Andrew D. Plunk

The persistent effects of minimum legal drinking age laws on drinking patterns later in life

BACKGROUND Exposure to permissive minimum legal drinking age (MLDA) laws not only affects young adults in the short term, but also later in life; for example, individuals who could legally purchase alcohol before the age of 21 are more likely to suffer from drinking problems as older adults, long after the laws had been changed. However, it is not known how permissive MLDA exposure affects specific drinking behavior. This present study uses changes in MLDA laws during the 1970s and 1980s as a natural experiment to investigate the potential impact of permissive MLDA exposure on average alcohol consumption, frequency of drinking, and patterns of binging and more moderate, nonheavy drinking. METHODS Policy exposure data were paired with alcohol use data from the 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey and the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions. Past-year drinkers born between 1949 and 1972 (n = 24,088) were included. Average daily intake, overall drinking frequency, and frequency of both binge episodes (5+ drinks) and days without a binge episode (nonheavy drinking) for the previous year at the time of interview were tracked for each respondent. RESULTS Exposure to permissive MLDAs was associated with higher odds to report frequent binging and lower odds to report any moderate drinking; these associations were largely driven by men and those who did not attend college. Overall drinking frequency and average alcohol consumption were not affected by MLDA exposure. CONCLUSIONS The ability to legally purchase alcohol before the age of 21 does not seem to increase overall drinking frequency, but our findings suggest that it is associated with certain types of problematic drinking behaviors that persist into later adulthood: more frequent binge episodes and less frequent nonheavy drinking. We also propose that policymakers and critics should not focus on college drinking when evaluating the effectiveness of MLDAs.

Intended and Unintended Effects of State-Mandated High School Science and Mathematics Course Graduation Requirements on Educational Attainment

Mathematics and science course graduation requirement (CGR) increases in the 1980s and 1990s might have had both intended and unintended consequences. Using logistic regression with Census and American Community Survey (ACS) data (n = 2,892,444), we modeled CGR exposure on (a) high school dropout, (b) beginning college, and (c) obtaining any college degree. Possible between-groups differences were also assessed. We found that higher CGRs were associated with higher odds to drop out of high school, but results for the college-level outcomes varied by group. Some were less likely to enroll, whereas others who began college were more likely to obtain a degree. Increased high school dropout was consistent across the population, but some potential benefit was also observed, primarily for those reporting Hispanic ethnicity.

Long-Term Effects of Laws Governing Youth Access to Tobacco

OBJECTIVES We sought to examine the association between policies governing access to tobacco during adolescence and subsequent adult smoking. METHODS We analyzed adult smoking data from the 1998 through 2006-2007 administrations of the US Current Population Survey Tobacco Use Supplement by employing a quasi experimental approach. Participants (n = 105,519) were adults, aged 18 to 34 years at the time of the survey. Smoking outcomes included having ever smoked 100 cigarettes, smoking at the time of the survey, and having smoked 10 or more cigarettes a day conditioned on being an ever smoker. These were predicted from exposure to state youth access policies at age 17 years. RESULTS Four of the 9 policies exhibited significant associations with reduced prevalence of 1 or more smoking outcomes, primarily among women. Lesser effects for other policies could not be ruled out. CONCLUSIONS Restrictions on youth access to tobacco might lead to reduction in smoking prevalence later in adulthood. The effect might be limited to women; we estimate that having all policies in place could be associated with a 14% reduction in lifetime smoking prevalence for women, and an additional 29% reduction in heavy smoking among ever smokers.

