Mental Health and Suicidality Among Racially/Ethnically Diverse Sexual Minority Youths

Objectives. We examined the relationships among sexual minority status, sex, and mental health and suicidality, in a racially/ethnically diverse sample of adolescents.Methods. Using pooled data from 2005 and 2007 Youth Risk Behavior Surveys within 14 jurisdictions, we used hierarchical linear modeling to examine 6 mental health outcomes across 6 racial/ethnic groups, intersecting with sexual minority status and sex. Based on an omnibus measure of sexual minority status, there were 6245 sexual minority adolescents in the current study. The total sample was n = 72 691.Results. Compared with heterosexual peers, sexual minorities reported higher odds of feeling sad; suicidal ideation, planning and attempts; suicide attempt treated by a doctor or nurse, and self-harm. Among sexual minorities, compared with White youths, Asian and Black youths had lower odds of many outcomes, whereas American Native/Pacific Islander, Latino, and Multiracial youths had higher odds.Conclusions. Although in general, sexual minority youths were at heightened risk for suicidal outcomes, risk varied based on sex and on race/ethnicity. More research is needed to better understand the manner in which sex and race/ethnicity intersect among sexual minorities to influence risk and protective factors, and ultimately, mental health outcomes.Over the past 20 years, research has documented elevated suicidality1—defined as behavior related to contemplating, attempting, or completing suicide2—among sexual minority youths (an umbrella term, generally including those who identify as lesbian, gay, bisexual, or transgender [LGBT]; engage in same-sex sexual behavior; or have same-sex attractions). This research has consistently demonstrated substantial sexual orientation disparities in suicidality, with sexual minority youths having higher prevalence of suicidality than their heterosexual peers.3–6 A recent review of the literature indicated that sexual minority youths are at least twice as likely as heterosexual youths to contemplate suicide, and 2 to 7 times as likely to attempt suicide.7 A meta-analysis found that 28% of sexual minority youths had a history of suicidality, compared with 12% of their heterosexual peers.8Despite the development of knowledge about suicidality among sexual minority youths, little is known about suicidality in sexual minority youths of color. To the extent that existing researchers have explored racial/ethnic differences, analyses have rarely gone beyond dichotomous (White vs “youths of color”) or trichotomous (White vs Black vs Latino) comparisons. As a result, there exists scant literature exploring the full spectrum of racial/ethnic differences in suicidality among sexual minority youths.The literature on suicide in the general adolescent population demonstrates racial/ethnic differences in suicide ideation and attempts. For example, prevalence of suicide among Native American and Alaska Native youths is twice that of other youths,9 and Latino youths are more likely than either Black or White youths to have considered and attempted suicide.10 Differences are further moderated by participants’ gender: girls are more likely to consider suicide and attempt suicide than boys,10 although boys are more likely to complete suicide.11Studies that have considered racial/ethnic differences in suicidality among sexual minority youths have found differences, though the patterns have been inconsistent. A study based on Youth Risk Behavior Survey (YRBS) data from Massachusetts, reported that among self-identified lesbian, gay, or bisexual (LGB) youths3 Latinos were significantly more likely than Whites to report past-year suicide attempt. Another study found that same-sex–attracted Black and White youths were more likely than their other-sex–attracted peers to report suicidal ideation, whereas same-sex–attracted Latino and Asian/Pacific Islander youths did not differ from other-sex–attracted peers.12 In a nonprobability sample of urban LGBT youths,13 Black and White youths were more likely to report suicidal ideation than Latinos; however, Latinos reported the highest frequency of suicide attempts. A study of New York City adults found that Latino and Black LGB participants were more likely to report serious suicide attempts than were White LGB participants, with most reported attempts occurring during adolescence and young adulthood.14 These conflicting results suggest that there are important differences in suicidality at the intersections of sexual minority status and race/ethnicity, yet further study requires data of sufficient scale and scope to enable analyses of low-prevalence behaviors across small subgroups of youths.To address the need for information about suicidality among racially/ethnically diverse sexual minority populations, we assess suicidality patterns among youths based on sexual orientation, race/ethnicity, and sex. With this, we respond to calls for public health to utilize minority stress and intersectional frameworks as potential lenses through which to understand health and health disparities among sexual minority populations.15,16 Rather than treating social identities as separate and discrete phenomena, our inquiry allows that co-occurring minority identities operate together. An intersectional approach suggests that sexual identity–race–sex intersections are informed by unique cultural, historical, social, and political factors that differentially influence life experiences, including discrimination based on such identities.17–19 In turn, minority stress theory posits that discriminatory experiences predispose populations to stress and adverse mental health outcomes, including suicidality.20The focus on health differences among sexual minority youths across race/ethnicity and sex is vital to creating effective health interventions and programs. Such a focus is particularly relevant within the context of youth suicide, as risk and protective factors associated with suicidality vary across both racial/ethnic and sexual minority groups, and there is a need to better integrate these bodies of research.21     

Out Yonder: Sexual-Minority Adolescents in Rural Communities in British Columbia

Objectives. We compared sexual-minority adolescents living in rural communities with their peers in urban areas in British Columbia, exploring differences in emotional health, victimization experiences, sexual behaviors, and substance use.Methods. We analyzed a population-based sample of self-identified lesbian, gay, or bisexual respondents from the British Columbia Adolescent Health Survey of 2003 (weighted n = 6905). We tested rural–urban differences separately by gender with the χ² test and logistic regressions.Results. We found many similarities and several differences. Rural sexual-minority adolescent boys were more likely than were their urban peers to report suicidal behaviors and pregnancy involvement. Rural sexual-minority adolescents, especially girls, were more likely to report various types of substance use. Rural status was associated with a lower risk of dating violence and higher risk of early sexual debut for sexual-minority girls and a higher risk of dating violence and lower risk of early sexual debut for sexual-minority boys.Conclusions. Location should be a demographic consideration in monitoring the health of sexual-minority adolescents. Lesbian, gay, and bisexual adolescents in rural communities may need additional support and services as they navigate adolescence.Adolescence is marked by many developmental tasks, including the unfolding of sexual identity. Adolescents who are lesbian, gay, or bisexual (LGB) face the additional challenge of being members of a sexual minority in a heterosexually dominant world. This may be an especially complex task in a rural environment, where heterosexism may be more pronounced¹ and supportive resources limited.² Scant research has compared the experiences of LGB adolescents in rural and urban areas.In the past decade, a growing number of population-based studies of LGB adolescents addressed the methodological criticisms of earlier studies that relied on urban samples, convenience samples, and samples of adolescents who may have been of legal adult age.^2–5 Population-based research on LGB adolescents has demonstrated that they face health disparities when compared with heterosexual adolescents. For example, LGB adolescents are at increased risk of being stigmatized and victimized.^3,6–11 LGB adolescents also experience higher rates of emotional distress and suicidality,^{3,6,8,11–16} substance use,^3,6,8,11,17 and risky sex,^6,8 which may put them at increased risk for HIV infection^18,19 and pregnancy.⁹Rural communities have several characteristics that may affect the experiences of LGB adolescents. Social isolation may be greater in rural regions, because the chance to identify with an LGB peer group may be limited or nonexistent.^2,20,21 Adolescents and their families may also lack access to resources for information and support.^2,20 Furthermore, more conservative attitudes in general, and negative attitudes or misconceptions about nonheterosexual orientations specifically, and less anonymity in small communities may make it harder for adolescents to openly express same-gender affections² and risk public disclosure.²² Thus, LGB adolescents in rural areas may face greater disparities and challenges compared with their urban counterparts.Results of research on rural–urban differences in the general population have been mixed. For example, a study of multiple data sets by the US National Center on Addiction and Substance Abuse found substance-use rates among rural adolescents to be generally higher.²³ Likewise, a study of more than 2000 students from urban, suburban, and rural schools in upstate New York found that rural adolescents were twice as likely as their suburban and urban counterparts to frequently use tobacco, alcohol, and other drugs and to have had sex.²⁴ Conversely, analyses of the 1999 US Youth Risk Behavior Survey found no differences among urban and nonurban adolescents on several substance-use and sexual behavior variables.²⁵ A separate report on health in the United States found that adolescent childbearing rates were lowest in suburban areas.²⁶ Studies of dating violence have also had mixed results, finding rural adolescents at higher risk²⁷ or lower risk.²⁸Only a few studies have directly compared LGB adolescents living in rural areas with those living in urban areas. Waldo et al. studied LGB rural and urban young people aged 15 to 21 years.²⁹ Urban participants were recruited through metropolitan community centers and rural participants through university student groups in a politically conservative town more than an hour away from a metropolitan center. They found rates of assault were lower for rural young people, but suicidality did not differ between rural and urban participants. In an analysis of population-based data from the US National Longitudinal Study of Adolescent Health, Galliher et al. defined urban, suburban, and rural from interviewers’ observations of the immediate are around the participant''s residence.¹² They found that rural sexual-minority adolescent girls reported more depressive symptoms, but rural adolescent boys, regardless of attraction status, reported a greater sense of school belonging, greater self-esteem, and fewer depressive symptoms.We used school-based representative data from British Columbia to explore differences in health and risk between LGB adolescents in rural communities and their urban counterparts. We focused on LGB adolescents only, because previous research has documented the health disparities between LGB and heterosexual adolescents. In contrast to previous studies,^12,29 we looked at a broader range of behaviors and used a standardized definition of rurality to categorize location.     

