco use.The 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA)1 gave the US Food and Drug Administration (FDA) the authority to regulate tobacco and marked a new beginning in the field of tobacco control. A number of restrictions arising from the FSPTCA have already taken place, including banning characterizing flavors in cigarettes and tobacco brand sponsorships of sports and entertainment events.1 At the same time, there has been increased use of noncigarette combustible products, such as cigars,2 and the introduction of several noncombustible tobacco products (NCPs), including e-cigarettes and snus. A spokesman for Phillip Morris recently called NCPs their “most exciting growth opportunity,”3^(p5) and several tobacco companies have endorsed their development for harm reduction.4–6 However, rather than promoting these products as a substitution for cigarettes, they are often advertised as an extension of major cigarette brands7 and promoted for use alongside cigarettes.8,9 These new products—as well as other noncigarette combustible products such as cigars and hookahs—also may be especially attractive to young adults.10–12Since the 1998 Master Settlement Agreement put forth restrictions on tobacco industry marketing to youths,13 young adults have become an increasingly important target audience.14,15 This is evident in the data, as approximately 20% of young adults still smoke cigarettes,16 and recent national data show that young adults aged 18 to 25 years had the highest prevalence of current tobacco use (40.8%) compared with youths (ages 12–17 years) or adults (ages 26 years and older).17 Use of certain noncigarette products are particularly high; for example, data from a nationally representative sample found that 30% of young adults aged 18 to 34 years had ever used cigars; 26% had used little cigars, cigarillos, or bidis; and 18% had used a hookah.18 This last finding corroborates other studies reporting high rates of hookah use among young adults,19–23 reaching past 30-day rates of 8.5% among college-age students.19 Young adults were also more likely than older adults to have ever used snus,10 and expressed interest in experimenting with the product.24 e-Cigarette use has also been reported to be inversely related to age,25,26 with rates in adults decreasing by 2% to 3% with every year of increased age.11Tobacco use is the number one cause of preventable death in America27 and results in almost 5.2 million years of potential life lost each year.28 In light of the increasingly diversified tobacco product marketplace, and the introduction of products that currently fall outside FDA regulatory authority, it is critical to monitor tobacco product use among young adults. This includes not only current, regular use but also experimentation. To decrease the prevalence and improve long-term health outcomes, focus should be extended to understanding to what extent consumers are using multiple tobacco products (poly-use). Little is known about patterns of poly-use, but studies suggest that this is becoming increasingly prevalent among young adults. For example, a recent study found that 30% of young adult current tobacco users had ever used multiple tobacco products,18 which corroborates findings in other samples.29,30 Another nationally representative study reported the highest prevalence of poly-use among those aged 18 to 24 years compared with those aged 25 years and older.17 This has implications as poly-users may have higher rates of nicotine addiction,7,31 may have more withdrawal symptoms during quit attempts,31 and may be less likely to quit.32Young adulthood marks a critical developmental period,33 one that often coincides with the both the initiation34–36 and establishment of regular tobacco use.35–37 Prevention efforts directed at this audience will depend on a precise understanding of the degree to which young adults are using different tobacco products. To address this, we examined the prevalence and patterns of tobacco product use over time, demographic correlates of use, and predictors of initiation among a large, nationally representative cohort of young adults. Data will help inform program planners and policymakers on the impact of new and alternative tobacco product use among young adults.     

