Preventive Medicine

E-cigarette Use Among Young Adults in the U.S. Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Mark Olfson, Melanie M. Wall, Shang-Min Liu, Ryan S. Sultan, Carlos Blanco Introduction Use of e-cigarettes is increasing among young adults in the U.S. Whether e-cigarette use serves as an aid to smoking reduction or cessation among young adults remains a matter of contention. This analysis examines patterns of e-cigarette use in relation to cigarette smoking in a nationally representative sample of U.S. young adults. Methods Data were analyzed from nationally representative U.S. adults, aged 18 to 35years (N=12,415), in the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. Logistic regression assessed associations between e-cigarette use and smoking intensity, continuity, and reduction while controlling for several potential confounding factors. Data were analyzed in 2018. Results Among cigarette smokers, e-cigarette use was associated with higher odds of tobacco use disorder (AOR=2.58, 95% CI=1.73, 3.83) and daily cigarette smoking (AOR=1.67, 95% CI=1.73, 3.83). Among adults aged 26–35years, e-cigarette use was also associated with heavy cigarette smoking (AOR=2.01, 95% CI=1.09, 3.74). Among lifetime smokers, e-cigarette use was associated with lower odds of stopping smoking (AOR=0.14, 95% CI=0.08, 0.23) and lower odds of a 50% reduction in cigarettes smoked per day (AOR=0.63, 95% CI=0.43, 0.93). Only 13.1% of young adults who ever used e-cigarettes reported using them to help stop or quit smoking. Conclusions Use of e-cigarettes by U.S. young adults, most of which is not intended to help reduce smoking, is related to more rather than less frequent and intensive cigarette smoking.

Fall Prevention Self-Management Among Older Adults: A Systematic Review Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Kumiko O. Schnock, Elizabeth P. Howard, Patricia C. Dykes Context Adequate self-management could minimize the impact of falls in older adults. The efficacy of fall prevention self-management interventions has been widely studied, yet little is known about why some older adults engage in fall prevention self-management actions and behaviors, whereas others do not. Through a systematic review of fall prevention self-management studies, this study identified characteristics and the personal, social, and environmental factors of older adults who engage in self-management actions and behaviors. Evidence acquisition Medical and nursing literature related to fall prevention self-management was searched in PubMed, Embase, and CINAHL (1997–2017), and relevant publications were selected by three researchers to assess whether the papers included subject characteristics and their fall prevention self-management actions and behaviors. GRADE (Grading of Recommendations, Assessment, Development and Evaluations) was used by the researchers to assess the quality of the included studies and to determine the significance of the extracted characteristics. Evidence synthesis Searching literature through 2017, a total of 972 papers were identified, and 28 papers remained after removing those that did not meet inclusion criteria. Nine papers that addressed subject characteristics in relation to the study outcomes were included in a sub-analysis. The authors identified the following characteristics of older adults who participated in fall prevention self-management actions and behaviors: younger males, not living alone and with self-reported good health, having greater fear of falling and high fall prevention self-efficacy, and possessing high motivation for engagement with self-management activities. Conclusions The systematic literature review revealed the personal characteristics of older adults who engage in fall prevention self-management actions and behaviors.

