Effect of Depression on Risky Drinking and Response to a Screening,Brief Intervention,and Referral to Treatment Intervention

We assessed alcohol consumption and depression in 234 American Indian/Alaska Native women (aged 18–45 years) in Southern California. Women were randomized to intervention or assessment alone and followed for 6 months (2011–2013). Depression was associated with risk factors for alcohol-exposed pregnancy (AEP). Both treatment groups reduced drinking (P < .001). Depressed, but not nondepressed, women reduced drinking in response to SBIRT above the reduction in response to assessment alone. Screening for depression may assist in allocating women to specific AEP prevention interventions.Women who consume alcohol and do not practice effective contraception are at risk for an alcohol-exposed pregnancy (AEP). AEPs can lead to fetal alcohol spectrum disorders, the leading known cause of developmental disabilities.1–3 Prepregnancy drinking, particularly heavy episodic or binge drinking, is a robust predictor of AEP.4 Depression has been linked to problem alcohol consumption in women5–7 and appears to predate8,9 and perhaps predict10 alcohol problems. Among American Indian/Alaska Native (AI/AN) women, studies have linked depression to problem drinking.11–13 However, risk factors for an AEP and interventions to reduce risk for AEP have not been well studied in AI/AN women.14 This is further complicated by variability among AI/AN populations in the prevalence of alcohol consumption11,15–20 and depression.13,21–23One approach to prevention of AEPs is screening, brief intervention, and referral to treatment (SBIRT).24,25 We previously tested the effectiveness of an SBIRT intervention in AI/AN women and found that whether women received an assessment followed by the SBIRT intervention or assessment alone, they reported a significant reduction in alcohol use. We examined depression as a predictor of vulnerability to having an AEP and explored whether depressed AI/AN women respond differently than nondepressed women to an SBIRT intervention.     

Screening,Brief Intervention,and Referral to Treatment: Public Health Training for Primary Care

Objectives. The purpose of this study was to elucidate changes in attitudes, experiences, readiness, and confidence levels of medical residents to perform screening, brief intervention, and referral to treatment (SBIRT) and factors that moderate these changes.Methods. A cohort of 121 medical residents received an educational intervention. Self-reported experience, readiness, attitude, and confidence toward SBIRT-related skills were measured at baseline and at follow-up. Analyses were conducted to evaluate the effects of medical specialization.Results. The intervention significantly increased experience (P < .001), attitude (P < .05), readiness (P < .001), and confidence (P < .001). Residents were more likely to report that their involvement influenced patients’ substance use. However, experience applying SBIRT skills varied by country of birth, specialty, and baseline scores.Conclusions. This study suggested that SBIRT training was an effective educational tool that increased residents’ sense of responsibility. However, application of skills might differ by specialization and other variables. Future studies are needed to explore and evaluate SBIRT knowledge obtained, within the context of cultural awareness and clinical skills.Substance use disorders are a major public health problem, contributing substantially to the nation''s morbidity and mortality. Substance abuse is estimated to cost more than $484 billion per year in the United States.1 Health care providers exert time and resources treating patients with substance abuse related injuries and illnesses. This suggests that health care providers have a vital role in the prevention and intervention of substance use disorders.Despite the US Preventive Services Task Force recommendation to provide screening and counseling for alcohol, tobacco, and illicit drug use among adults, pregnant women, and adolescents, many medical health care professionals face barriers and challenges providing early intervention, motivating change of behavior, facilitating access to treatment when appropriate, and improving quality of care with at-risk users.2 Barriers to providing optimal care may include deficient clinical skills and knowledge,3 negative attitudes,4 and discomfort with patient discussions about substance use.5 Studies suggest physicians report low confidence in their skills and poor satisfaction in treating substance use disorders,6,7 and often overlook the opportunity to diagnose alcohol problems in primary care settings.4,8–11 When health care professionals confront the consequences of substance abuse during patient care, they often lack the expertise to facilitate behavior change.12 Overall training in substance use related diagnosis, treatment, and prevention with chronic disease management has been inadequate for physicians.13 To address the demand for prevention and intervention in the health care setting, health care professionals must have the education and training to effectively identify substance use problems, provide behavioral counseling, and coordinate treatment. Increased education, cultural awareness, and clinical skills training of health care professionals on substance use disorders is imperative in providing quality and competent care for patients. According to the Substance Abuse and Mental Health Administration and the Office of National Drug Control Policy, screening, brief, intervention, and referral to treatment (SBIRT) is a comprehensive and integrated public health approach to the delivery of early intervention and treatment services for substance use disorders.14,15 The SBIRT approach reduces substance use consumption, improves population health, and promotes health equity through the effective integration of primary care with public health.16 Alcohol screening and brief intervention offers an evidence-based and cost-effective approach.17,18 There is strong evidence documenting the efficacy and effectiveness of screening brief intervention in reducing alcohol consumption for at-risk individuals in meta-analyses of randomized control trials and systematic reviews.19–21 In addition, the efficacy and cost effectiveness of SBIRT has been demonstrated in primary care, emergency departments, and trauma centers.22 Thus, the integration of SBIRT training for primary care residency programs lays the foundation for physician practices that may ultimately reduce substance abuse among at-risk users and dependent patients.Research suggests that medical specialization influences screening and brief interventions among physicians. Freidmann et al. 23 found that physicians practicing internal medicine and psychiatry were more likely to screen patients than family medicine or obstetrics/gynecology physicians. Also within this study, psychiatrists were most likely to attempt a brief intervention.23 However, little is known about the influence of SBIRT training on the health care providers’ attitudes, experiences, readiness, and confidence in performing SBIRT-related skills. In an evaluation of an SBIRT curriculum for emergency department providers, significant improvements in the providers’ self-reported confidence in ability and responsibility to intervene were noted.22The purpose of this study was to examine changes in residents’ attitude, experience, confidence, and readiness to implement SBIRT with patients. The study also elucidated the moderating effects on changes in attitudes, experiences, readiness, and confidence level of medical residents.     

