Ann Malarcher

Acute stroke care in the US: results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry.

Background and Purpose— The Paul Coverdell National Acute Stroke Registry is being developed to improve the quality of acute stroke care. This article describes key features of acute stroke care from 4 prototype registries in Georgia (Ga), Massachusetts (Mass), Michigan (Mich), and Ohio. Methods— Each prototype developed its own sampling scheme to obtain a representative sample of hospitals. Acute stroke admissions were identified using prospective (Mass, Mich) or retrospective (Ga, Ohio) methods. All prototypes used a common set of case definitions and data elements. Weighted site-specific frequencies were generated for each outcome. Results— A total of 6867 admissions from 98 hospitals were included; the majority were ischemic strokes (range, 52% to 70%) with transient ischemic attack and intracerebral hemorrhage comprising the bulk of the remainder. Between 19% and 26% of admissions were younger than age 60 years, and between 52% and 58% were female. Black subjects varied from 7.1% (Mich) to 30.6% (Ga). Between 20% and 25% of admissions arrived at the emergency department within 3 hours of onset. Treatment with recombinant tissue plasminogen activator (rtPA) was administered to between 3.0% (Ga) and 8.5% (Mass) of ischemic stroke admissions. Of 118 subjects treated with intravenous rtPA, <20% received it within 60 minutes of arrival. Compliance with secondary prevention practices was poorest for smoking cessation counseling and best for antithrombotics. Conclusions— A minority of acute stroke patients are treated according to established guidelines. Quality improvement interventions, targeted primarily at the health care systems level, are needed to improve acute stroke care in the United States.

Adverse childhood experiences are associated with the risk of lung cancer: a prospective cohort study

BackgroundStrong relationships between exposure to childhood traumatic stressors and smoking behaviours inspire the question whether these adverse childhood experiences (ACEs) are associated with an increased risk of lung cancer during adulthood.MethodsBaseline survey data on health behaviours, health status and exposure to adverse childhood experiences (ACEs) were collected from 17,337 adults during 1995-1997. ACEs included abuse (emotional, physical, sexual), witnessing domestic violence, parental separation or divorce, or growing up in a household where members with mentally ill, substance abusers, or sent to prison. We used the ACE score (an integer count of the 8 categories of ACEs) as a measure of cumulative exposure to traumatic stress during childhood. Two methods of case ascertainment were used to identify incident lung cancer through 2005 follow-up: 1) hospital discharge records and 2) mortality records obtained from the National Death Index.ResultsThe ACE score showed a graded relationship to smoking behaviors. We identified 64 cases of lung cancer through hospital discharge records (age-standardized risk = 201 × 100,000-1 population) and 111 cases of lung cancer through mortality records (age-standardized mortality rate = 31.1 × 100,000-1 person-years). The ACE score also showed a graded relationship to the incidence of lung cancer for cases identified through hospital discharge (P = 0.0004), mortality (P = 0.025), and both methods combined (P = 0.001). Compared to persons without ACEs, the risk of lung cancer for those with ≥ 6 ACEs was increased approximately 3-fold (hospital records: RR = 3.18, 95%CI = 0.71-14.15; mortality records: RR = 3.55, 95%CI = 1.25-10.09; hospital or mortality records: RR = 2.70, 95%CI = 0.94-7.72). After a priori consideration of a causal pathway (i.e., ACEs → smoking → lung cancer), risk ratios were attenuated toward the null, although not completely. For lung cancer identified through hospital or mortality records, persons with ≥ 6 ACEs were roughly 13 years younger on average at presentation than those without ACEs.ConclusionsAdverse childhood experiences may be associated with an increased risk of lung cancer, particularly premature death from lung cancer. The increase in risk may only be partly explained by smoking suggesting other possible mechanisms by which ACEs may contribute to the occurrence of lung cancer.