Suicidal Behavior Among Female Sex Workers in Goa, India: The Silent Epidemic

Objectives. We sought to study suicidal behavior prevalence and its association with social and gender disadvantage, sex work, and health factors among female sex workers in Goa, India.Methods. Using respondent-driven sampling, we recruited 326 sex workers in Goa for an interviewer-administered questionnaire regarding self-harming behaviors, sociodemographics, sex work, gender disadvantage, and health. Participants were tested for sexually transmitted infections. We used multivariate analysis to define suicide attempt determinants.Results. Nineteen percent of sex workers in the sample reported attempted suicide in the past 3 months. Attempts were independently associated with intimate partner violence (adjusted odds ratio [AOR] = 2.70; 95% confidence interval [CI] = 1.38, 5.28), violence from others (AOR = 2.26; 95% CI = 1.15, 4.45), entrapment (AOR = 2.76; 95% CI = 1.11, 6.83), regular customers (AOR = 3.20; 95% CI = 1.61, 6.35), and worsening mental health (AOR = 1.05; 95% CI = 1.01, 1.11). Lower suicide attempt likelihood was associated with Kannad ethnicity, HIV prevention services, and having a child.Conclusions. Suicidal behaviors among sex workers were common and associated with gender disadvantage and poor mental health. India''s widespread HIV-prevention programs for sex workers provide an opportunity for community-based interventions against gender-based violence and for mental health services delivery.Suicide is a public health priority in India. Rates of suicide in India are 5 times higher than in the developed world,^1,2 with particularly high rates of suicide among young women.^3–5 Verbal autopsy surveillance from southern India suggests that suicide accounts for 50% to 75% of all deaths among young women, with average suicide rates of 158 per 100 000.²Common mental disorders such as depressive and anxiety disorders, and social disadvantage such as gender-based violence and poverty, are major risk factors for suicide among women.^1,3,6–8 Although research from high-income countries shows that common mental disorders are a major contributor to the risk of suicidal behavior, their role is less clear in low- and middle-income countries in which social disadvantage has been found to be at least as important.^1,3,6–8 Gender disadvantage is increasingly seen as an important contributing factor to the high rates of suicide seen among women in Asia.^1,3,6,7 Gender-based violence is a common manifestation of gender disadvantage and has been linked with common mental disorders and suicide in population-based studies of women and young adults in Goa, India.^4,5,9 Lack of autonomy, early sexual debut, limited sexual choices, poor reproductive health, and social isolation are other manifestations of gender disadvantage.Sex work in India is common. An estimated 0.6% to 0.7% of the female adult urban population are engaged in commercial sexual transactions.¹⁰ Studies from developed nations have found a high prevalence of self-harming behaviors in people engaged in transactional sexual activity.¹¹ There is also growing evidence suggesting that HIV-positive individuals from traditionally stigmatized groups report higher rates of violence exposure and suicidal ideation.^12,13 Female sex workers in India are a traditionally stigmatized group, with high prevalence of HIV¹⁰ and levels of stigma and violence that relate to the context of their work.¹⁴ Yet, despite substantial investigation of their reproductive and sexual health needs, there is virtually no information on suicide and its determinants among female sex workers from low- and middle-income countries.¹⁵As demonstrated in the hierarchical conceptual framework outlined in Figure 1,^4,5,9 we hypothesized that gender disadvantage, sex work, and health factors together with factors indicative of social disadvantage are distal determinants of female sex workers'' vulnerability to suicidal behaviors,^4,5,9,15 the effects of which would be mediated though poor mental health.³ We studied the burden of suicidal behaviors in a cross-sectional sample of female sex workers in Goa, India. We explored the association of sociodemographic factors, type of sex work, sexual health, and gender disadvantage, with and without measures of poor mental health, on suicide attempts in the past 3 months.Open in a separate windowFIGURE 1A conceptual framework for social risk factors for suicide among female sex workers in India.Note. STI = sexually transmitted infection.     

Exploring Alcohol-Use Behaviors Among Heterosexual and Sexual Minority Adolescents: Intersections With Sex,Age, and Race/Ethnicity