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.     

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.     

Social support, exposure to violence and transphobia, and correlates of depression among male-to-female transgender women with a history of sex work

Objectives. We determined racial/ethnic differences in social support and exposure to violence and transphobia, and explored correlates of depression among male-to-female transgender women with a history of sex work (THSW).Methods. A total of 573 THSW who worked or resided in San Francisco or Oakland, California, were recruited through street outreach and referrals and completed individual interviews using a structured questionnaire.Results. More than half of Latina and White participants were depressed on the basis of Center For Epidemiologic Studies Depression Scale scores. About three quarters of White participants reported ever having suicidal ideation, of whom 64% reported suicide attempts. Half of the participants reported being physically assaulted, and 38% reported being raped or sexually assaulted before age 18 years. White and African American participants reported transphobia experiences more frequently than did others. Social support, transphobia, suicidal ideation, and levels of income and education were significantly and independently correlated with depression.Conclusions. For THSW, psychological vulnerability must be addressed in counseling, support groups, and health promotion programs specifically tailored to race/ethnicity.The term “transgender” has been used as an umbrella term, capturing people who do not conform with a binary male–female gender category.¹ In this study, we use the term “transgender women” or “male-to-female transgender women” to describe individuals who were born biologically male but self-identify as women and desire to live as women.² Although transgender persons or those who identify their gender other than male or female have been historically reported in many cultures around the world, their social roles, status, and acceptance have varied across time and place.³ In the United States, as part of the gay rights movement in the 1970s, a transgender civil rights movement emerged to advocate for transgender people''s equal rights and to eradicate discrimination and harassment in their daily lives.⁴ However, transphobia—institutional, societal, and individual-level discrimination against transgender persons—is still pervasive in the United States and elsewhere. It often takes the form of laws, regulations, violence (physical, sexual, and verbal), harassment, prejudices, and negative attitudes directed against transgender persons.^5–7Studies have reported that transgender persons lack access to gender-sensitive health care^6,8,9 and often experience transphobia in health care and treatment.^5,9 Transgender persons are frequently exposed to violence, sexual assault, and harassment in everyday life, mainly because of transphobia.^5–7,9–11 Physical and sexual assaults and violence, and verbal and nonphysical harassment, derive from various perpetrators (e.g., strangers, acquaintances, partners, family members, and police officers). Transgender persons suffer from assaults, rape, and harassment at an early age, and these experiences persist throughout life.¹ A number of studies have examined violence and harassment against sexual minorities, although these have mainly focused on gay men.^12–15 A limited literature has described the prevalence of violence, transphobia, and health disparities among transgender persons.^7–9Psychological indicators such as depression and suicidal ideation and attempts have been reported among transgender persons.^{5,6,10,16–18} Transgender women of color, such as African Americans, Latinas, and Asians/Pacific Islanders (APIs), are at high risk for adverse health outcomes because of racial/ethnic minority status and gender identity,⁶ as well as for depression through exposure to transphobia.¹⁹ Although transgender persons have reported relatively high rates of using basic health care services,²⁰gender-appropriate mental health services are needed,⁵ particularly among African Americans.²¹ A lack of social support, specifically from the biological family, is commonly reported among transgender persons and is associated with discomfort and lack of security and safety in public settings.²² Sparse research exists on social support among transgender persons, although such support could ameliorate adverse psychological consequences associated with transphobia and also mitigate racial discrimination for transgender persons of color.Because of relatively high rates of unemployment, lack of career training and education, and discrimination in employment, many transgender women engage in sex work for survival.^23,24 Sex work is linked to high-risk situations, including substance abuse, unsafe sex, and sexual and physical abuse.²⁵ Physical abuse, social isolation, and the social stigma associated with sex work exacerbate transgender women''s vulnerability to mental illness and HIV risk.^5,17 High HIV seroprevalence rates among transgender women have been reported,^5,20,26–28 particularly among racial/ethnic minorities,⁵ substance users,²⁷ and sex workers.^{20,24,25,29–31} Transgender women of color face multiple adversities, such as racial and gender discrimination; transphobia; economic challenges including unemployment, substance abuse, HIV and other sexually transmitted infections; and mental illness. However, few studies have investigated racial/ethnic differences in psychological status among transgender women of color in relation to social support and exposure to transphobia.To develop culturally appropriate and transgender specific mental health promotion programs, we describe the prevalence of violence, transphobia, and social support in relation to racial/ethnic background among transgender women with a history of sex work (THSW). We also investigated the role of social support and exposure to transphobia on participants’ levels of depression.     

The Relationship Between Discrimination and Substance Use Disorders Among Lesbian, Gay, and Bisexual Adults in the United States