Sex Differences in US Mortality Rates for Stroke and Stroke Subtypes by Race/Ethnicity and Age, 1995–1998

Background and Purpose— Ischemic stroke accounts for 70% to 80% of all strokes, but intracerebral and subarachnoid hemorrhagic strokes have greater fatality. Age-standardized death rates from overall stroke are higher among men than women, but little is known about sex differences in stroke subtype mortality by race/ethnicity. Methods— We analyzed 1995 to 1998 national death certificate data to compare sex-specific age-standardized death rates (per 100 000) for ischemic stroke (n=507 256), intracerebral hemorrhagic stroke (n=98 709), and subarachnoid hemorrhagic stroke (n=27 334) among whites, blacks, American Indians/Alaska Natives, Asians/Pacific Islanders, and Hispanics. We calculated rate ratios and 95% CIs comparing women with men within age and racial/ethnic groups. Results— Age-specific rates of ischemic and intracerebral hemorrhagic stroke deaths were lower for women than for men aged 25 to 44 and 45 to 64 years but were higher for ischemic stroke among older women, aged ≥65 years. Only among whites did women have higher age-standardized rates of ischemic stroke. Age-standardized death rates for intracerebral hemorrhagic stroke among women were lower than or similar to those among men in all racial/ethnic groups. Women had higher risk of death from subarachnoid hemorrhagic; this sex differential increased with age. Conclusions— The female-to-male mortality ratio differs for stroke subtypes by race/ethnicity and age. A primary public health effort should focus on increasing the awareness of stroke symptoms, particularly among people at high risk, to decrease delay in early detection and effective stroke treatment.

Predictors of smoking cessation in U.S. adolescents

OBJECTIVE To identify factors that predict quitting among adolescent smokers. METHODS Adolescent smokers aged 12-19 years (N = 633) from the national Teenage Attitudes and Practices Survey I (1989), were followed up in the Teenage Attitudes and Practices Survey II (1993). Multiple logistic regression was applied to identify the predictors of quitting. RESULTS A total of 15.6% of adolescent smokers had quit smoking at the follow-up survey four years later. There was no significant difference in the quit rate by age, gender, or ethnicity. Five baseline factors were identified in a multivariate analysis as significant predictors of quitting: frequency of smoking, length of past quit attempts, self-estimation of likelihood of continuing smoking, mothers smoking status, and depressive symptoms. The more risk factors the adolescents had, the less likely they would succeed in quitting. CONCLUSIONS Quitting smoking by adolescents is influenced by multiple biological, behavioral, and psychosocial variables. Identifying these variables can help tailor cessation programs to more effectively help adolescents quit smoking.

Racial and Ethnic Disparities in Cardiovascular Risk Factors Among Stroke Survivors United States 1999 to 2001

Background and Purpose— Stroke mortality is higher among US blacks than it is among US whites. Few studies have examined racial and ethnic differences in the prevalence of cardiovascular disease (CVD) risk factors among stroke survivors, especially among Hispanics. Methods— Data are from 96 501 persons aged18 years or older who participated in the 1999, 2000, or 2001 National Health Interview Survey, a continuous annual household-based survey of the US population. Participants reported a history of stroke, hypertension, diabetes, myocardial infarction, and coronary heart disease. Other CVD risk factors were current smoking, overweight/obese, inadequate physical activity, and binge drinking. Results— Stroke was reported by 2.8% of blacks, 1.3% of Hispanics, and 2.2% of whites. Among 2265 stroke survivors, blacks were 1.65-times more likely (95% CI, 1.55 to 1.75) and Hispanics were 0.73-times less likely (95% CI, 0.69 to 0.78) than whites to report hypertension. Hispanics and blacks were more likely than whites to report diabetes (P < 0.05). Hispanics and blacks were less likely than whites to report total coronary heart disease (P < 0.05). Overweight was 1.63-times higher among blacks (95% CI, 1.55 to 1.73) and 1.36-times higher (95% CI, 1.30 to 1.44) among Hispanics than whites. Blacks were 1.82-times more likely (95% CI, 1.71 to 1.94) and Hispanics 2.09-times more likely (95% CI, 1.98 to 2.22) than whites to report inadequate levels of physical activity. Binge drinking and smoking were less common among Hispanics and Blacks than among whites (P < 0.05). Conclusions— Racial and ethnic disparities exist in stroke prevalence and CVD risk behaviors and medical history. Targeted secondary prevention will be important in reducing disparities among Hispanic and black stroke survivors.