Return of individual genetic results in a high-risk sample: enthusiasm and positive behavioral change

Purpose:The goal of this study was to examine participant responses to disclosure of genetic results in a minority population at high risk for depression and anxiety.Methods:Eighty-two subjects in a genetic study of nicotine dependence were offered personalized genetic results. All were nicotine-dependent and 64% self-identified as African American. Pathway Genomics was used to evaluate genetic risks for five complex diseases. Participants returned 4–8 weeks after enrollment for in-person genetic counseling interviews and evaluation of baseline measures. A telephone follow-up was performed 4–8 weeks later to assess responses to results.Results:Fifty of the 82 subjects (61%) were interested in receiving genetic results. These participants had multiple risk factors, including high baseline measures of depression (66%) and anxiety (32%), as well as low rates of employment (46%), adequate health literacy (46%), and health insurance (45%). Pathway Genomics reported “increased risk” for at least one disease in 77% of subjects. Ninety-five percent of participants reported that they appreciated the genetic results, and receiving these results was not associated with changes in symptoms of depression or anxiety. Furthermore, after return of genetic results, smoking cessation attempts increased (P = 0.003).Conclusion:Even in an underserved population at high risk for adverse psychological reactions, subjects responded positively to personalized genetic results.Genet Med 17 5, 374–379.

Patterns of youth tobacco and polytobacco usage: The shift to alternative tobacco products

ABSTRACT Background: Despite significant declines in youth cigarette smoking, overall tobacco usage remains over 20% as non-cigarette tobacco product usage is increasingly common and polytobacco use (using 1+ tobacco product) remains steady. Objectives: The present study was designed to identify patterns of youth tobacco use and examine associations with sociodemographic characteristics and tobacco dependence. Methods: The current analysis uses Latent Class Analysis (LCA) to examine the 6,958 tobacco users (n = 2,738 female) in the National Youth Tobacco Survey (2012 and 2013). We used as indicators past month use of tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookah, snus, pipes, bidis, and kreteks) and regressed resulting classes on sociodemographic characteristics and tobacco dependence. Results: Nine classes emerged: cigarette smokers (33.4% of sample, also included small probabilities for use of cigars and e-cigarettes), cigar smokers (16.8%, nearly exclusive), smokeless tobacco users (12.3%, also included small probabilities for cigarettes, cigars, snus), hookah smokers (11.8%), tobacco smokers/chewers (10.7%, variety of primarily traditional tobacco products), tobacco/hookah smokers (7.2%), tobacco/snus/e-cig users (3.3%), e-cigarette users (2.9%,), and polytobacco users (1.7%, high probabilities for all products). Compared to cigarette smokers, tobacco/hookah smokers and hookah smokers were more likely to report Hispanic ethnicity. Polytobacco users were more likely to report dependence (AOR:2.77, 95% CI:[1.49–5.18]), whereas e-cigarette users were less likely (AOR:0.49, 95% CI:[0.24–0.97]).Conclusion: Findings are consistent with other research demonstrating shifts in adolescent tobacco product usage towards non-cigarette tobacco products. Continuous monitoring of these patterns is needed to help predict if this shift will ultimately result in improved public health.

A reexamination of medical marijuana policies in relation to suicide risk

OBJECTIVES Previous research has suggested that medical marijuana policies lead to reductions in suicide rates. In this study, we further investigate the association between these policies and within-state changes in suicide risk. METHODS Data on suicide deaths (n=662,993) from the National Vital Statistics System Multiple Cause of Death files were combined with living population data. Fixed-effects regression methods were employed to control for state differences in suicide rates and national and state secular trends. Analyses extended prior research that suggested a protective effect of medical marijuana policies by incorporating newer data and additional covariates. RESULTS After adjustment for race/ethnicity, tobacco control policies, and other covariates, we found no association between medical marijuana policy and suicide risk in the population ages 15 and older (OR=1.000; 95% CI: 0.956, 1.045; p=0.98), among men overall (OR=0.996; 95% CI: 0.951, 1.043; p=0.87) or for any other age-by-sex groups. CONCLUSION We find no statistically significant association between medical marijuana policy and suicide risk. These results contradict prior analyses which did not control for race/ethnicity and certain state characteristics such as tobacco control policies. Failure to control for these factors in future analyses would likely bias estimates of the associations between medical marijuana policy and health outcomes.