Objectives. We examined the associations between 3 types of discrimination (sexual orientation, race, and gender) and substance use disorders in a large national sample in the United States that included 577 lesbian, gay, and bisexual (LGB) adults.Methods. Data were collected from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, which used structured diagnostic face-to-face interviews.Results. More than two thirds of LGB adults reported at least 1 type of discrimination in their lifetimes. Multivariate analyses indicated that the odds of past-year substance use disorders were nearly 4 times greater among LGB adults who reported all 3 types of discrimination prior to the past year than for LGB adults who did not report discrimination (adjusted odds ratio = 3.85; 95% confidence interval = 1.71, 8.66).Conclusions. Health professionals should consider the role multiple types of discrimination plays in the development and treatment of substance use disorders among LGB adults.Substance use disorders have been shown to be more prevalent among lesbian, gay, and bisexual (LGB) adults than among heterosexual adults in the United States.^1–6 Despite this evidence, little empirical work has focused on why such differences exist between LGB and heterosexual adults. Many studies have posited that differences in rates of mental health problems and substance abuse are related to social stressors such as discrimination,^7–11 yet no large-scale national studies have examined the relationship between multiple types of discrimination and substance use disorders. Meyer''s minority stress model posits that discrimination, internalized homophobia, and social stigma can create a hostile and stressful social environment for LGB adults that contributes to mental health problems, including substance use disorders.^10,11 An assumption of this model is that minority stress is unique and additive to general stressors that all people experience.Meyer''s model connects the literature demonstrating higher odds of mental health problems and substance use disorders among LGB populations with well-established social science research that demonstrates the link between stress or stressful life events and poor health outcomes.^12–15 Lesbian, gay, and bisexual adults experience discrimination at the structural and institutional level, such as in access to housing, employment, medical care, and basic civil rights,^16,17 as well as at the individual level in the form of harassment and violence.^18–22 Discriminatory experiences have been shown to operate as stressors in the lives of LGB people and, in turn, they are significantly associated with psychiatric disorders,⁹ psychological distress,^9,20,23 and depressive symptoms.^20,24Although the minority stress model provides a useful theoretical framework for understanding health disparities among LGB adults, only a handful of studies have directly assessed discrimination among LGB populations, and even fewer have examined the relationships between discrimination and health outcomes. Extant research on health outcomes related to discrimination has focused on blood pressure,¹⁷ psychological distress,^24,25 mental health disorders,⁹ and general psychological and physical health.²⁶ Given that exposure to both acute and chronic stress has long been associated with substance abuse and relapse in the general population,^26,27 research on the association between experiences of discrimination and substance use disorders among LGB adults is warranted.In our investigation, we assumed that LGB adults are at heightened risk for substance use disorders as a consequence of cultural and environmental factors associated with being part of a stigmatized and marginalized population, not because of their sexual orientation. Building on previous work documenting the impact of multiple stigmatized statuses among sexual minority people^11,28,29 as well as the work of Krieger et al.,¹⁶ we sought to examine the relationships between 3 types of discrimination (sexual orientation, race/ethnicity, and gender) and substance use disorders. We used data from wave 2 of the 2004–2005 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to test the hypothesis that LGB adults who reported more types of discrimination would be more likely to meet criteria for substance use disorders than would those who reported fewer types or who did not report discrimination.     

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.     

Destigmatizing Alcohol Dependence: The Requirement for an Ethical (Not Only Medical) Remedy

The disease model of alcohol dependence or “alcoholism” is often presented as the linchpin in addressing the condition successfully. It has been argued, for example, that adopting a medical approach will reduce the stigma that impedes the provision and acceptance of treatment. However, the medical paradigm has existed for many years without significantly affecting the negative social attitudes that surround dependence.I argue that a reductive scientific approach is not equipped to address the socioethical tensions that dependence creates.To lessen the stigmatization of dependence, it is important to integrate ethical analysis into policy debates on the condition.ALCOHOL DEPENDENCE, AS part of the broader category of substance dependence, is identified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition as “a cluster of cognitive, behavioral, and physiological symptoms” and is characterized by withdrawal, tolerance, and compulsive alcohol use.1 The dependent continue drinking “despite evidence of adverse psychological or physical consequences (e.g., depression, blackouts, liver disease …).” Dependent drinkers experience considerable disability as a result of their chronic substance use.2 The biopsychosocial nature of the condition and the influence of environmental factors on its psychobiological features is well established.3,4 In this respect, the availability of substances, low socioeconomic status, and stress exacerbate the condition.5The 2009 National Survey on Drug Use and Health estimates that 15.4 million people in the United States are dependent on or abuse alcohol, and another 3.2 million have similar problems with both illicit drugs and alcohol.6 The prevalence of dependence has been reported as 12.5% over a life course and 3.8% in the previous 12 months (43 093 individuals).2 In addition to the harms it causes to individual health, Turner has highlighted that alcohol dependence is detrimental to “all Americans” either directly (e.g., via violence and automobile accidents) or through its burden on the common good.7 Alcohol misuse and dependence has been estimated to cost the United States $185 billion per annum.8     