Objectives. We examined sexual orientation status differences in alcohol use among youths aged 13 to 18 years or older, and whether differences were moderated by sex, age, or race/ethnicity.Methods. We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys and conducted weighted analyses, adjusting for complex design effects. We operationalized sexual orientation status with items assessing sexual orientation identity, sexual behavior, sexual attraction, or combinations of these.Results. Compared with exclusively heterosexual youths, sexual-minority youths were more likely to report each of the primary study outcomes (i.e., lifetime and past-month alcohol use, past-month heavy episodic drinking, earlier onset of drinking, and more frequent past-month drinking). Alcohol-use disparities were larger and more robust for (1) bisexual youths than lesbian or gay youths, (2) girls than boys, and (3) younger than older youths. Few differences in outcomes were moderated by race/ethnicity.Conclusions. Bisexual youths, sexual-minority girls, and younger sexual-minority youths showed the largest alcohol-use disparities. Research is needed that focuses on identifying explanatory or mediating mechanisms, psychiatric or mental health comorbidities, and long-term consequences of early onset alcohol use, particularly frequent or heavy use, among sexual-minority youths.Although alcohol consumption by youths has declined in recent years, it remains a major public health problem.1 Underage drinking is associated with a range of physical, academic, and social problems. Youths who drink, especially those who drink heavily, are more likely to engage in delinquent behavior, experience violence and victimization, and commit suicide.1,2 Of great concern is that alcohol consumption is a leading contributor to injury, the main cause of death for people younger than 21 years.1 Early onset drinking is also associated with increased risk for developing an alcohol-use disorder during the lifespan.3Despite the fact that almost all US youths grow up in a culture permeated by alcohol, the prevalence of early and heavy drinking and its consequences vary across demographic groups. For example, considerable variation exists in alcohol consumption between White and racial/ethnic–minority youths; data consistently show the highest rates of drinking and drinking-related problems among White and American Indian or Alaska Native youths, followed by Hispanic/Latino, Black/African American, and Asian youths.4–6 Non-Hispanic White youths generally start drinking at younger ages than their racial/ethnic minority counterparts. Greater percentages of racial/ethnic minority youths abstain or drink very little,7 and significant differences exist in levels of drinking between racial/ethnic minority boys and girls.7 Generally, across racial/ethnic groups, prevalence rates of drinking for boys and girls tend to be similar in younger age groups2; among older adolescents, however, more boys than girls engage in frequent and heavy drinking,2 and boys show higher rates of drinking-related consequences.8Alcohol use and heavy drinking are more prevalent among lesbian, gay, and bisexual (LGB) youths and adults than among their heterosexual counterparts, and this is especially true for LGB girls and women.9–12 Because most research on alcohol use among youths has focused on heterosexual youths or has not assessed sexual orientation, little is known about how sexual orientation interacts with other demographic characteristics to influence drinking patterns. Studies comparing sexual-minority and heterosexual adults suggest that drinking patterns of sexual minorities differ in substantial ways from those of the general population. For example, differences in alcohol-use patterns between lesbian or bisexual women and gay or bisexual men are much smaller than those between heterosexual women and men.12–18 Also, rates and patterns of drinking may be more similar among sexual minorities across racial/ethnic minority statuses, compared with their heterosexual counterparts.19Few studies have examined alcohol-use disparities among subgroups of sexual-minority youths (SMYs; < 18 years). In a meta-analysis, Marshal et al.20 found that SMYs had more than twice the odds of ever drinking alcohol, and 3 of the 4 studies that examined alcohol-related effects for boys and girls separately reported larger alcohol-use disparities among girls than among boys.21–23 Moreover, although studies analyzed by Marshal et al.20 included racially and ethnically diverse samples, none examined the intersecting influences of sexual-minority and racial/ethnic status on substance-use outcomes.The current analyses build on existing literature in 2 ways. First, previous studies with SMYs have examined a limited number of alcohol-use outcomes (e.g., any lifetime drinking).21,22,24 Second, researchers have typically combined subgroups of SMYs25–31 in analyses—often because of small subgroup sample sizes. Because alcohol-use patterns appear to differ on the basis of how sexual orientation is defined—that is, whether data are analyzed on the basis of sexual identity, behavior, attraction, or some combination of these17,32–34—we extended previous work25,35 by examining a variety of sexual-orientation subgroup differences. In addition to our primary goal of examining sexual-orientation differences in alcohol-use patterns, we conducted moderation analyses to determine whether relations between sexual orientation and drinking patterns varied on the basis of sex, age, or race/ethnicity.     

Up in Smoke: Vanishing Evidence of Tobacco Disparities in the Institute of Medicine’s Report on Sexual and Gender Minority Health

The Institute of Medicine (IOM) released a groundbreaking report on lesbian, gay, bisexual, and transgender (LGBT) health in 2011, finding limited evidence of tobacco disparities. We examined IOM search terms and used 2 systematic reviews to identify 71 articles on LGBT tobacco use. The IOM omitted standard tobacco-related search terms. The report also omitted references to studies on LGBT tobacco use (n = 56), some with rigorous designs. The IOM report may underestimate LGBT tobacco use compared with general population use.Tobacco remains the leading cause of premature mortality in the United States1; however, burdens of the epidemic are not equally shared among groups with various sociodemographic characteristics.2–4 Over the past 20 years, evidence has accumulated that lesbian, gay, bisexual, and transgender (LGBT) individuals (i.e., sexual and gender minorities) are among the groups at higher risk for smoking.5Two separate systematic reviews about the prevalence5 and etiology6 of smoking among sexual minorities report on the results of 63 unduplicated studies. Combined, the results suggest “compelling evidence that an elevated prevalence of tobacco use among LGBT men and women exists” compared with heterosexual men and women,5^(p279) a sentiment echoed by both the American Lung Association7 and Healthy People 2020.8By contrast, in the groundbreaking report on LGBT health by the Institute of Medicine (IOM),9 which is used by federal agencies and funders to set public health policy and priorities, tobacco use is largely absent and the limited discussion is equivocal: smoking rates among youths “may be higher”9^(p4) and adults “may have higher rates.”9^(p5) Given the seeming disconnect between the tobacco literature and the findings of the IOM report, we sought to identify possible gaps in tobacco-related evidence in the IOM report.     

Secondhand Smoke Exposure Among Young Adult Sexual Minority Bar and Nightclub Patrons