Medical Marijuana Laws and Suicide

Anderson et al. report an analysis of the association between state medical marijuana laws and suicide rates in the United States over the period 1990 to 2007.(1) They found that medical marijuana legalization was associated with reduction in suicide risk for men, with a 10.9% decline in risk for men aged 20 to 29 and 30 to 39 years. Unfortunately, there are several reasons to believe that this work produced a biased estimate of this association. (Am J Public Health. Published online ahead of print June 11, 2015: e1. doi:10.2105/AJPH.2015.302745). Language: en

Declines in prevalence of adolescent substance use disorders and delinquent behaviors in the USA: a unitary trend?

BACKGROUND Downward trends in a number of adolescent risk behaviors including violence, crime, and drug use have been observed in the USA in recent years. It is unknown whether these are separate trends or whether they might relate to a general reduction in propensity to engage in such behaviors. Our objectives were to quantify trends in substance use disorders (SUDs) and delinquent behaviors over the 2003-2014 period and to determine whether they might reflect a single trend in an Externalizing-like trait. METHODS We analyzed data from 12 to 17 year old participants from the National Survey on Drug Use and Health, a representative survey of the household dwelling population of the USA, across the 2003-2014 period (N = 210 599). Outcomes included past-year prevalence of six categories of substance use disorder and six categories of delinquent behavior. RESULTS Trend analysis suggested a net decline of 49% in mean number of SUDs and a 34% decline in delinquent behaviors over the 12-year period. Item Response Theory models were consistent with the interpretation that declines in each set of outcomes could be attributed to changes in mean levels of a latent, Externalizing-like trait. CONCLUSIONS Our findings suggest that declines in SUDs and some delinquent behaviors reflect a single trend related to an Externalizing-like trait. Identifying the factors contributing to this trend may facilitate continued improvement across a spectrum of adolescent risk behaviors.

Public health research, deception, and distrust.