Health Information–Seeking Behaviors,Health Indicators,and Health Risks

Objectives. We examined how different types of health information–seeking behaviors (HISBs)—no use, illness information only, wellness information only, and illness and wellness information combined—are associated with health risk factors and health indicators to determine possible motives for health information seeking.Methods. A sample of 559 Seattle–Tacoma area adults completed an Internet-based survey in summer 2006. The survey assessed types of HISB, physical and mental health indicators, health risks, and several covariates. Covariate-adjusted linear and logistic regression models were computed.Results. Almost half (49.4%) of the sample reported HISBs. Most HISBs (40.6%) involved seeking a combination of illness and wellness information, but both illness-only (28.6%) and wellness-only (30.8%) HISBs were also widespread. Wellness-only information seekers reported the most positive health assessments and the lowest occurrence of health risk factors. An opposite pattern emerged for illness-only information seekers.Conclusions. Our findings reveal a unique pattern of linkages between the type of health information sought (wellness, illness, and so on) and health self-assessment among adult Internet users in western Washington State. These associations suggest that distinct health motives may underlie HISB, a phenomenon frequently overlooked in previous research.Internet access is a widely available technology in the United States.^1,2 Among the variety of online activities, searching for and using health information appear to be particularly prevalent, undertaken by between 40% and 70% of US adults.^1,3–7 Hoping to take advantage of the Internet''s potential,⁸ public health practitioners, clinicians, and researchers have contributed to an emerging literature detailing characteristics of individuals engaging in health information–seeking behaviors (HISBs), exploring motives for engaging in HISBs, and documenting the types of health and medical information being sought.^9–11Previous HISB research has primarily examined how patients seek and use health information across diverse health care contexts, yielding the recurrent observation that individuals striving to deal with stressful health challenges—such as a recent illness diagnosis or chronic disease management—were strongly motivated to engage in Internet HISBs.^9,10,12–14 Several population-based studies,^9,15–21 many of which have also conceptualized HISB primarily as “a key coping strategy in health-promotive activities and psychosocial adjustment to illness,”^22(p1006) have yielded corresponding evidence. It should be recognized, however, that a cluster of these studies^17–19,21 were informed by a common evidentiary resource (i.e., 2000–2002 Pew Internet and American Life Project data), potentially exaggerating the apparent consistency of the “disease and illness” motivation for HISB.Although informative, the predominant focus in previous research on a “disease and illness” motive for HISB has left the hypothesis that healthy individuals may pursue information to maximize positive health outcomes essentially unexplored.²³ A small but growing body of findings suggests, however, that many individuals actively seek out wellness information (e.g., information promoting a healthy lifestyle). Specifically, emerging evidence reveals a positive association between a self-reported “health-conscious” or “health-active” orientation and engaging in wellness information–seeking behavior.^20,24–27 Indeed, since 2000, the proportion of American adults reporting that they have looked online for diet, exercise, or fitness information has increased substantially and generally exceeds the proportion seeking online information about disease and illness topics (e.g., cancer, arthritis, diabetes).^28,29Pandey et al. have asked, “Is it a disease or an affliction that motivates the use of the internet, or is it that the well and the healthy use the internet in a proactive manner?”^23(p180) As this question highlights, the nearly exclusive focus in previous research on Internet HISB as a response to health-threatening situations has left questions regarding the potential positive health outcomes motivating HISB unanswered.²² We aimed to fill this knowledge gap and further expand understanding of linkages between HISB and health perceptions and behaviors. Specifically, we compared mental and physical health indicators and health risk factors across 4 discrete categories of Internet HISBs—no use, illness content only, wellness content only, and illness and wellness content combined—among a sample of adults in the Seattle–Tacoma, Washington area to explore motivations of HISB.     

Consistency and Change in Club Drug Use by Sexual Minority Men in New York City, 2002 to 2007

We used repeated cross-sectional data from intercept surveys conducted annually at lesbian, gay, and bisexual community events to investigate trends in club drug use in sexual minority men (N = 6489) in New York City from 2002 to 2007. Recent use of ecstasy, ketamine, and γ-hydroxybutyrate decreased significantly. Crystal methamphetamine use initially increased but then decreased. Use of cocaine and amyl nitrates remained consistent. A greater number of HIV-positive (vs HIV-negative) men reported recent drug use across years. Downward trends in drug use in this population mirror trends in other groups.“Club drugs” are illicit substances consumed in social or party situations¹ to increase social disinhibition and heighten sensual and sexual experiences.^2,3 This category typically includes ecstasy (3,4 methylenedioxymethamphetamine), γ-hydroxybutyrate (GHB), and ketamine,⁴ although recent reports also have included cocaine⁵ and crystal methamphetamine.⁶Concern about club drug use has increased because of consistent associations with unprotected sexual intercourse.^7–9 Given the high rates of use⁴ among men who have sex with men, most club drug research has focused on this population—and on identified gay and bisexual men specifically.^10,11 Published prevalence estimates are quite variable, ranging, for example, from 6% to 65% for crystal methamphetamine^9,12 and from 7% to 93% for ecstasy.^13,14 However, epidemiological trends remain unknown, and most studies contributing prevalence data have 1 or more significant limitations, including use of cross-sectional designs or small sample sizes, recruitment solely at bars or circuit parties, or investigation of some but not all club drugs.We used a repeated cross-sectional design¹⁵ to investigate trends in the prevalence of recent club drug use (and amyl nitrates or “poppers”) between 2002 and 2007 among urban sexual minority men. Given consistent differences in rates of use between HIV-positive and HIV-negative men, we reported differences by HIV serostatus.     

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.     

Correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand

Objectives. We examined correlates of incarceration among young methamphetamine users in Chiang Mai, Thailand in 2005 to 2006.Methods. We conducted a cross-sectional study among 1189 young methamphetamine users. Participants were surveyed about their recent drug use, sexual behaviors, and incarceration. Biological samples were obtained to test for sexually transmitted and viral infections.Results. Twenty-two percent of participants reported ever having been incarcerated. In multivariate analysis, risk behaviors including frequent public drunkenness, starting to use illicit drugs at an early age, involvement in the drug economy, tattooing, injecting drugs, and unprotected sex were correlated with a history of incarceration. HIV, HCV, and herpes simplex virus type 2 (HSV-2) infection were also correlated with incarceration.Conclusions. Incarcerated methamphetamine users are engaging in behaviors and being exposed to environments that put them at increased risk of infection and harmful practices. Alternatives to incarceration need to be explored for youths.Over the past decade, methamphetamine use has increased exponentially and reached epidemic proportions, particularly in North America¹ and Southeast Asia.² The methamphetamine epidemic has been concentrated among adolescents and young adults and has significant public health implications² because methamphetamine use has been associated with high-risk behaviors including multiple sexual partners, contractual sex, polydrug use, and aggression.^3,4Thailand has experienced a steadily increasing methamphetamine epidemic since 1996.⁵ By 2003, an estimated 3 500 000 Thais had ever used methamphetamines.⁶ In 1996, Thailand criminalized methamphetamines, treating the trafficking, possession, and use of methamphetamines with the same severity as heroin-related offenses.⁷ In 2003 the government began a “war on drugs” in an attempt to control the epidemic.^8,9 In combination, these events led to a doubling in the number of incarcerated individuals between 1996 and 2004.^7,10 In 2005, 64% of Thai inmates were drug offenders,¹¹ and in 2006, 75% of drug-related arrests and charges were related to methamphetamines.¹² Treatment for methamphetamine use is limited. Institutional management of methamphetamine users includes the use of rehabilitation centers, military-style boot camps, compulsory drug treatment centers, and prisons.¹¹A history of incarceration has been associated with negative health outcomes, including sexually transmitted infections (STIs) and blood-borne viruses, particularly syphilis,¹³ herpes,¹⁴ HIV,^10,15,16 hepatitis b (HBV),^17,18 and HCV.^18–21 The prevalence of these pathogens has been found to be much higher in prisons than in the general population.^22–26 Although these infections may be a result of a high-risk lifestyle leading to incarceration, it is also clear that the prison system exposes individuals to environments and behaviors that increase their risk of acquiring these infections, such as tattooing,^{10,18,21,27–29} unprotected sex as a result of limited condom availability,²⁷ and using shared needles to inject drugs.^27,30,31With so many young methamphetamine users entering the judicial system, it is important to understand the characteristics of this group so that appropriate public health interventions can be designed. Young methamphetamine users need to be diverted away from the judicial system to decrease high-risk behaviors that may impact their own well-being and that of the community.As part of a randomized controlled trial to reduce the risks associated with methamphetamine use among youths in Chiang Mai, Thailand, we investigated behavioral and viral correlates of incarceration among a sample of 1189 young adults aged 18 to 25 years.     