Quitting Smoking Among Adults - United States, 2000-2015:

Quitting cigarette smoking benefits smokers at any age (1). Individual, group, and telephone counseling and seven Food and Drug Administration-approved medications increase quit rates (1-3). To assess progress toward the Healthy People 2020 objectives of increasing the proportion of U.S. adults who attempt to quit smoking cigarettes to ≥80.0% (TU-4.1), and increasing recent smoking cessation success to ≥8.0% (TU-5.1),* CDC assessed national estimates of cessation behaviors among adults aged ≥18 years using data from the 2000, 2005, 2010, and 2015 National Health Interview Surveys (NHIS). During 2015, 68.0% of adult smokers wanted to stop smoking, 55.4% made a past-year quit attempt, 7.4% recently quit smoking, 57.2% had been advised by a health professional to quit, and 31.2% used cessation counseling and/or medication when trying to quit. During 2000-2015, increases occurred in the proportion of smokers who reported a past-year quit attempt, recently quit smoking, were advised to quit by a health professional, and used cessation counseling and/or medication (p<0.05). Throughout this period, fewer than one third of persons used evidence-based cessation methods when trying to quit smoking. As of 2015, 59.1% of adults who had ever smoked had quit. To further increase cessation, health care providers can consistently identify smokers, advise them to quit, and offer them cessation treatments (2-4). In addition, health insurers can increase cessation by covering and promoting evidence-based cessation treatments and removing barriers to treatment access (2,4-6).

Dose-Response Relationship Between Cigarette Smoking and Risk of Ischemic Stroke in Young Women

Background and Purpose— Although cigarette smoking is known to be a risk factor for ischemic stroke, there are few data on the dose-response relationship between smoking and stroke risk in a young ethnically diverse population. Methods— We used data from the Stroke Prevention in Young Women Study, a population-based case-control study of risk factors for ischemic stroke in women aged 15 to 49 years to examine the relationship between cigarette smoking and ischemic stroke. Historical data, including smoking history, was obtained through standardized interviews. Odds ratios (OR) were estimated using logistic regression. Cases (n=466) were women with stroke in the greater Baltimore-Washington area, and controls (n=604) were women free of a stroke history identified by random digit dialing. Results— After multivariable adjustment, the OR comparing current smokers to never smokers was 2.6 (P<0.0001); no difference in stroke risk was observed between former smokers and never smokers. Adjusted OR increased with increasing number of cigarettes smoked per day (OR=2.2 for 1 to 10 cigs/d; 2.5 for 11 to 20 cigs/d; 4.3 for 21 to 39 cigs/d; 9.1 for 40 or more cigs/d). Conclusion— These results suggest a strong dose-response relationship between cigarette smoking and ischemic stroke risk in young women and reinforce the need for aggressive smoking cessation efforts in young adults.