Food Security and 10-Year Cardiovascular Disease Risk Among U.S. Adults Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Kelsey A. Vercammen, Alyssa J. Moran, Amanda C. McClain, Anne N. Thorndike, Aarohee P. Fulay, Eric B. Rimm Introduction Cardiovascular disease is a leading cause of mortality in the U.S. Although the risk of cardiovascular disease can be mitigated substantially by following a healthy lifestyle, adhering to a healthy diet and other healthy behaviors are limited by reduced food security. This study aims to determine the association between food security and cardiovascular disease risk. Methods Three samples from the 2007–2014 National Health and Nutrition Examination Survey were examined: (1) 7,340 non-fasting adults (aged 40–79 years); (2) 13,518 non-fasting adults (aged 20–64 years); and (3) 6,494 fasting adults (aged 20–64 years). Food security was assessed using the U.S. Household Food Security Survey Module, with households categorized as having full, marginal, low, or very low food security. Regressions were conducted in 2018 to test the associations between food security status and odds of ≥20% 10-year cardiovascular disease risk among middle-aged to older adults (OR, 95% CI) and cardiovascular disease risk factors among all adults (β, 95% CI). Results Compared with adults with full food security, those with very low food security had higher odds of ≥20% 10-year cardiovascular disease risk (OR=2.36, 95% CI=1.25, 4.46), whereas those with marginal food security had higher systolic blood pressure (β=0.94 mmHg, 95% CI=0.09, 1.80). Compared with adults with full food security, adults with different levels of food security had higher BMIs (marginal: 0.76, 95% CI=0.26, 1.26; low: 0.97, 95% CI=0.34, 1.60; and very low: 1.03, 95% CI=0.44, 1.63) and higher odds of current smoking (marginal: OR=1.43, 95% CI=1.17, 1.75; low: OR=1.47, 95% CI=1.22, 1.77; and very low: OR=1.95, 95% CI=1.60, 2.37). Conclusions Adults with food insecurity have elevated cardiovascular disease risk factors and excess predicted 10-year cardiovascular disease risk. Substantially improving food security may be an important public health intervention to reduce future cardiovascular disease in the U.S. population.

State-Level Beer Excise Tax and Firearm Homicide in Adolescents and Young Adults Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Robert A. Tessler, Stephen J. Mooney, D. Alex Quistberg, Ali Rowhani-Rahbar, Monica S. Vavilala, Frederick P. Rivara Introduction This study sought to determine the association between changes in state-level beer excise tax and firearm homicide rates among individuals aged 15–34years. Methods A time series analysis with synthetic controls was conducted for the years 2003–2015. Exposed states changed the beer excise tax during the study period. Synthetic controls were weighted mimics that combined portions of unexposed states using state–year specific demographic and firearm covariates. Average annual incidence rate differences were calculated between each exposed state and its synthetic control. Alcohol taxes were available through the National Institute of Alcohol Abuse and Alcoholism and firearm homicide rates were obtained from the Centers for Disease Control and Prevention. States that changed the beer excise tax but for which <2years of pre-exposure data were available were excluded. Data were collected in 2017 and analyzed in 2018. Results Five states met inclusion criteria, and all raised the beer excise tax: Illinois (2009), New York (2009), North Carolina (2009), Connecticut (2011), and Rhode Island (2013). The percentage increase in beer excise tax ranged from 10% to 27%. Differences in pre-exposure firearm homicide rates between exposed states and synthetic controls were minimal. The increase in beer excise tax was associated with a lower average annual firearm homicide rate in all states except Illinois (Rhode Island: incidence rate difference= –2.48, Connecticut: incidence rate difference= –2.57, New York: incidence rate difference= –1.45, North Carolina: incidence rate difference= –0.45, and Illinois: incidence rate difference=1.54 per 100,000 population). Conclusions Among individuals aged 15–34years, price-sensitive consumption of beer may represent one feasible tool for policymakers seeking to reduce rates of firearm homicide.

Health Insurance Coverage Among U.S. Workers: Differences by Work Arrangements in 2010 and 2015 Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Chia-ping Su, Abay Asfaw, Sara L. Tamers, Sara E. Luckhaupt Introduction For most Americans, health insurance is obtained through employers. Health insurance coverage can lead to better health outcomes, yet disparities in coverage exist among workers with different sociodemographic and job characteristics. This study compared uninsured rates among workers with different work arrangements. Methods Data from the 2010 and 2015 National Health Interview Survey–Occupational Health Supplements were used to capture a representative sample of the U.S. civilian, non-institutionalized population. Associations between work arrangement and lack of health insurance were analyzed, adjusting for covariates. Analyses were performed during 2016–2018. Results The percentage of workers aged 18–64years without health insurance coverage decreased significantly by 6.8% among workers in all work arrangement categories between 2010 and 2015. However, workers in nonstandard work arrangements were still more likely than standard workers to have no health insurance coverage. In 2015, for workers to have no health insurance the ORs were 4.92 (95% CI=3.91, 6.17) in independent, 2.87 (95% CI=2.00, 4.12) in temporary or contract, and 2.79 (95% CI=0.34, 0.41) in other work arrangements. Standard full-time workers in small establishments and standard part-time workers were also more likely to have no health insurance coverage (OR=2.74, 95% CI=2.27, 3.31, and OR=1.65, 95% CI=1.25, 2.18, respectively). Conclusions Important disparities in health insurance coverage among workers with different work arrangements existed in 2010 and persisted in 2015. Further research is needed to monitor coverage trends among workers.