Question Context and Priming Meaning of Health: Effect on Differences in Self-Rated Health Between Hispanics and Non-Hispanic Whites

Objectives. We examined the implications of the current recommended data collection practice of placing self-rated health (SRH) before specific health-related questions (hence, without a health context) to remove potential context effects, between Hispanics and non-Hispanics.Methods. We used 2 methodologically comparable surveys conducted in English and Spanish that asked SRH in different contexts: before and after specific health questions. Focusing on the elderly, we compared the influence of question contexts on SRH between Hispanics and non-Hispanics and between Spanish and English speakers.Results. The question context influenced SRH reports of Spanish speakers (and Hispanics) significantly but not of English speakers (and non-Hispanics). Specifically, on SRH within a health context, Hispanics reported more positive health, decreasing the gap with non-Hispanic Whites by two thirds, and the measurement utility of SRH was improved through more consistent mortality prediction across ethnic and linguistic groups.Conclusions. Contrary to the current recommendation, asking SRH within a health context enhanced measurement utility. Studies using SRH may result in erroneous conclusions when one does not consider its question context.Hispanics in the United States have emerged as an important group for public health research because of their noteworthy population growth. The past decade saw a rapid increase of the Hispanic population from 35.3 million to 50.5 million, corresponding to 12.5% and 16.3% of the total population.1 In states such as California, New Mexico, and Texas, Hispanics make up more than 35% of the population. Although not the majority in the general population, Hispanics contributed more than half of the US population growth.One distinctive characteristic of Hispanics is their language use. Four out of 10 Hispanics are reported to speak English less than very well, hence being classified as “linguistically isolated.”2 The linguistic isolation rate is estimated to be more than 90% for some Hispanic subgroups, such as older low-income Cuban women in Miami.3 Although not a health risk factor itself, low English proficiency (LEP) is related to many health outcomes through the socioeconomic gradient, such as education, poverty, and access to health care. Because the failure to capture LEP persons produces data misrepresenting the population,4–6 it has become standard practice for government and academic surveys in the United States to conduct interviews in both English and Spanish. The National Health Interview Survey (NHIS), for example, has conducted Spanish interviews consistently since 1997 and with standardized translated questionnaires since 2004.Hispanics’ health has been compared with that of other racial/ethnic groups,7–11 creating a famous term, “Hispanic paradox.” Even though correlates of health, such as income and education, are estimated to be lower for Hispanics than for non-Hispanic Whites, Hispanics show better health outcomes than non-Hispanic Whites or comparable health outcomes to non-Hispanic Whites.12–18 One exception to the paradox is the measure self-rated health (SRH), which consistently shows less favorable outcomes for Hispanics compared with non-Hispanic Whites.7,19,20 Self-rated health is a simple survey item asking respondents for their subjective assessment about their own health by using some variations of a 4- or 5-point Likert response scale. One of the scales ranging from “excellent,” “very good,” “good,” “fair,” to “poor” is popular in the United States, and another scale using “very good” to “very poor,” supported by the World Health Organization, is popular elsewhere.21The popularity of SRH not only in health research22–26 but also in other social sciences27–31 led the US National Center for Health Statistics to organize a conference dedicated to this particular item, the Conference on the Cognitive Aspects of the Self-Rated Health Status, in 1993.32 Because of its proven utility as a strong and independent predictor of subsequent mortality,33–39 various health conditions,40-43 and health care utilization,44–46 the World Health Organization,47 the US Centers for Disease Control and Prevention,48 and the European Commission49 have recommended SRH as a reliable measure of monitoring population health.Self-rated health is also used as a practical tool for comparing various population groups associated with country,50–52 gender,53 race,41 socioeconomic status,54,55 educational attainment,56 poverty status,57 and immigration status,58 often leading to discussions about health disparities. Although it is critical to use items with comparable measurement properties across comparison groups, the measurement utility of SRH has been mostly examined with English speakers or northern Europeans.44,59–61 Beyond these groups, the performance of SRH has been found to be inconsistent, leading to questionable comparability.9,21,25,29,62–68The literature on the utility of SRH for US Hispanics is spotty and does not provide clear conclusions and appears to have overlooked methodological limitations in the data.8,10,64,69 Some studies have used data that did not include LEP Hispanics,64 and some used SRH asked in different contexts.8,10,69 The former is no longer a serious issue because the current survey practice accommodates LEP Hispanics. However, the question context may raise a concern as it has been suggested as a future research topic for SRH,70,71 including the seminal work by Idler and Benyamini.36Particularly for Hispanics, a recent study by Lee and Grant72 suggests troublesome implications. They conducted an experiment where the order of SRH in a questionnaire was randomized: SRH was asked as either a first health-related item after a few demographic questions (i.e., without a health context) or after a series of questions on chronic health conditions (i.e., within a health context). Whereas English-speaking respondents’ SRH reports remained consistent regardless of the question context, Spanish-speaking respondents’ reports were found to be unstable depending on the context. Specifically, Spanish-speaking respondents reported significantly and substantively better health on SRH asked within than without a health context. Reflecting LEP among Hispanics, their SRH rating was also affected by the question context. The question context effect is of concern in its own right. When the context interacts with interview language or respondents’ cultural background as in this example, it becomes even more important, because systematic incomparability is introduced.We further examined the effect of SRH question contexts with the US elderly population. Using data from surveys conducted in both English and Spanish, we examined how the question context affects (1) the estimates of SRH for each linguistic group, (2) the comparisons of health between 2 linguistic groups, and (3) the predictive power of SRH for subsequent mortality. Because Spanish-language use is tightly related to ethnicity, we also included Hispanics and non-Hispanics in the study.     