Objectives. We compared exposure to secondhand smoke (SHS) and attitudes toward smoke-free bar and nightclub policies among patrons of lesbian, gay, bisexual, and transgender (LGBT) and non-LGBT bars and nightclubs.Methods. We conducted randomized time–location sampling surveys of young adults (aged 21–30 years) in 7 LGBT (n = 1113 patrons) and 12 non-LGBT (n = 1068 patrons) venues in Las Vegas, Nevada, in 2011, as part of a cross-sectional study of a social branding intervention to promote a tobacco-free lifestyle and environment in bars and nightclubs.Results. Compared with non-LGBT bars and nightclubs, patrons of LGBT venues had 38% higher adjusted odds of having been exposed to SHS in a bar or nightclub in the past 7 days but were no less likely to support smoke-free policies and intended to go out at least as frequently if a smoke-free bar and nightclub law was passed.Conclusions. The policy environment in LGBT bars and nightclubs appears favorable for the enactment of smoke-free policies, which would protect patrons from SHS and promote a smoke-free social norm.Secondhand smoke (SHS) exposure increases the risk of cardiovascular disease, respiratory conditions, and cancer.1 Bars and nightclubs are tobacco-friendly environments that the tobacco industry uses as marketing and promotional venues.2–4 In the absence of a smoke-free law that covers bars and nightclubs, these venues can also have particularly high levels of SHS.5,6Bars and nightclubs have played an important role historically in the lesbian, gay, bisexual, and transgender (LGBT) rights movement, and they serve as a welcoming social venue.7,8 However, compared with non-LGBT venues, LGBT bars and nightclubs may be particularly tobacco friendly, because smoking rates are higher among LGBT than heterosexual individuals.9,10 According to the 2009 to 2010 National Adult Tobacco Use Survey, prevalence of tobacco use was significantly higher among LGBT than heterosexual participants (38.5% vs 25.3%).10 Also, the tobacco industry has targeted LGBT individuals and young adults with bar and nightclub advertisements and promotions.2,11,12 Previous studies with men who have sex with men conducted in Tucson, Arizona; Portland, Oregon; and Los Angeles, California, indicated an association between frequency of LGBT bar attendance and smoking.13,14 Although it is well established that LGBT individuals have high smoking rates,9,15 less is known about exposure to SHS in LGBT bars and nightclubs.Smoke-free laws, which restrict smoking in certain areas, are an important intervention to reduce or eliminate SHS exposure.5,6,16 Smoke-free policies have been shown to reduce asthma exacerbations and heart attacks17,18 and to contribute to smoking reduction or cessation.19 Smoke-free bar and nightclub environments might contribute to lowering rates of smoking among the LGBT population.Pizacani et al. examined attitudes about SHS in Oregon and Washington among heterosexual and LGB individuals and found no significant differences by sexual orientation among individuals living in Washington.20 However, among Oregon residents, gay smokers were more likely than heterosexual male smokers to support banning smoking in bars. In addition, lesbian nonsmokers living in Oregon were more likely than heterosexual female nonsmokers to support such a ban. McElroy et al. found that a lower percentage of LGBT than non-LGBT individuals in Missouri supported smoke-free bar policies; however, this difference was not significant after adjustment for other demographic factors.21 Kelly et al. found no difference in support for the New York state smoke-free law between LGBT and heterosexual individuals in New York City nightclubs.22 However, in a nationwide study, King et al. found significantly higher prevalence of support for smoke-free bars, casinos, and clubs among heterosexual than LGBT participants. (49.5% vs 43.0%)23Nevada has historically lagged behind the nation in enacting smoke-free policies.24 In 2001, Nevada ranked last in percentage of employees covered by a smoke-free policy. Between 1993 and 1999, the percentage of employees covered ranged from 33.3% to 48.7%. By 1999, Nevada was the only state with fewer than half of employees covered by a smoke-free policy.24 In 2006, Nevada passed a state smoke-free law that exempted bars, nightclubs, and gaming areas. This law also removed preemption, allowing local communities to pass stronger smoke-free policies.25 As of January 2013, bars and nightclubs in Nevada were still exempt from the smoke-free law.26We compared SHS exposure and attitudes toward smoke-free bars and nightclubs among patrons of LGBT and non-LGBT bars and nightclubs in Las Vegas, Nevada, in 2011. We assessed (1) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of past-7-day exposure to SHS in a bar or nightclub, (2) whether frequently going out to LGBT venues was an independent predictor of 7-day exposure to SHS in a bar or nightclub, (3) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of intention to continue to go out as frequently as before if a smoke-free law was enacted, and (4) whether being present in an LGBT venue (vs a non-LGBT venue) was an independent predictor of opposition to smoke-free bar and nightclub policies.     

Protective Factors in the Lives of Bisexual Adolescents in North America

Objectives. We compared protective factors among bisexual adolescents with those of heterosexual, mostly heterosexual, and gay or lesbian adolescents.Methods. We analyzed 6 school-based surveys in Minnesota and British Columbia. Sexual orientation was measured by gender of sexual partners, attraction, or self-labeling. Protective factors included family connectedness, school connectedness, and religious involvement. General linear models, conducted separately by gender and adjusted for age, tested differences between orientation groups.Results. Bisexual adolescents reported significantly less family and school connectedness than did heterosexual and mostly heterosexual adolescents and higher or similar levels of religious involvement. In surveys that measured orientation by self-labeling or attraction, levels of protective factors were generally higher among bisexual than among gay and lesbian respondents. Adolescents with sexual partners of both genders reported levels of protective factors lower than or similar to those of adolescents with same-gender partners.Conclusions. Bisexual adolescents had lower levels of most protective factors than did heterosexual adolescents, which may help explain their higher prevalence of risky behavior. Social connectedness should be monitored by including questions about protective factors in youth health surveys.Adolescence is a key developmental period with long-term effects on physical and psychological health, and adolescents negotiate a variety of environmental challenges during these years. Although public health practice often focuses on preventing or decreasing health risks, in the past decade increasing attention has been paid to identifying protective factors that can foster healthy development. Protective factors are events, circumstances, and life experiences that promote confidence and competence among adolescents and help to protect them from negative developmental risks and health outcomes.^1,2 Such protective resources enhance resilience among adolescents who face adversities,³ and they arise from individual characteristics and social environments such as families, schools, and communities.⁴Several individual assets and external resources have been identified as protective factors that reduce the likelihood of risky behaviors such as suicidality, substance use, unprotected sexual behavior, and disordered eating. Individual-level protective factors include higher levels of self-esteem, psychological well-being, and religiosity.^5–8 Relational factors such as strong connectedness to family^5,7–13 and school^{5,7,9,10,12,13} also reduce the likelihood of engaging in behaviors that compromise health. Some community-level factors also appear to be protective against risk taking among adolescents; these include the presence of a caring adult role model outside the family^8,13 and community involvement, including volunteering.⁸Most studies focus on adolescents in general, but some populations, such as lesbian, gay, and bisexual adolescents, face greater environmental challenges in negotiating adolescence and navigating developmental tasks. LGB adolescents are disproportionately subjected to violence and harassment at school^14–16 and to physical and sexual abuse.^17,18 In addition, LGB adolescents are more likely than their heterosexual peers to be involved in health-compromising behaviors, including substance use,^14–17 risky sexual behaviors and injection drug use,^14,19,20 and suicide attempts.^{10,14,15,17,21–24}Researchers have recently started illuminating relationships between lower levels of protective factors and negative health outcomes among LGB adolescents. In an analysis of the 2004 Minnesota Student Survey, Eisenberg and Resnick found that LGB students were less likely than were other students to report high levels of family connectedness, teacher caring, other adult caring, and perceived safety at school.²⁵ However, these protective factors, when present, decreased the likelihood of suicidal ideation and attempts, and protective factors accounted for more of the variation in suicide behaviors than did sexual orientation. Similarly, in his analysis of the National Longitudinal Study of Adolescent Health, Ueno found that less-positive relationships with parents, school, and friends explained higher levels of psychological distress among sexual-minority students than among heterosexual students.²⁶ Homma and Saewyc found that higher levels of perceived family caring and more-positive perceptions of school climate were linked to lower levels of emotional distress among Asian American LGB high school students in Minnesota.²⁷These studies provide some evidence that protective factors may work in similar ways for LGB adolescents as for other adolescents, but not consistently; for example, high levels of religious involvement in a faith with negative attitudes about nonheterosexual orientations might actually be more harmful than protective. Further, if LGB adolescents as a group experience lower levels of these assets, this might help explain their higher risks. Only a handful of population-based studies have focused on sexual-minority adolescents and protective factors, and they provide limited information about protective factors among bisexual adolescents separately from gay or lesbian adolescents; most research combines these groups because of small samples. Measuring sexual orientation during adolescence can be difficult; sexual identity development is a task of adolescence, and many youths engage in exploration of romantic attraction, sexual behavior, or identity labels during the adolescent years. Behavior and self-labeling may be discordant at various times, and there is evidence that some adolescents’ perception of their orientation and labels will shift during adolescence and young adulthood.In the few studies that have disaggregated the groups, bisexual adolescents were more likely than were heterosexual peers to report risky sexual behaviors,^19,20 suicide attempts,¹⁶ victimization,¹⁶ delinquency,²⁸ and substance use^16,28; in some cases gay and lesbian adolescents did not significantly differ from their heterosexual peers in these risks.^16,19,28 Some studies used romantic attraction as a measure of orientation,^23,24,26 some used self-labels,^18,22 and some used gender of sexual partners.^{16,20,25,27,28} Few studies offer the opportunity to incorporate correlates for orientation measured in different ways in the same data set.No matter how it is measured, it is important to examine levels of protective factors among bisexual adolescents separately, given the greater likelihood of risk-taking behavior and negative experiences at school among bisexual students. Drawing on data from different waves of the National Longitudinal Study of Adolescent Health, 2 studies have found lower levels of connectedness to family and school and lower perceived caring by other adults among bisexual than among heterosexual adolescents.^29,30 Bisexual and gay or lesbian adolescents generally did not differ in their levels of protective factors, but this may have been partly attributable to relatively small samples of LGB adolescents in the longitudinal study cohort, which limits statistical power for comparisons between the 2 groups. Furthermore, the study is nationally representative of US adolescents in general but may not reflect the full ethnic diversity of LGB populations across the United States or Canada. Studies analyzing larger regional population-based surveys offer opportunities to confirm those findings for specific regions.Identifying whether protective factors work similarly for bisexual adolescents and their peers is useful, but it is equally important to monitor whether bisexual adolescents have the same levels of those protective factors in their lives. We therefore explored levels of protective factors among bisexual adolescents compared with heterosexual, mostly heterosexual, and gay or lesbian peers in 6 school-based surveys in the midwestern United States and western Canada. We posed 3 questions: (1) Are levels of protective factors different between bisexual adolescents and heterosexual adolescents? (2) Are levels of protective factors different between bisexual adolescents and gay or lesbian adolescents? (3) Are these patterns consistent across varying measures of sexual orientation?     