Public Health Workforce Development Needs: A National Assessment of Executives' Perspectives Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Jonathon P. Leider, Fatima Coronado, Kyle Bogaert, Elizabeth Gould Introduction Workforce development is one of the ten essential public health services. Recent studies have better characterized individual worker perceptions regarding workforce interests and needs, but gaps remain around workforce needs from program managers' perspectives. This study characterized management perspectives regarding subordinate's abilities and training needs and perceived challenges to recruitment and retention. Methods In 2017, the Directors Assessment of Workforce Needs Survey was sent to 574 managers at state health agencies across the U.S. Respondents were invited based on the positions they held (i.e., to be included, respondents had to be employed as managers and oversee specific program areas). In 2018, descriptive statistics were calculated, including Fisher's exact for inferential comparisons and Tukey's test for multiple comparisons, as appropriate. Results Response rate was 49% after accounting for undeliverable e-mails; 226 respondents met the inclusion criteria. The largest perceived barriers to staff recruitment were wages or salaries (74%) and private sector competition (56%). Similarly, wages or salaries were identified as the main cause of turnover by 70% of respondents, followed by lack of opportunities for advancement (68%), and opportunities outside the agency (67%). Conclusions The Directors Assessment of Workforce Needs Survey fills important knowledge gaps and complements previously identified evidence to guide refinement of workforce development efforts. Although competition from the private sector remains challenging, these findings indicate that recruitment and retention must be top priorities in state health agencies nationwide. Prioritizing individual state health agency workforce gaps and committing to provide specific local-level interventions to those priorities is crucial for individual health agencies.

Regular Sunscreen Use and Risk of Mortality: Long-Term Follow-up of a Skin Cancer Prevention Trial Publication date: Available online 16 March 2019 Source: American Journal of Preventive Medicine Author(s): Akiaja R. Lindstrom, Lena A. von Schuckmann, Maria Celia B. Hughes, Gail M. Williams, Adele C. Green, Jolieke C. van der Pols Introduction Sunscreen is widely used to protect the skin from harmful effects of sun exposure. However, there are concerns that sunscreens may negatively affect overall health. Evidence of the general safety of long-term regular sunscreen use is therefore needed. Methods The effect of long-term sunscreen use on mortality was assessed over a 21-year period (1993–2014) among 1,621 Australian adults who had participated in a randomized skin cancer prevention trial of regular versus discretionary sunscreen use (1992–1996). In 2018, an intention-to-treat analysis was conducted using Cox proportional hazards regression to compare death rates in people who were randomized to apply sunscreen daily for 4.5years, versus randomized to use sunscreen at their usual, discretionary level. All-cause mortality and deaths resulting from cardiovascular disease, cancer, and other causes were considered. Results In total, 160 deaths occurred in the daily sunscreen group compared with 170 deaths in the discretionary sunscreen group (hazard ratio=0.94, 95% CI=0.76, 1.17); 59vs 76 cardiovascular disease deaths (hazard ratio=0.77, 95% CI=0.55, 1.08), 63vs 58 cancer deaths (hazard ratio=1.09, 95% CI=0.76, 1.57), and 45vs 44 deaths resulting from other causes (hazard ratio=1.02, 95% CI=0.67, 1.54) occurred respectively. Conclusions Regular use of a sun protection factor 16 sunscreen on head, neck, arms, and hands for 4.5years did not increase mortality.