Fatty,Fatty, Two-by-Four: Weight-Teasing History and Disturbed Eating in Young Adult Women

Objective. We investigated the long-term effect of weight teasing during childhood.Methods. Young adult women (n = 1533; aged 18–26 years) from 3 large universities participated in a survey (Fall 2009 to Spring 2010) that assessed disturbed eating behaviors; weight status at ages 6, 12, and 16 years; and weight-teasing history.Results. Nearly half of the participants were weight-teased as a child. Participants who experienced childhood weight teasing were significantly more likely to have disturbed eating behaviors now than non–weight-teased peers. As the variety of weight teasing insults recalled increased, so did disturbed eating behaviors and current body mass index. Those who recalled their weight at ages 6, 12, or 16 years as being heavier than average endured weight teasing significantly more frequently and felt greater distress than their lighter counterparts.Conclusions. Weight teasing may contribute to the development of disturbed eating and eating disorders in young women. Health care professionals, parents, teachers, and other childcare givers must help shift social norms to make weight teasing as unacceptable as other types of bullying. To protect the health of children, efforts to make weight teasing unacceptable are warranted.Nearly one quarter of the population is subjected to taunts and jeers, such as “chubby,” “tubby,” and “fatso,” during their lifetimes.1 Weight-related teasing is especially prevalent during childhood and adolescence,2,3 and may be on the rise with the increasing rates of overweight and obesity in youths.4 At greatest risk for being teased are those who have “violated” social norms.5 Social norms, a construct of the Theory of Reasoned Action and Theory of Planned Behavior,6 are “written and unwritten rules that define ‘appropriate’ thoughts, feelings, and behaviors of a culture and exert pressure on people to believe and behave in a certain way.”7^(p152) In fact, overweight youths are the targets of weight-related teasing more often than their average-weight peers—about one fifth of average-weight girls and nearly half of overweight girls report being teased about their weight at least a few times each year.2 Females are at greater risk for weight-teasing insults than males,8 perhaps because of greater societal pressures to achieve the “thin ideal” body type.9,10According to Haines et al., “Despite increased media and research attention on bullying and hate speech, weight-related teasing and the biased weight-related norms that influence such behaviors do not appear to be abating.”11^(pS23) The prevalence and persistence of weight teasing is troubling because of the pernicious effects it can have on physical and emotional health.12 Weight-related teasing can lead to poorer overall health, diminished social well-being, and body dissatisfaction.13 Even more worrisome are longitudinal research findings linking weight teasing insults to disturbed eating behaviors.14,15Disturbed eating includes unhealthy or extreme weight-control behaviors, such as self-induced vomiting and medication misuse (e.g., laxatives), and binge eating.16,17 These practices can escalate into a full-blown eating disorder.16,17 Longitudinal data indicate that disturbed eating behaviors are common in adolescence and track into young adulthood, thereby placing youths at an increased eating-disorder risk.18Little is known about the long-term effects of weight teasing during childhood on eating behaviors. In addition, previous investigations of weight-related teasing and disturbed eating practices did not use instruments that assessed the full array of eating disorder diagnostic criteria elucidated in the Diagnostic Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).19 Previous weight-teasing research also has neglected exploration of other salient disturbed eating behaviors, such as emotional eating, disinhibited eating, and dichotomous thinking with regard to food. Increased emotional eating (i.e., eating in response to a mood) and disinhibited eating (i.e., uncontrolled eating) are common among dieters and binge eaters.20,21 Although identified as a common factor among those who have eating disorders,22 dichotomous thinking (i.e., rigid, “black and white” cognitive thinking style) remains an understudied psychological construct.22,23 The rigid dietary “rules” in dichotomous thinking (e.g., good food vs bad food) may help maintain disturbed eating behaviors and increase the frequency of behaviors (e.g., binge eating, purging) following any breach of dietary rules.24 This “all or nothing” attitude toward eating may place an individual at risk for eating disorders.The goal of this research was to expand our understanding of the long-term effect of weight teasing during childhood on a broad array of current disturbed eating behaviors of healthy young adult women. A second goal was to explore relationships among recollections of body weight during the growing years, frequency and effect of weight-teasing insults, and current disturbed eating behaviors.     