Prevalence,Harm Perceptions,and Reasons for Using Noncombustible Tobacco Products Among Current and Former Smokers

Objectives. We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.Methods. We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use.Results. Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes.Conclusions. Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.The use of noncombustible tobacco products has increased rapidly in recent years1–3 and may continue to rise in response to restrictions such as smoke-free indoor air laws and rising cigarette taxes.4–8 Noncombustible tobacco products can be grouped into 2 broad categories—aerosolized products such as e-cigarettes, or more accurately termed electronic nicotine delivery systems (ENDS), which deliver nicotine primarily through vapor inhalation that mimics smoking a traditional cigarette,9 and smokeless tobacco products such as chew, dip, or snuff; snus; and dissolvables, which deliver nicotine via oral mucosal absorption.10 These products are marketed to appeal to unique target audiences,9,11–13 such as smokers and young adults, and vary in levels of harmful constituents.9Noncombustible tobacco products are a critical part of the tobacco industry’s strategy to navigate the changing tobacco product landscape. Phillip Morris14,15 and RJ Reynolds16 have announced their intent to develop and market noncombustible tobacco products as part of a shift to reduced harm products.17 In some cases, noncombustible tobacco products have been used to expand the appeal of established cigarette brands to a broader spectrum of consumers, as with RJ Reynolds’s Camel Snus product.18 Most ENDS are marketed and sold independently; however, this is changing with Lorillard’s acquisition of blu eCigs in 201219,20 and the recent launches of RJ Reynolds’s Vuse digital vapor cigarettes21,22 and Altria’s MarkTen e-cigarettes.23Noncombustible tobacco product awareness and prevalence vary by product. In 2010, approximately 40% of adults reported awareness of e-cigarettes,24,25 rising to nearly 60% in 201125; awareness approached 75% among current and former smokers in 2010 to 2011.26 Between 1.8% and 3.4% of the adult general population has tried an e-cigarette,24,25,27,28 including up to 21.2% of current smokers.25,26 More than 40% of adults have heard of snus,29 5% have tried the product,29 and 1.4% are current users.30 Awareness of dissolvables is low (10%), and use is even lower (0.5%).29 Noncombustible tobacco product use is highest among young adults26,31 and smokers.24,27,28Although use of noncombustible tobacco products could potentially reduce harm associated with smoking if they replace cigarettes,32,33 some studies suggest that current smokers who use noncombustible tobacco products do not reduce combustible use and may delay cessation.12,34–37 For example, a study by Wetter et al.38 found that dual users of smokeless tobacco products and cigarettes were less likely to quit than were either smokeless tobacco product or cigarette users alone. This is of concern given the rising rates of dual use; a recent study reported that 30% of young adults who smoke cigarettes use at least 1 other tobacco product.31 Dual use is more prevalent among men,39,40 those of lower socioeconomic status,39,41 and youths and young adults.35,41,42Studies show that most users (65%–85%) perceive ENDS as less harmful than cigarettes,24,26,43 and 40% to 50% perceive snus and dissolvables as equally harmful as cigarettes.29 Few studies have examined reasons for use; one study of visitors to ENDS and smoking cessation Web sites found that nearly 85% used ENDS because they believed that they were less toxic than tobacco; other responses included use of ENDS to deal with cravings or withdrawal, to quit smoking, and to save money.43 Focus group research has shown that adults associate snus and dissolvables with historic images of chewing tobacco,34,44 express skepticism that the products are safer than cigarettes,34 do not view them as substitutes for cigarettes,34,44 and express concern about the user’s lack of control of nicotine ingestion relative to cigarettes.44 By contrast, young adults expressed positive perceptions of snus, dissolvables, and ENDS, in part because of a willingness to experiment with new products and because they are available in flavors.45With the ever-changing tobacco marketplace and the tobacco companies’ commitment to the development and promotion of noncombustible tobacco products, surveillance is critical. This study built on previous research to provide current estimates of noncombustible tobacco product use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population