Suicide Risk in Nursing Homes and Assisted Living Facilities: 2003–2011

Objectives. We investigated the epidemiology of suicide among adults aged 50 years and older in nursing homes and assisted living facilities and whether anticipating transitioning into long-term care (LTC) is a risk factor for suicide.Methods. Data come from the Virginia Violent Death Reporting System (2003–2011). We matched locations of suicides (n = 3453) against publicly available resource registries of nursing homes (n = 285) and assisted living facilities (n = 548). We examined individual and organizational correlates of suicide by logistic regression. We identified decedents anticipating entry into LTC through qualitative text analysis.Results. Incidence of suicide was 14.16 per 100 000 in nursing homes and 15.66 in the community. Better performance on Nursing Home Compare quality metrics was associated with higher odds of suicide in nursing homes (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.21, 3.14). Larger facility size was associated with higher suicide risk in assisted living facilities (OR = 1.01; 95% CI = 1.00, 1.01). Text narratives identified 38 decedents anticipating transitioning into LTC and 16 whose loved one recently transitioned or resided in LTC.Conclusions. LTC may be an important point of engagement in suicide prevention.Approximately 40% of adults aged 65 years and older will need skilled residential nursing care at some point in their lifetime.1 Older adults have among the highest suicide risks in the United States2; the rate of suicide among men aged 65 years and older is 30 per 100 000; by contrast, it is 7 per 100 000 for men younger than 25 years.3 A key element of suicide prevention is the identification of points of engagement to interact with potential victims.4 Risk factors for suicide, such as social isolation, depression, and functional impairment, are common among long-term care (LTC) residents,5–7 and these facilities may therefore be important locations for preventing suicide among older adults. Indeed, the 1987 Nursing Home Reform Act mandated screening of LTC admissions to facilitate appropriate placement and increased psychiatric services,8 and the Minimum Data Set 3.0 includes a mandatory screener for depressive symptoms and suicidal ideation.9 Nearly 1.5 million adults reside in nursing homes,10,11 and another 1 million reside in assisted living facilities.12Little is known regarding risk and protective factors for suicide in LTC.13 In 2011 the Substance Abuse and Mental Health Services Administration released a tool kit on preventing suicide in senior-living communities, which notes,

We do not know how many residents of senior living communities attempt suicide or die by suicide. But, we do know that a suicide in a facility . . . profoundly impacts the lives of everyone concerned—residents, families, and staff.^14(p4)

Suicidal ideation is common among LTC residents, with between 5% and 33% reporting ideation (active or passive) within the past month.15 As a result, suicide risk may be substantial in these facilities despite countervailing factors such as regular monitoring by staff and limited access to lethal means. The handful of studies that have compared incidence of completed suicide in LTC to the general community are mixed, with 1 reporting higher16 and another reporting lower17 risk in these settings.Suicidal behavior in LTC likely reflects a combination of factors shared with community cases (e.g., presence of a psychiatric disorder), as well as factors that are unique to LTC (e.g., facility characteristics). For example, bed size (number of beds) and high staff turnover have been associated with higher risk of suicidal behaviors among residents.18,19 However, these studies were conducted in the 1980s, prior to the growth of assisted living,20 which reduces their applicability to modern facilities. Finally, it is unknown whether the transition to LTC, or the process of having a loved one transition, is a risk factor for suicide.21 These transitions often involve a complex interplay of social and psychological factors, including feelings of autonomy, social connectedness, and identity,22,23 and can produce feelings of anxiety, loneliness, and hopelessness because they affect a people’s sense of being at home, which is not simply their physical residence.24 Such transitions have potential implications for the psychological well-being of caregivers of the person moving into LTC as well.25To identify whether LTC settings are important points of engagement for reducing suicide risk among older adults,4,26 we analyzed data from the 2003 to 2011 Virginia Violent Death Reporting System (VVDRS). We aimed to (1) describe the epidemiology of completed suicide in nursing homes and assisted living facilities, (2) examine whether facility characteristics were related to suicide risk, and (3) assess whether the process of transitioning into an LTC facility was associated with suicide.     

Loose Cigarette Purchasing and Nondaily Smoking Among Young Adult Bar Patrons in New York City