“You Don't Go Tell White People Nothing”: African American Women's Perspectives on the Influence of Violence and Race on Depression and Depression Care

Objectives. We sought to understand how African American women''s beliefs regarding depression and depression care are influenced by racism, violence, and social context.Methods. We conducted a focus group study using a community-based participatory research approach. Participants were low-income African American women with major depressive disorder and histories of violence victimization.Results. Thirty women participated in 4 focus groups. Although women described a vicious cycle of violence, depression, and substance abuse that affected their health, discussions about health care revolved around their perception of racism, with a deep mistrust of the health care system as a “White” system. The image of the “strong Black woman” was seen as a barrier to both recognizing depression and seeking care. Women wanted a community-based depression program staffed by African Americans that addressed violence and drug use.Conclusions. Although violence and drug use were central to our participants'' understanding of depression, racism was the predominant issue influencing their views on depression care. Providers should develop a greater appreciation of the effects of racism on depression care. Depression care programs should address issues of violence, substance use, and racism.Although it is unclear whether racial disparities in depressive symptoms can be explained by cultural or socioeconomic factors,^1–6 there is ample evidence that important differences exist in depression care. African Americans are significantly less likely than Whites to receive guideline-appropriate depression care.^7,8 Several studies have shown that in real-world settings primary care physicians are less likely to detect, treat, refer, or actively manage depression in minority patients than in White patients.^9–13 Also, African Americans are less likely than Whites to seek specialty mental health care, accept recommendations to take antidepressants, or view counseling as an acceptable option.^8,14–16Part of understanding a woman''s depression is recognizing the social context in which she lives. Violence is a huge problem in our society, and minority and low-income populations bear a disproportionate burden. Studies consistently show that the prevalence of intimate partner violence (IPV) is higher among African American women than among non-Hispanic Whites,^17–20 although much of this disparity can be attributed to economic factors.²¹ There is a strong association between violence victimization and depression.^22–31 Despite the important relationship between IPV and mental health, several studies conducted in predominantly non-Hispanic White populations have shown that depressed women with a history of IPV are less likely than other depressed women to seek mental health care.^32,33 African American violence survivors may have even greater distrust of the mental health system and encounter more systemic and cultural barriers to receiving care than non-Hispanic Whites.Our objective in this qualitative study was to understand the experiences and beliefs of depressed African American women residing in Portland, Oregon, a city with relatively low racial diversity, regarding depression and depression care. We focused in particular on understanding how their social context and their experiences of violence influenced their beliefs and choices.     

Association of Depressive Symptoms and Substance Use With Risky Sexual Behavior and Sexually Transmitted Infections Among African American Female Adolescents Seeking Sexual Health Care

Objectives. We examined how depression and substance use interacted to predict risky sexual behavior and sexually transmitted infections (STIs) among African American female adolescents.Methods. We measured depressive symptoms, substance use, sexual behavior, and STIs in 701 African American female adolescents, aged 14 to 20 years, at baseline and at 6-month intervals for 36 months in Atlanta, Georgia (2005–2007). We used generalized estimating equation models to examine effects over the 36-month follow-up period.Results. At baseline, more than 40% of adolescents reported significant depressive symptoms; 64% also reported substance use in the 90 days before assessment. Depression was associated with recently incarcerated partner involvement, sexual sensation seeking, unprotected sex, and prevalent STIs (all P < .001). In addition, adolescents with depressive symptoms who reported any substance use (i.e., marijuana, alcohol, Ecstasy) were more likely to report incarcerated partner involvement, sexual sensation seeking, unprotected sex, and have an incident STI over the 36-month follow-up (all P < .05).Conclusions. African American female adolescents who reported depressive symptoms and substance use were more likely to engage in risky behavior and acquire incident STIs. This population might benefit from future prevention efforts targeting the intersection of depression and substance use.Although self-exploration and identity seeking are healthy aspects of adolescence, certain adverse behaviors, such as substance use and risky sexual behavior, have also been associated with adolescence. HIV, other sexually transmitted infections (STIs), and adolescent pregnancy are significant contributors to female adolescents’ morbidity and mortality in the United States.1 Adolescents aged 15 to 24 years account for approximately 50% of new STI cases each year,2 and it is estimated that 24.1% of adolescent girls aged 14 to 19 years have 1 of 5 commonly reported STIs (herpes simplex virus, trichomonaisis, chlamydia, gonorrhea, and human papilloma virus).3 Minority adolescents are disproportionately at higher risk for HIV and other STIs relative to their White counterparts.4 For example, African American adolescents account for 65% of HIV diagnoses among individuals aged 13 to 24 years.5 Among African American female adolescents aged 14 to 19 years, a national study found that 44% had at least 1 STI.3 Because African American female adolescents are at heightened risk for engaging in risky sexual behavior and STI acquisition, it is important to gain a better understanding of factors that may be associated with these risks. Two such factors are depressive symptoms and substance use or abuse.6–15In a national survey, 4.3% of youths, aged 12 to 17 years, reported current depression, and girls, regardless of age, were more likely to report depression than boys (6.7% vs 4.0%).16 In addition, 1 study found that among adolescents in mental health treatment, girls were more likely to use condoms inconsistently and were more than 9 times likely to contract an STI than were boys.17 The National Longitudinal Study of Adolescent Health found that 19.7% of African American female adolescents reported recent and chronic depressive symptoms compared with 13% among White female adolescents.18 Other studies found rates of depressive symptoms ranging from 40% to 55% among African American female adolescents.6,7,19 Previous research among African American female adolescents reported that depressive symptoms were associated with inconsistent condom use,6,10,12 multiple sexual partners,7,9,10 risky male sexual partners,6 sexual contact while high on alcohol or drugs,6,7,9,11 low frequency of sexual communication,6,7 fear of communication about condoms,6,7 self-reported previous or current STI,7,8,10 and biologically confirmed STIs.6With regards to substance use, a national survey revealed that among African American female 9th to 12th graders, 31.3% reported current alcohol use (vs 35.7% for White and 39.7% for Hispanic), 11.5% reported 5 or more drinks in a sitting (vs 21.1% for White and 22.6% for Hispanic), 27.1% reported current marijuana use (vs 18% for White and 27.4% for Hispanic), and 2.1% reported ever using Ecstasy (vs 4.6% for White and 10.1% for Hispanic).20 Another study found that approximately 27% of African American female adolescents reported having 3 or more drinks in a sitting.13 Substance use often co-occurred with sexual risk behaviors,20 placing adolescents at increased risk for less condom use. Among young African American women, substance use was associated with inconsistent condom use,13,15 sexual sensation seeking,13 multiple sexual partners,13,15 risky sexual partners,15 having sexual intercourse while high on alcohol or drugs,13 and STIs.13–15Previous studies established the relationship between depression, substance use, and risky sexual behavior, and although limited, some studies examined the longitudinal effects of depressive symptoms and substance use on sexual risk-taking among African American female adolescents.7,11–13,15 However, to our knowledge, there is scant research available on the interaction of depressive symptoms and substance use to longitudinally predict sexual risk-taking and STIs among this population. A previous study found that substance use mediated the relationship between depression and substance use, but this effect was only significant for male adolescents and not for female adolescents.8 In addition, this previous study sample included adolescents from multiple ethnicities; thus, the findings might not be applicable to African American adolescents.Because of the impact of these 2 factors on sexual risk-taking, combined with increased HIV/STI vulnerability among African American female adolescents, we aimed to expand upon the existing literature on depression, substance use, and risky sexual behavior in African American female adolescents. To advance the current knowledge and inform HIV/STI prevention efforts among this group, we examined the longitudinal effects of depression and substance use on risky sexual behavior and STI contraction, as well as the interaction between these 2 factors among a clinic-based sample of African American female adolescents over an extended period (36-month follow-up).     