Objectives. We aimed to determine the percentage of suicide attempts attributable to individual Axis I and Axis II mental disorders by studying population-attributable fractions (PAFs) in a nationally representative sample.Methods. Data were from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004–2005), a large (N = 34 653) survey of mental illness in the United States. We used multivariate logistic regression to compare individuals with and without a history of suicide attempt across Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders (anxiety, mood, psychotic, alcohol, and drug disorders) and all 10 Axis II personality disorders. PAFs were calculated for each disorder.Results. Of the 25 disorders we examined in the model, 4 disorders had notably high PAF values: major depressive disorder (PAF = 26.6%; 95% confidence interval [CI] = 20.1, 33.2), borderline personality disorder (PAF = 18.1%; 95% CI = 13.4, 23.5), nicotine dependence (PAF = 8.4%; 95% CI = 3.4, 13.7), and posttraumatic stress disorder (PAF = 6.3%; 95% CI = 3.2, 10.0).Conclusions. Our results provide new insight into the relationships between mental disorders and suicide attempts in the general population. Although many mental illnesses were associated with an increased likelihood of suicide attempt, elevated rates of suicide attempts were mostly attributed to the presence of 4 disorders.With almost 1 million deaths worldwide every year and a rate increase of 60% over the past 45 years, suicide is clearly a major public health problem.¹ Although the US Surgeon General has prioritized suicide prevention,² suicidal behavior has not significantly decreased in the United States.³ Suicide attempts are strong risk factors for eventual suicide completion^4–6; therefore, understanding and modifying risk factors for suicide attempts remain a promising approach to reducing suicide rates.Unfortunately, our understanding of the risk factors for suicide attempts is plagued by poor specificity. Vigorous study efforts have identified multiple risk factors, including several sociodemographic factors and mental disorders.^3,7–10 However, significant associations between candidate risk factors and suicide attempts are tempered by low positive predictive values.¹¹ The population-attributable fraction (PAF; also known as the population-attributable risk) has emerged as a promising statistical tool to better quantify the effect of risk factors on a given outcome at the population level. The PAF describes the reduction in incidence of a particular outcome if the entire population was not exposed to the examined risk factor.¹²The PAF has been underused in the study of suicide risk factors.^13,14 A recent review of the PAF in suicide research¹⁵ showed that existing studies examining the PAFs of risk factors for suicide attempts have focused primarily on depression and mood disorders, with PAFs ranging from 28% to 74%.^14,16–21 A small number of studies have investigated the PAFs of substance use disorders and anxiety disorders for suicide attempts, also with mixed findings.^14,18,22 Other findings suggest that the risk of suicide attempts attributable to mental disorders is largely explained by the association between mental disorders and suicidal ideation.⁹ A major limitation in the literature is that relatively few mental disorders have been examined by using PAFs for suicide attempts. Despite substantial evidence for the causative role of personality disorders in suicidal behavior,^23–25 the PAF of personality disorders has been examined in only 1 study to date, and that study was unable to examine the effects of individual personality disorders.¹⁸ Borderline personality disorder is a strong risk factor for suicide attempts,²⁵ yet the PAF of borderline personality disorder for suicide attempts is unknown. Posttraumatic stress disorder (PTSD) is another disorder associated with suicide attempts,^26,27 yet the proportion of suicide attempts attributable to PTSD has not been examined. Furthermore, many previous studies included limited adjustment for confounding factors. Even though several mental disorders have been labeled as risk factors for suicidal behavior,⁷ many studies using the PAF do not adjust for mental disorders other than the disorder of interest. The PAF is based on the assumption that the examined risk factor is causally related to the outcome,¹² and given the high rates of comorbidity of mental disorders,²⁸ multivariate models examining a comprehensive range of mental disorders are needed to provide a more realistic assessment of the PAF for a specific mental illness.Our primary objective was to examine the proportion of suicide attempts attributable to specific mental disorders. To address the limitations of the existing literature, we used the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC),²⁹ wave 2, as the data set. This data set features a very large sample size (N = 34 653), includes a comprehensive assessment of Axis I disorders and all 10 Axis II personality disorders, and is representative of the US population. On the basis of existing literature showing high PAF values for major depressive disorder and other mood disorders, we hypothesized that whereas several mental disorders would be independently associated with suicide attempts, major depressive disorder and other mood disorders would account for the highest proportion of suicide attempts.^16,21 We further hypothesized that anxiety and substance use disorders would have lower PAF values for suicide attempts, on the basis of previous studies that often showed lower PAF values.^14,18,22 The limited literature on the PAFs of personality disorders for suicide attempts suggested that we would find low PAF values; however, because of its consistently demonstrated association with suicide attempts, we anticipated that borderline personality disorder would have a relatively high PAF value.     

Suicide,Guns, and Public Policy

Suicide is a serious public health concern that is responsible for almost 1 million deaths each year worldwide. It is commonly an impulsive act by a vulnerable individual. The impulsivity of suicide provides opportunities to reduce the risk of suicide by restricting access to lethal means.In the United States, firearms, particularly handguns, are the most common means of suicide. Despite strong empirical evidence that restriction of access to firearms reduces suicides, access to firearms in the United States is generally subject to few restrictions.Implementation and evaluation of measures such as waiting periods and permit requirements that restrict access to handguns should be a top priority for reducing deaths from impulsive suicide in the United States.

“Knowing is not enough; we must apply. Willing is not enough; we must do.”1a

—Johann Wolfgang von Goethe

Suicide is a complex behavior involving the intentional termination of one’s own life. The prevalence, causes, means, and prevention of suicide have been extensively studied and widely reported.1b–4 The World Health Organization (WHO) has identified suicide as a serious public health concern that is responsible for more deaths worldwide each year than homicide and war combined,5 with almost 1 million suicides now occurring annually. In 2007, the Centers for Disease Control and Prevention (CDC) reported that 34 598 Americans died by suicide, far more than the 18 361 murders during the same period.6 Among Americans younger than 40 years, suicide claimed more lives (n = 13 315) than any other single cause except motor vehicle accidents (n = 23 471).6Psychiatric disorders are present in at least 90% of suicide victims, but untreated in more than 80% of these at the time of death.7 Treatment of depression and other mood disorders is therefore a central component of suicide prevention. Other factors associated with suicidal behavior include physical illness, alcohol and drug abuse, access to lethal means, and impulsivity. All of these are potentially amenable to modification or treatment if recognized and addressed. It is important to distinguish between impulsivity as a personality trait and the impulsivity of the act of suicide itself. It is not generally appreciated that suicide is often an impulsive final act by a vulnerable individual8 who may or may not exhibit the features of an impulsive personality.9The impulsivity of suicide provides opportunities to reduce suicide risk by restriction of access to lethal means of suicide (“means restriction”). Numerous medical organizations and governmental agencies, including the WHO,5 the European Union,10 the Department of Health in England,11 the American College of Physicians,12 the CDC,4,13 and the Institute of Medicine,14 have recommended that means restriction be included in suicide prevention strategies. In the United States, firearms are the most common means of suicide,15 with a suicide attempt with a firearm more likely to be fatal than most other means.16 In a study of case fatality rates in the northeastern United States, it was found that 91% of suicide attempts by firearms resulted in death.17 By comparison, the mortality rate was 84% by drowning and 82% by hanging; poisoning with drugs accounted for 74% of acts but only 14% of fatalities. Many studies have shown that the vast majority of those who survive a suicide attempt do not go on to die by suicide. A systematic review of 90 studies following patients after an event of self-harm found that only two pecent went on to die by suicide in the following year and that seven percent had died by suicide after more than nine years.18The availability of guns in the community is an important determinate of suicide attempts by gun.19 Given the public health importance of suicide and what is known about the role of guns in suicide, strategies that keep guns out of the hands of individuals who intend self-harm are worthy of careful scrutiny. Since a handgun (revolver or pistol) is far more likely to be used for suicide than a long gun (shotgun or rifle),20 it may be particularly beneficial to focus suicide prevention efforts on this type of weapon. Only a small minority of states restrict access to handguns by methods such a waiting period, a permit requiring gun safety training, or safe storage of guns in the home. In 2010, US Department of Justice reported that only 15 states had a waiting period for purchasing a handgun.21 Although federal law prohibits the sale of handguns to persons younger than 21 years, in the absence of federal preemption (i.e., the removal of legislative authority from a lower level of government), some states and municipalities allow the sale of handguns to younger individuals.21     