Objectives. We examined loose cigarette (loosie) purchasing behavior among young adult (aged 18–26 years) smokers at bars in New York City and factors associated with purchase and use.Methods. Between June and December 2013, we conducted cross-sectional surveys (n = 1916) in randomly selected bars and nightclubs. Using multivariable logistic regression models, we examined associations of loose cigarette purchasing and use with smoking frequency, price, social norms, cessation behaviors, and demographics.Results. Forty-five percent (n = 621) of nondaily smokers and 57% (n = 133) of daily smokers had ever purchased a loosie; 15% of nondaily smokers and 4% of daily smokers reported that their last cigarette was a loosie. Nondaily smokers who never smoked daily were more likely than were daily smokers to have last smoked a loosie (odds ratio = 7.27; 95% confidence interval = 2.35, 22.48). Quitting behaviors and perceived approval of smoking were associated with ever purchasing and recently smoking loosies.Conclusions. Loosie purchase and use is common among young adults, especially nondaily smokers. Smoking patterns and attitudes should be considered to reduce loose cigarette purchasing among young adults in New York City.Widespread adoption of clean indoor air laws and cigarette tax increases denormalize smoking behavior1 and decrease smoking rates.2,3 Although increasing taxes is one of the most effective means of smoking prevention and reduction,3 the increased price of cigarettes can also lead to tax-avoidant behaviors, such as buying untaxed packs smuggled from states with lower cigarette taxes and purchasing loose cigarettes, or “loosies.”4–6 In New York City (NYC), where a cigarette pack costs about $11.50, it has become common for smokers to purchase discounted packs and individual cigarettes from street peddlers and friends.7,8Much of the research exploring loosie purchasing in the United States has focused on underage or low-income minority populations, often in urban areas.7,9,10 One study found that in early 1993, 70% of stores in central Harlem sold loosies to minors.7 Another study conducted with a 2005–2006 convenience sample in inner-city Baltimore found that 77% of African American smokers aged 18 to 24 years had purchased loosies in the past month.11 Similarly, loosie purchasing in Mexico was more common among younger smokers with lower incomes.12Availability and visibility of loosies can promote smoking and encourage relapse.13 We defined nondaily smokers as those who smoked on 1 to 29 of the past 30 days.14,15 Shiffman et al. found that nondaily smokers were more likely than daily smokers to report that social and environmental stimuli motivated their smoking behavior.16 More specifically, cues such as taste, smell, social goading to smoke, and specific situations (e.g., smoking after meals) are more likely to be reported as motivators to smoke by nondaily smokers than by daily smokers.16 Because social–environmental cues have substantial impact on nondaily smokers’ motivation to smoke, it is likely that the cue of seeing loosies in one’s environment also motivates nondaily smokers to smoke.16Previous research substantiates this claim, with 1 study showing that people who regularly saw loosies available for purchase were more likely to be current smokers.17 Therefore, the widespread availability of loosies may have a greater impact on nondaily smokers. Nondaily smokers make up a third of US smokers,18,19 and nondaily smoking is increasingly common among young adults.20 Many young adults who smoke on only some days do not self-identify as smokers,21 and nondaily smoking is frequently paired with alcohol consumption.22–24 Nondaily and light smoking carry a lower, but substantial, risk for lung cancer and a similar risk as does daily smoking for cardiovascular disease.25–27 Occasional smokers also have higher smoking-related morbidity and mortality than do people who have never smoked.26,28–30Nondaily smoking can be a long-term behavior pattern31,32 or a transition to or from daily smoking.31 Nondaily smokers include different subgroups that may have very different smoking patterns or motivations to quit.33,34 Nondaily smokers who previously smoked daily have been defined in previous research as converted nondaily smokers. Nondaily smokers who have never smoked daily are defined as native nondaily smokers.18,19 Important differences exist between these subgroups of smokers: converted nondaily smokers are more likely to quit smoking than are native nondaily smokers and daily smokers,18,19 although most converted and native nondaily smokers were unable to remain abstinent for more than 90 days.19Loosie purchasing and use may play an important role in promoting continued tobacco use among nondaily smokers. The 2010 NYC Community Health Survey35 found that more than one third (34%) of young adult nondaily smokers (aged 18–26 years) reported that their last cigarette smoked was a loosie, compared with 14% of young adult daily smokers. Another study of NYC adults demonstrated that nondaily smokers were more likely to purchase loose cigarettes than were light and heavy smokers.36 To the best of our knowledge, little is known about the factors associated with loosie purchasing among nondaily smokers in the United States.We sought to better understand the factors associated with loosie purchasing among NYC young adults, specifically to determine (1) loosie purchase and use rates among converted nondaily, native nondaily, and daily smokers; (2) whether loosie purchase or use are associated with perceived social norms of smoking behavior; and (3) whether loosie purchasing is associated with smoking cessation intention or behavior.     