The Role of Young Adults’ Pleasure Attitudes in Shaping Condom Use

Condoms can help young adults protect themselves from sexually transmitted infections and unintended pregnancy. We examined young people’s attitudes about whether condoms reduced pleasure and how these attitudes shape condom practices. We used a nationally representative sample of 2328 heterosexually active, unmarried 15- to 24-year-old young adults to document multivariate associations with condom nonuse at the last sexual episode. For both young men and women, pleasure-related attitudes were more strongly associated with lack of condom use than all sociodemographic or sexual history factors. Research and interventions should consistently assess and address young people’s attitudes about how condoms affect pleasure.Because of their unique ability to prevent both pregnancy and sexually transmitted infections (STIs), male condoms are a vital public health tool. For decades, researchers have worked to understand and promote young adults’ consistent condom use. Although 15- to 24-year-old young adults represent only 25% of the sexually experienced population in the United States, they account for 53% of all unintended pregnancies1 and nearly half of all new STI cases.2Many studies document the sociodemographic and sexual history factors most associated with young adults’ condom use,3–5 including age, education, and number of sexual partners.6 Research also explores psychosocial factors such as self-esteem7,8 and condom self-efficacy,9 as well as gender inequality that may render condom use especially difficult for young women.10 Relatively little research explores young people’s attitudes about condoms and sexual pleasure.Burgeoning research among samples of “older” adults11,12 and college students13,14 has suggested that attitudes about how condoms affected sexual pleasure might influence condom use practices, although this work has primarily focused on men.15,16 One exploratory mixed-gender study documented that both adult women and men who reported that condoms undermine arousal and enjoyment were least likely to use them.17 However, fewer studies have explored such pleasure attitudes among adolescents and young adults, especially among young women,18 and no nationally representative studies of this topic exist for any age group. We addressed these limitations using a nationally representative sample of young adult women and men to assess how attitudes about condoms and sexual pleasure might be related to condom practices.     

Promoters and Barriers to Fruit, Vegetable, and Fast-Food Consumption Among Urban, Low-Income African Americans��A Qualitative Approach

To identify promoters of and barriers to fruit, vegetable, and fast-food consumption, we interviewed low-income African Americans in Philadelphia. Salient promoters and barriers were distinct from each other and differed by food type: taste was a promoter and cost a barrier to all foods; convenience, cravings, and preferences promoted consumption of fast foods; health concerns promoted consumption of fruits and vegetables and avoidance of fast foods. Promoters and barriers differed by gender and age. Strategies for dietary change should consider food type, gender, and age.Diet-related chronic diseases—the leading causes of death in the United States^1,2—disproportionately affect African Americans^3–7 and those having low income.^8–10 Low-income African Americans tend to have diets that promote obesity, morbidity, and premature mortality^3,4,11,12; are low in fruits and vegetables^13–18; and are high in processed and fast foods.^19–23Factors that may encourage disease-promoting diets include individual tastes and preferences, cultural values and heritage, social and economic contexts, and systemic influences like media and marketing.^24–30 Because previous research on dietary patterns among low-income African Americans has largely come from an etic (outsider) perspective, it has potentially overlooked community-relevant insights, missed local understanding, and failed to identify effective sustainable solutions.³¹ Experts have therefore called for greater understanding of an emic (insider) perspective through qualitative methods.³¹ However, past qualitative research on dietary patterns among low-income African Americans has been limited, focusing mostly or exclusively on ethnic considerations,^28,29 workplace issues,¹⁰ women,^32–38 young people,^38,39 or only those with chronic diseases^34,36,39,40 and neglecting potentially important differences by age and gender.^31,41–43To build on prior research, we conducted interviews in a community-recruited sample using the standard anthropological technique of freelisting.^44–46 Our goals were (1) to identify the promoters of and barriers to fruit, vegetable, and fast-food consumption most salient to urban, low-income African Americans and (2) to look for variation by gender and age.     

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.