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement

We implemented an innovative, brief, easy-to-administer 2-part intervention to enhance coping and treatment engagement. The intervention consisted of safety planning and structured telephone follow-up postdischarge with 95 veterans who had 2 or more emergency department (ED) visits within 6 months for suicide-related concerns (i.e., suicide ideation or behavior). The intervention significantly increased behavioral health treatment attendance 3 months after intervention, compared with treatment attendance in the 3 months after a previous ED visit without intervention. The trend was for a decreasing hospitalization rate.Approximately 400 000 to 500 000 US emergency department (ED) visits occur annually for suicide attempts.1,2 The ED is a primary site for the treatment of suicide attempts, and for many patients, ED interventions are the only treatment they receive.3 As many as 60% of suicidal ED patients are stabilized and discharged directly to outpatient care.1,2 Unfortunately, only 50% of these patients follow up on their referrals and attend 1 or more outpatient behavioral health sessions.3 Consequently, costly repeat ED visits and additional suicidal behavior are frequent. As many as 30% of patients presenting to the ED for a suicide-related concern return to the ED for another suicide-related concern within 1 year,4 and 2-year follow-up suicide mortality rates among suicide attempters are estimated at 2%.5 Recurrent suicidal behavior and limited outpatient treatment engagement are similarly significant problems among veterans,6–8 who may be at greater risk for suicide than civilians despite more recent reductions.9,10 Given that the ED is the only place where many suicidal individuals receive care, it could be an important intervention site to increase outpatient treatment engagement and reduce repeat suicidal behavior, ED visits, and hospitalizations.11     

Research Funded by the National Institutes of Health on the Health of Lesbian,Gay, Bisexual,and Transgender Populations

Objectives. We examined the proportion of studies funded by the National Institutes of Health (NIH) that focused on lesbian, gay, bisexual, and transgender (LGBT) populations, along with investigated health topics.Methods. We used the NIH RePORTER system to search for LGBT-related terms in NIH-funded research from 1989 through 2011. We coded abstracts for LGBT inclusion, subpopulations studied, health foci, and whether studies involved interventions.Results. NIH funded 628 studies concerning LGBT health. Excluding projects about HIV/AIDS and other sexual health matters, only 0.1% (n = 113) of all NIH-funded studies concerned LGBT health. Among the LGBT-related projects, 86.1% studied sexual minority men, 13.5% studied sexual minority women, and 6.8% studied transgender populations. Overall, 79.1% of LGBT-related projects focused on HIV/AIDS and substantially fewer on illicit drug use (30.9%), mental health (23.2%), other sexual health matters (16.4%), and alcohol use (12.9%). Only 202 studies examined LGBT health–related interventions. Over time, the number of LGBT-related projects per year increased.Conclusions. The lack of NIH-funded research about LGBT health contributes to the perpetuation of health inequities. Here we recommend ways for NIH to stimulate LGBT-related research.In 2010, the National Institutes of Health (NIH) commissioned the Institute of Medicine (IOM) to systematically examine the state of lesbian, gay, bisexual, and transgender (LGBT) health.1 The IOM’s report on the health of LGBT populations contributed to advancing the field of LGBT health by identifying research gaps and developing an agenda to guide NIH in enhancing its portfolio in this area.1The findings highlighted in the IOM report are stark and reflect the inadequacy of LGBT health research to date. In general, LGBT populations experience stigma associated with their sexual and gender minority status, disproportionate behavioral risks and psychosocial health problems, and higher chronic disease risk factors than their heterosexual and cisgender counterparts.1–3 (Cisgender refers to congruence between the gender category assigned to an individual at birth and the gender identity experienced by that individual.4) The greatest focus of LGBT health research to date is on the increased risk and incidence of HIV/AIDS and other sexually transmitted infections among sexual minority men.1,5–8 Research on the health of sexual minority women and transgender populations is limited.1 We know that LGBT people experience disproportionate mental health and substance use problems relative to their heterosexual and cisgender counterparts.1,9–14 Inequities have also been documented in access to and utilization of health care among LGBT populations.1,15–18 But research is lacking for many other pertinent LGBT health issues, including the effects of problematic access to care, homophobia, violence, homelessness, tobacco use, and obesity.1NIH is the largest funder of medical research in the world,19 but its contribution to the emerging body of knowledge on LGBT health was minimal from 1974 to 199220 and remains undocumented for more recent years. In response to the findings and recommendations in the IOM report, NIH in 2012 invited grant proposals for research on the health of lesbian, gay, bisexual, transgender, and intersex populations.21–23 To accomplish the Healthy People 2020 goal of health equity for LGBT populations,2 public health researchers and practitioners need a large body of evidence for appropriate and effective means of improving health in these groups. However, the number of evidence-based interventions that succeed in improving the health and well-being of LGBT populations is unknown, and the extent to which they are being developed, implemented, and evaluated at NIH has yet to be illuminated. With NIH calling for new proposals, a comprehensive assessment of its funding of LGBT health research to date is necessary to ensure that funding is targeted to fill existing gaps in research.Therefore, we aimed to understand the proportion and content areas of NIH-funded research from 1989 through 2011 that focused on the health and well-being of LGBT populations. We analyzed the overall proportions of NIH-funded studies that examined the health of LGBT populations, and we recorded the subpopulations included in these projects (e.g., sexual minority women, sexual minority men, transgender persons). We examined the content areas of LGBT health–related research for the LGBT population as a whole and by subpopulations. We also analyzed the health foci of LGBT health–related research after excluding studies about HIV/AIDS and other sexual health matters for the LGBT population as a whole and by subpopulations. We examined projects funded to develop, implement, and evaluate public health interventions that address the unique needs of the LGBT population as a whole and by subpopulations. Finally, we examined LGBT health–related projects funded by NIH over time.     

Policy Support, Norms, and Secondhand Smoke Exposure Before and After Implementation of a Comprehensive Smoke-Free Law in Mexico City