Non-clinical Prevention Opportunities and Waste in the U.S. Healthcare System Publication date: Available online 14 March 2019 Source: American Journal of Preventive Medicine Author(s): J. Mac McCullough, Matthew Speer, Steven M. Teutsch, Jonathan E. Fielding

U.S. Emergency Department Visits Resulting From Nonmedical Use of Pharmaceuticals, 2016 Publication date: Available online 6 March 2019 Source: American Journal of Preventive Medicine Author(s): Andrew I. Geller, Deborah Dowell, Maribeth C. Lovegrove, Jana K. McAninch, Sandra K. Goring, Kathleen O. Rose, Nina J. Weidle, Daniel S. Budnitz Introduction National data on morbidity from nonmedical use of pharmaceuticals are limited. This study used nationally representative, public health surveillance data to characterize U.S. emergency department visits for acute harms from nonmedical use of pharmaceuticals and to guide prevention efforts. Methods Data collected in 2016 from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project were analyzed in 2018 to calculate national estimates of emergency department visits for harms from nonmedical use of pharmaceuticals. Results Based on 5,130 surveillance cases, there were an estimated 358,247 emergency department visits (95% CI=280,675, 435,819) in 2016 for harms from nonmedical use of pharmaceuticals and 41.1% resulted in hospitalization (95% CI=32.3%, 49.8%). One half (50.9%, 95% CI=46.6%, 55.3%) of estimated visits involved patients aged ≤34 years; more than one half of estimated visits also involved non-pharmaceutical substances (52.9%, 95% CI=49.7%, 56.1%), including illicit drugs in 34.1% (95% CI=30.9%, 37.2%) and alcohol in 21.8% (95% CI=19.8%, 23.9%). Overall, benzodiazepines were implicated in 46.9% (95% CI=42.5%, 51.2%) of estimated emergency department visits for nonmedical use of pharmaceuticals but were the only substance implicated in just 6.5% (95% CI=5.1%, 7.9%). Prescription opioids were implicated in 36.2% (95% CI=30.8%, 41.7%) of estimated emergency department visits and were the only substance implicated in 11.3% (95% CI=8.6%, 14.0%). Conclusions Although prescription opioids or benzodiazepines are frequently implicated in emergency department visits for nonmedical use, because other substances and additional pharmaceuticals are most often involved, prescribing clinicians should consider implementing specific screening to address polysubstance use and, when warranted, treatment interventions.

Wellness Committee Status and Local Wellness Policy Implementation Over Time Publication date: March 2019 Source: American Journal of Preventive Medicine, Volume 56, Issue 3 Author(s): Carolyn D. McIlree, Hannah G. Lane, Yan Wang, Erin R. Hager Introduction Local Wellness Policies are school-district documents containing guidelines for schools to promote nutrition/physical activity. In cross-sectional studies, schools with wellness committees are more likely to implement Local Wellness Policies. This prospective cohort study examines associations between wellness committee status over time and change in Local Wellness Policy implementation using a biennial, statewide survey. Methods School administrators completed surveys following the 2012–2013 (Wave I) and 2014–2015 (Wave II) school years, including a 17-item Local Wellness Policy implementation scale. Four wellness committee status categories included established (both Waves, 35%); new (Wave II only, 22%); discontinued (Wave I only, 13%); and never (neither Wave, 30%). Linear mixed models conducted in 2017–2018 compared LWP implementation change across status groups, accounting for clustering and school characteristics. Results Of 1,333 schools, 701 had Wave I data (53%); 748 Wave II (56%); and 441 both (33%). Schools were 69% elementary, 56% suburban, and 35% and 28% had majority (≥75%) African American/Hispanic or low-income student body, respectively. At Wave I, schools with wellness committees (established/discontinued groups) had higher Local Wellness Policy implementation (mean=32.0, SD=11.5, and mean=28.3, SD=11.4, respectively) compared with schools without committees (never/new: mean=15.4, SD=10.7 and mean=17.6, SD=11.4, respectively, F=64.9, p≤0.001). Over time, never and established groups maintained low and high Local Wellness Policy implementation, respectively. Compared with never, new committees increased implementation by 9.9 points (SE=1.8, p<0.001), and discontinued committees decreased by 11.2 (SE=2.1, p<0.001). Conclusions Forming and maintaining wellness committees encourages Local Wellness Policy implementation and should be a recommended strategy for school wellness promotion.