We share McCambridge and colleagues’ (2013) view that substantive ethical guidance is lacking for public health research, especially in applied settings like substance abuse epidemiology. Further, the case-based approach that they describe is especially appropriate for a field like public health, where the particular factors that influence our decision making, both ethically and methodologically, often vary considerably from one context to another. We thus appreciate their contribution and view it as an important starting point for further discussion, especially insofar as it highlights an unmet need for developing cases that are broadly relevant to applied public health researchers. Unfortunately, while their approach has merit, we remain unconvinced that deception was justified in the authors’ research, in large part because they are likely underestimating the harm that it creates, both to participants and to researchers, who have a harder time recruiting people who do not trust them. More importantly, even if deception was warranted in the context of their specific research, the authors have described a series of very particular cases that do not justify the practice in other settings. Case-based reasoning is most useful when we have established, relatively uncontested paradigm cases that outline when certain actions are ethically appropriate, given the contextual constraints of each specific case (Jonsen 2001). New cases can then be compared to the paradigm case to determine whether the context of the new case would impact how we deliberate about the morality of the action in question. That said, McCambridge and colleagues would likely maintain that their cases are nonparadigmatic by their very nature; they seem to expect that their conclusions will generate disagreement. However, it is a useful starting point to more fully explore how their cases are not appropriate for other contexts. That is, examining when these cases fail to generalize to other settings, or pointing out when we do not have enough information to decide whether these cases generalize, can help us determine what features paradigmatic public health research ethics cases should have, which we hope contributes to further discussion of these important topics. To start, while the authors listed many contextual features of their studies, they gave little insight on the relative significance of each, which might change as the features themselves change. The authors also did not often explore how a given contextual constraint might differ and, more importantly, how such a change would directly impact the decision to use deception. In short, the authors listed many of the things that influenced their decision making, but did not describe the relevant process by which they deliberated about and weighed each issue. These are important omissions, as they make it difficult to apply these cases to other settings. For example, McCambridge and colleagues imply that members of their study population are less likely to be harmed by deception because they are not vulnerable. Even if this is true in the specific context of their research, most substance-abusing populations are almost by definition vulnerable in some way. McCambridge and colleagues do at one point note that researchers know little about the potential harm caused by deception outside of college student populations, but do not offer other guidance. How then should the vulnerability or stigma associated with alcohol or even another drug, which can be quite significant for some users or for other substances, affect a researcher’s decision to deceive his or her participants? On a related note, how should vulnerability associated with race or ethnicity be treated, even for normative alcohol use, which itself is not stigmatizing? The interplay between vulnerability and deception also raises questions about another contextual constraint that McCambridge and colleagues only briefly touched upon: public trust in research. This is especially important when working with populations that are vulnerable or stigmatized irrespective of their drug use and that are already distrustful of research. For example, many African Americans distrust researchers, which has had a long-standing impact on their participation in research (Gamble 1993). This distrust is perpetuated by a range of factors, including a shared folk history that features “body snatchers” and “night doctors” who robbed graves for bodies upon which to experiment (Fry 1975; Savitt 1982; Waite 1945), the lingering impact of the Tuskegee syphilis experiments (Jones 1993), and, more recently, through mainstream media coverage about the development of the HeLa cell line (Skloot 2010). However, focus-group feedback cited by the authors suggests that distrust was an issue for their study populations, as well: The other main finding concerned heightened distrust of research invitations, and although this was interwoven with confidentiality and privacy concerns about Internet use in general, it suggested a paradoxical harm arising from, or accentuated by, debriefing itself. (McCambridge et al. 2013, 45) The authors state that this feedback led them to rethink debriefing following deception and that they are “considering not doing so” (45). We are inclined to assign this harm not to the debriefing per se, as a reaction to the deception itself. This feedback was also from participants whom the authors describe as nonvulnerable college students; it is reasonable to assume that individuals from more vulnerable populations would react with even greater distrust, especially if it came to light that there had been a series of deceptive studies, for example, by featuring nonefficacious treatment, which only became known after the fact because debriefing was not performed. Along similar lines, even if one accepts deception generally, we also wonder whether basing the decision to deceive on the likelihood of causing harm has the potential to increase bias and reduce generalizability. In effect, conditioning on the likelihood of promoting harm would mean conditioning on vulnerability, which implies that college students would likely be the population of choice when deception is used in alcohol research. While college students do exhibit high rates of problematic drinking, research that focuses on them is not always applicable to other populations, since college education itself is associated with lower risk overall. For example, low education is associated both with earlier substance abuse (Johnson et al. 1999) and with decreased health more generally (Walsemann, Bell, and Hummer 2012). In summary, McCambridge and colleagues’ cases do seem limited and are likely not broadly applicable to other contexts. Even if one assumes that their use of deception was acceptable, it is not clear what this would imply for other researchers, or whether choosing study populations based on the likelihood of deception causing harm might itself be methodologically limiting. Despite these concerns, we appreciate their work on this topic and hope that the discussion that it starts leads to further work to develop a robust case-based framework that will help applied public health researchers better understand how context affects their ethical considerations.

What's Trust Got To Do With It? Ensuring Meaningful Community Engagement

ISSN: 1526-5161 (Print) 1536-0075 (Online) Journal homepage: http://www.tandfonline.com/loi/uajb20 Whats Trust Got To Do With It? Ensuring Meaningful Community Engagement Andrew Plunk & Sarah Gehlert To cite this article: Andrew Plunk & Sarah Gehlert (2018) Whats Trust Got To Do With It? Ensuring Meaningful Community Engagement, The American Journal of Bioethics, 18:4, 53-55, DOI: 10.1080/15265161.2018.1431325 To link to this article: https://doi.org/10.1080/15265161.2018.1431325