Objectives. We assessed attitudes and beliefs about smoke-free laws, compliance, and secondhand smoke exposure before and after implementation of a comprehensive smoke-free law in Mexico City.Methods. Trends and odds of change in attitudes and beliefs were analyzed across 3 representative surveys of Mexico City inhabitants: before implementation of the policy (n = 800), 4 months after implementation (n = 961), and 8 months after implementation (n = 761).Results. Results indicated high and increasing support for 100% smoke-free policies, although support did not increase for smoke-free bars. Agreement that such policies improved health and reinforced rights was high before policy implementation and increased thereafter. Social unacceptability of smoking increased substantially, although 25% of nonsmokers and 50% of smokers agreed with smokers'' rights to smoke in public places at the final survey wave. Secondhand smoke exposure declined generally as well as in venues covered by the law, although compliance was incomplete, especially in bars.Conclusions. Comprehensive smoke-free legislation in Mexico City has been relatively successful, with changes in perceptions and behavior consistent with those revealed by studies conducted in high-income countries. Normative changes may prime populations for additional tobacco control interventions.Smoke-free policies can reduce involuntary exposure to toxic secondhand tobacco smoke (SHS), reduce tobacco consumption and promote quitting,^1,2 and shift social norms against smoking.^3–5 These policies are fundamental to the World Health Organization''s Framework Convention on Tobacco Control, an international treaty that promotes best-practices tobacco control policies across the world.⁶Evidence of successful implementation of smoke-free policies generally comes from high-income countries. Low- and middle-income countries increasingly bear the burden of tobacco use,⁷ however, and these countries may face particular challenges in implementing smoke-free policies, including greater social acceptability of tobacco use, shorter histories of programs and policies to combat tobacco-related dangers, and greater tolerance of law breaking.^8–10 There is a need for research that will help identify effective strategies for promoting and implementing smoke-free policies in low- and middle-income countries.Studies in high-income countries generally indicate that popular support for laws that ban smoking in public places and workplaces is strong and increases after such laws are passed.^11–15 Weaker laws that allow smoking in some workplaces can leave policy support unchanged.¹⁶ Policy-associated increases in support have been shown across populations that include smokers^{11,13,14,17,18} and bar owners and staff.^19,20 Beliefs about rights to work in smoke-free environments¹¹ and the health benefits of these environments²¹ have also been shown to increase with policy implementation. Support for banning smoking in all workplaces appears high in Latin American countries,²² but responses to smoke-free policies are less well known. In Uruguay, the first country in the Americas to prohibit smoking in all workplaces, including restaurants and bars,²³ support before the law was unknown. However, the level of support was high among both the general population²² and smokers²⁴ after the law''s implementation.Compliance with smoke-free laws in high-income countries has been good, particularly when laws apply across all workplaces, including restaurants and bars, and involve media campaigns. Self-reported declines in exposure in regulated venues^11,17,25 are consistent with findings from observational studies,^11,26 biomarkers of exposure,^11,25,27 and air quality assessments.^11,12Approximately 26% of Mexican adults residing in urban areas smoke.⁸ Most Mexicans recognize the harms of SHS and support smoke-free policies.^9,24,28,29 According to an opinion poll conducted before the August 2007 passage of a smoke-free law in Mexico City, about 80% of both Mexico City inhabitants and Mexicans in general supported prohibiting smoking in enclosed public places and workplaces.²⁸ In 2006, 60% of smokers reported that their workplace had a smoking ban, with Mexico City smokers reporting the lowest percentage of workplace bans at 37%.²⁴Mexico City''s smoke-free workplace law^30–32 initially allowed for designated smoking areas that were ventilated and physically separate.^22,33 Concerns about the inequity of this law for small business owners who could not afford to build designated smoking areas led the hospitality industry to support a comprehensive smoke-free law^31,32 that prohibited smoking inside all enclosed public places and workplaces, including public transport, restaurants, and bars. This law entered into force on April 3, 2008.Media coverage of the law was similar to that in high-income countries, pitting arguments about the government''s obligation to protect citizens from SHS dangers against arguments about discrimination toward smokers and the “slippery slope” of regulating behavior^4,32,34 (J. F. Thrasher et al., unpublished data, 2010). Most print media coverage was either positive or neutral, with much less coverage pitched against tobacco control policies.³⁴In the month before and after the law came into effect, the Mexico City Ministry of Health and nongovernmental organizations disseminated print materials and aired radio spots describing the dangers of SHS and the benefits of the law.³⁰ Community health promoters informed businesses about the law. From September through December 2008, a television, radio, print, and billboard campaign emphasized the law''s benefits.³⁵ We assessed, among Mexico City inhabitants, the prevalence of and increases in support, beliefs, norms, and compliance around the smoke-free law, as well as decreases in SHS exposure.     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data

Objectives. We sought to determine the magnitude, direction, and statistical significance of the relationship between active travel and rates of physical activity, obesity, and diabetes.Methods. We examined aggregate cross-sectional health and travel data for 14 countries, all 50 US states, and 47 of the 50 largest US cities through graphical, correlation, and bivariate regression analysis on the country, state, and city levels.Results. At all 3 geographic levels, we found statistically significant negative relationships between active travel and self-reported obesity. At the state and city levels, we found statistically significant positive relationships between active travel and physical activity and statistically significant negative relationships between active travel and diabetes.Conclusions. Together with many other studies, our analysis provides evidence of the population-level health benefits of active travel. Policies on transport, land-use, and urban development should be designed to encourage walking and cycling for daily travel.Many nations throughout the world have experienced large increases in obesity rates over the past 30 years.^1,2 The World Health Organization estimates that more than 300 million adults are obese,³ putting them at increased risk for diseases such as diabetes, hypertension, cardiovascular disease, gout, gallstones, fatty liver, and some cancers.^4,5 Several studies have linked the increase in obesity rates to physical inactivity^6–8 and to widespread availability of inexpensive, calorie-dense foods and beverages.^1,9The importance of physical activity for public health is well established. A US Surgeon General''s report in 1996, Physical Activity and Health,¹⁰ summarized evidence from cross-sectional studies; prospective, longitudinal studies; and clinical investigations. The report concluded that physical inactivity contributes to increased risk of many chronic diseases and health conditions. Furthermore, the research suggested that even 30 minutes per day of moderate-intensity physical activity, if performed regularly, provides significant health benefits. Subsequent reports have supported these conclusions.^11–13The role of physical activity in prevention of weight gain is well documented.¹⁴ Strong evidence from cross-sectional studies has established an inverse relationship between physical activity and body mass index.^15,16 In addition, longitudinal studies have shown that exercisers gain less weight than do their sedentary counterparts.^6,8 Thus, the obesity epidemic may be explained partly by declining levels of physical activity.^1,17,18A growing body of evidence suggests that differences in the built environment for physical activity (e.g., infrastructure for walking and cycling, availability of public transit, street connectivity, housing density, and mixed land use) influence the likelihood that people will use active transport for their daily travel.^19,20 People who live in areas that are more conducive to walking and cycling are more likely to engage in these forms of active transport.^21–25 Walking and cycling can provide valuable daily physical activity.^26–30 Such activities increase rates of caloric expenditure,³¹ and they generally fall into the moderate-intensity range that provides health benefits.^32–35 Thus, travel behavior could have a major influence on health and longevity.^29,30,36,37Over the past decade, researchers have begun to identify linkages between active travel and public health.^38–40 Cross-sectional studies indicate that walking and cycling for transport are linked to better health. The degree of reliance on walking and cycling for daily travel differs greatly among countries.^39,41 European countries with high rates of walking and cycling have less obesity than do Australia and countries in North America that are highly car dependent.²⁶ In addition, walking and cycling for transport are directly related to improved health in older adults.⁴² The Coronary Artery Risk Development in Young Adults Study found that active commuting was positively associated with aerobic fitness among men and women and inversely associated with body mass index, obesity, triglyceride levels, resting blood pressure, and fasting insulin among men.^26,39,41,43Further evidence of the link between active commuting and health comes from prospective, longitudinal studies.⁴⁴ Matthews et al. examined more than 67 000 Chinese women in the Shanghai women''s health study and followed them for an average of 5.7 years.³⁷ Women who walked (P < .07) and cycled (P < .05) for transport had lower rates of all-cause mortality than did those who did not engage in such behaviors. Similarly, Andersen et al. observed that cycling to work decreased mortality rates by 40% among Danish men and women.³⁶ A recent analysis of a multifaceted cycling demonstration project in Odense, Denmark, reported a 20% increase in cycling levels from 1996 to 2002 and a 5-month increase in life expectancy for males.⁴⁵We analyzed recent evidence from a variety of data sources that supports the crucial relationship between active travel, physical activity, obesity, and diabetes. We used city- and state-level data from the United States and national aggregate data for 14 countries to determine the magnitude, direction, and statistical significance of each relationship.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.