Alcohol Intake, Type of Beverage, and the Risk of Cerebral Infarction in Young Women

Background and Purpose— The relationship between alcohol consumption and cerebral infarction remains uncertain, and few studies have investigated whether the relationship varies by alcohol type or is present in young adults. We examined the relationship between alcohol consumption, beverage type, and ischemic stroke in the Stroke Prevention in Young Women Study. Methods— All 59 hospitals in the greater Baltimore-Washington area participated in a population-based case-control study of stroke in young women. Case patients (n=224) were aged 15 to 44 years with a first cerebral infarction, and control subjects (n=392), identified by random-digit dialing, were frequency matched by age and region of residence. The interview assessed lifetime alcohol consumption and consumption and beverage type in the previous year, week, and day. ORs were obtained from logistic regression models controlling for age, race, education, and smoking status, with never drinkers as the referent. Results— Alcohol consumption, up to 24 g/d, in the past year was associated with fewer ischemic strokes (<12 g/d: OR 0.57, 95% CI 0.38 to 0.86; 12 to 24 g/d: OR 0.38, 95% CI 0.17 to 0.86; >24 g/d: OR 0.95, 95% CI 0.43 to 2.10) in comparison to never drinking. Analyses of beverage type (beer, wine, liquor) indicated a protective effect for wine consumption in the previous year (<12 g/wk: OR 0.58, 95% CI 0.35 to 0.97; 12 g/wk to <12 g/d: OR 0.55, 95% CI 0.28 to 1.10; ≥12 g/d: OR 0.92, 95% CI 0.23 to 3.64). Conclusions— Light to moderate alcohol consumption appears to be associated with a reduced risk of ischemic stroke in young women.

Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence.

Background Approximately 50% of smokers die prematurely from tobacco-related diseases. In July 2006, the Massachusetts health care reform law mandated tobacco cessation coverage for the Massachusetts Medicaid population. The new benefit included behavioral counseling and all medications approved for tobacco cessation treatment by the U.S. Food and Drug Administration (FDA). Between July 1, 2006 and December 31, 2008, a total of 70,140 unique Massachusetts Medicaid subscribers used the newly available benefit, which is approximately 37% of all Massachusetts Medicaid smokers. Given the high utilization rate, the objective of this study is to determine if smoking prevalence decreased significantly after the initiation of tobacco cessation coverage. Methods and Findings Smoking prevalence was evaluated pre- to post-benefit using 1999 through 2008 data from the Massachusetts Behavioral Risk Factor Survey (BRFSS). The crude smoking rate decreased from 38.3% (95% C.I. 33.6%–42.9%) in the pre-benefit period compared to 28.3% (95% C.I.: 24.0%–32.7%) in the post-benefit period, representing a decline of 26 percent. A demographically adjusted smoking rate showed a similar decrease in the post-benefit period. Trend analyses reflected prevalence decreases that accrued over time. Specifically, a joinpoint analysis of smoking prevalence among Massachusetts Medicaid benefit-eligible members (age 18–64) from 1999 through 2008 found a decreasing trend that was coincident with the implementation of the benefit. Finally, a logistic regression that controlled for demographic factors also showed that the trend in smoking decreased significantly from July 1, 2006 to December 31, 2008. Conclusion These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and involves broad promotion can significantly reduce smoking prevalence.

Long-Term Trends in Adolescent and Young Adult Smoking in the United States: Metapatterns and Implications

OBJECTIVES We sought to describe long-term adolescent and young adult smoking trends and patterns. METHODS We analyzed adolescent data from Monitoring the Future, 1976 to 2005, and young adult (aged 18-24 years) data from the National Health Interview Survey, 1974 to 2005, overall and in subpopulations to identify trends in current cigarette smoking prevalence. RESULTS Five metapatterns emerged: we found (1) a large increase and subsequent decrease in overall smoking over the past 15 years, (2) a steep decline in smoking among Blacks through the early 1990s, (3) a gender gap reversal among older adolescents and young adults who smoked over the past 15 years, (4) similar trends in smoking for most subgroups since the early 1990s, and (5) a large decline in smoking among young adults with less than a high school education. CONCLUSIONS Long-term patterns for adolescent and young adult cigarette smoking were decidedly nonlinear, and we found evidence of a cohort effect among young adults. Continued strong efforts and a long-term societal commitment to tobacco use prevention are needed, given the unprecedented declines in smoking among most subpopulations since the mid- to late 1990s.