Impact of Alcohol Use and Bar Attendance on Smoking and Quit Attempts Among Young Adult Bar Patrons

Objectives. We examined cigarette smoking and quit attempts in the context of alcohol use and bar attendance among young adult bar patrons with different smoking patterns.Methods. We used randomized time location sampling to collect data among adult bar patrons aged 21 to 26 years in San Diego, California (n = 1235; response rate = 73%). We used multinomial and multivariate logistic regression models to analyze the association between smoking and quit attempts and both drinking and binge drinking among occasional, regular, very light, and heavier smokers, controlling for age, gender, race/ethnicity, and education.Results. Young adult bar patrons reported high rates of smoking and co-use of cigarettes and alcohol. Binge drinking predicted smoking status, especially occasional and very light smoking. All types of smokers reported alcohol use, and bar attendance made it harder to quit. Alcohol use was negatively associated with quit attempts for very light smokers, but positively associated with quitting among heavier smokers.Conclusions. Smoking and co-use of cigarettes and alcohol are common among young adult bar patrons, but there are important differences by smoking patterns. Tobacco interventions for young adults should prioritize bars and address alcohol use.Tobacco is responsible for approximately 443 000 deaths in the United States annually,1,2 but cessation before the age of 30 years avoids most of the long-term health consequences of smoking.3 As smoking prevalence has declined,4 nondaily smoking and low-level daily cigarette consumption,5–7 also referred to as occasional or light smoking patterns, have increased.8–11 Nondaily smokers made up 4.1% of the US adult population in 2006,12 increasing from 3.2% in 1997 and 1998.6 Nondaily smokers accounted for 19.9% of current smokers in 2006,12 increasing from 16.0% in 1997 and 1998.6 Younger age is associated with occasional smoking,9,13 and nondaily smoking is common among young adults. In 1997 and 1998, 5.5% of young adults aged 18 to 24 years were nondaily smokers, accounting for 19.9% of young adult smokers, the highest proportion of nondaily smoking among all age groups.6Alcohol complicates occasional or light smoking in young adults, and it often plays a powerful catalyst role in facilitating and maintaining smoking.14 Young adults report that alcohol increases the enjoyment of and desire for cigarettes,15,16 and tobacco enhances the desired effect of alcohol.17–19 The co-use of cigarettes and alcohol has been described as like “milk and cookies” or “peanut butter with jelly.”20The co-use of tobacco and alcohol among young adults15,21,22 poses a serious health threat. Use of both cigarettes and alcohol increases the risk for certain cancers (e.g., mouth, throat, esophagus, upper aerodigestive tract)23–25 and makes it more difficult to quit either substance.26–28 In a 2001–2002 national study, 2.9% of adults aged 18 years and older (6.2 million) reported both alcohol use disorders and a dependence on nicotine by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, and young adults aged 18 to 24 years exhibited the highest rates of this comorbidity.22Bars and nightclubs are key public venues where young adults congregate and use both alcohol and tobacco. Tobacco companies have targeted young adults, using entertaining events to reinforce a smoker-friendly atmosphere in bars and nightclubs.16,29–31 Many tobacco marketing events have encouraged alcohol use by offering alcohol discounts, paraphernalia, or by holding alcohol drinking contests.16,29,30,32 The strong rewarding effects of nicotine paired with alcohol,33–35 the aggressive tobacco marketing linked with alcohol,32 and the peer acceptance of smoking while drinking at parties in bars and nightclubs20 have put young adult bar patrons at high risk for tobacco use and co-use of tobacco and alcohol, even for occasional and light smokers.To our knowledge, no study has examined the co-use of tobacco and alcohol among young adult bar patrons. This is a hard-to-reach population often underrepresented in national surveillance studies. Additionally, no study has assessed co-use behavior among young adult occasional and light smokers, an increasingly common behavior. We examined patterns of smoking and quit attempts in the context of alcohol use and bar attendance among 4 groups of young adult smokers attending bars in San Diego, California, including occasional, regular, very light, and heavier smokers.