Marcos Sanches

Effects of the minimum legal drinking age on alcohol-related health service use in hospital settings in Ontario: A regression-discontinuity approach

OBJECTIVES We assessed the impact of the minimum legal drinking age (MLDA) on hospital-based treatment for alcohol-related conditions or events in Ontario, Canada. METHODS We conducted regression-discontinuity analyses to examine MLDA effects with respect to diagnosed alcohol-related conditions. Data were derived from administrative records detailing inpatient and emergency department events in Ontario from April 2002 to March 2007. RESULTS Relative to youths slightly younger than the MLDA, youths just older than the MLDA exhibited increases in inpatient and emergency department events associated with alcohol-use disorders (10.8%; P = .048), assaults (7.9%; P < .001), and suicides related to alcohol (51.8%; P = .01). Among young men who had recently crossed the MLDA threshold, there was a 2.0% increase (P = .01) in hospitalizations for injuries. CONCLUSIONS Young adults gaining legal access to alcohol incur increases in hospital-based care for a range of serious alcohol-related conditions. Our regression-discontinuity approach can be used in future studies to assess the effects of the MLDA across different settings, and our estimates can be used to inform cost-benefit analyses across MLDA scenarios.

Impacts of the minimum legal drinking age legislation on in‐patient morbidity in Canada, 1997–2007: a regression‐discontinuity approach

AIMS To provide novel, population-based estimates of the influence of minimum legal drinking age (MLDA) legislation on target in-patient hospital events in Canada. DESIGN Regression-discontinuity analyses on rates of Canadian in-patient admissions. SETTING All in-patient hospitalizations in Canada (except Québec) between 1 April 1997 and 31 March 2007. PARTICIPANTS Individuals aged 15-22 years admitted to hospital. MEASUREMENTS International Classification of Diseases-9/10 codes for alcohol-use disorders/poisoning, injury, suicide, assault and motor vehicle accidents were considered as target morbidity conditions. FINDINGS Compared with the baseline hospitalization rate just prior to the MLDA, admissions at the MLDA rose significantly (P ≤ 0.001) for alcohol-use disorders/poisoning for males (17.3%) and females (21.1%), as well as for suicide events for the combined sample (9.6%, P = 0.029). Among males, there was a significant 4.4% increase (P = 0.001) in a broad class of injuries, including a 9.2% jump (P = 0.020) in admissions for motor vehicle accidents compared with the baseline hospitalization rate just prior to the MLDA. CONCLUSION Removal of minimum legal drinking age restrictions is associated with significant population-level increases in hospital admissions among young adults in Canada for alcohol-use disorders/poisoning, as well as for other serious injuries, especially among males. Current international minimum legal drinking age policy discussions should account for the impact of the minimum legal drinking age on severe morbidity outcomes.

Impacts of drinking-age laws on mortality in Canada, 1980–2009

BACKGROUND Given the recent international debates about the effectiveness and appropriate age setpoints for legislated minimum legal drinking ages (MLDAs), the current study estimates the impact of Canadian MLDAs on mortality among young adults. Currently, the MLDA is 18 years in Alberta, Manitoba and Québec, and 19 years in the rest of Canada. METHODS Using a regression-discontinuity approach, we estimated the impacts of the MLDAs on mortality from 1980 to 2009 among 16- to 22-year-olds in Canada. RESULTS In provinces with an MLDA of 18 years, young men slightly older than the MLDA had significant and abrupt increases in all-cause mortality (14.2%, p=0.002), primarily due to deaths from a broad class of injuries [excluding motor vehicle accidents (MVAs)] (16.2%, p=0.008), as well as fatalities due to MVAs (12.7%, p=0.038). In provinces/territories with an MLDA of 19 years, significant jumps appeared immediately after the MLDA among males in all-cause mortality (7.2%, p=0.003), including injuries from external causes (10.4%, p<0.001) and MVAs (15.3%, p<0.001). Among females, there were some increases in mortality following the MLDA, but these jumps were statistically non-significant. CONCLUSIONS Canadian drinking-age legislation has a powerful impact on youth mortality. Given that removal of MLDA restrictions was associated with sharp upturns in fatalities among young men, the MLDA likely reduces population-level mortality among male youth under the constraints of drinking-age legislation. Alcohol-control policies should target the transition across the MLDA as a pronounced period of mortality risk, especially among males.

Impacts of the Minimum Legal Drinking Age on Motor Vehicle Collisions in Québec, 2000−2012

BACKGROUND International debates are occurring about the effectiveness of minimum legal drinking age laws. Most minimum legal drinking age evaluation studies have focused on motor vehicle collision outcomes, but this literature is primarily based on naturalistic experiments involving legislation changes in the U.S. in the mid-1980s. Few studies have provided up-to-date estimates of the impacts of Canadian drinking age laws on motor vehicle collisions to inform current policy discussions. PURPOSE To estimate the impacts of minimum legal drinking age legislation on motor vehicle collisions occurring in 2000-2012 in Québec, a province with a minimum legal drinking age of 18 years. METHODS Using Québec Ministry of Transportation records of police-reported motor vehicle collisions in 2000-2012, regression-discontinuity analyses were employed to assess the impacts of the minimum legal drinking age on motor vehicle collisions. All data were analyzed in 2013. RESULTS Relative to individuals slightly younger than the minimum legal drinking age, male and female drivers just older than the minimum legal drinking age had a significant and abrupt increase of approximately 6% (men, 6.3%, p=0.003; women, 5.9%, p=0.047) in population-level motor vehicle collisions, as well as a significant 11.1% (p=0.001) rise in nighttime motor vehicle collisions (a proxy for alcohol-related collisions). CONCLUSIONS Drinking-age laws continue to be an integral component of contemporary alcohol-control and driving-related policies designed to limit motor vehicle collisions among youth. In addition, the regression-discontinuity approach can guide future work to estimate potential minimum legal drinking age impacts on other health outcomes.

Hazardous birthday drinking among young people: population‐based impacts on emergency department and in‐patient hospital admissions

BACKGROUND AND AIMS There is growing concern about the possible adverse health impacts of binge drinking during birthday celebrations among adolescents and young adults. We estimate the impacts of birthday alcohol use on adolescent and young adult in-patient/emergency department (ED) hospital admissions. DESIGN We employed Autoregressive Integrated Moving Average (ARIMA) intervention analysis to assess whether the rate of ICD-10 alcohol-use-disorder (AUD) events per 1000 in-patient/ED admissions increased significantly during birthday weeks. SETTING All in-patient/ED admissions in Ontario, Canada from 1 April 2002 to 31 March 2007. PARTICIPANTS Individuals aged 12-30 years. MEASUREMENTS AUD events per 1000 in-patient/ED admissions by age in weeks. FINDINGS Multiple increases were found. The largest occurred during the birthday week of 19 years of age, the beginning of the minimum legal drinking age (MLDA) in Ontario: AUD admission rates increased (spiked) by 38.30 per 1000 total admissions [95% confidence interval (CI) = 34.66-41.94] among males (a 114.3% increase over baseline), and by 28.13 (95% CI = 25.56-30.70) among females (a 164.0% increase). Among both genders, the second largest birthday-week spikes occurred during ages 20-22 years, followed by somewhat lower but still pronounced birthday-week spikes during ages 23-26 years and 30 years (all these spikes: P < 0.05). Birthday-week spikes occurred as early as age 16 years for males and 14 years for females (both spikes: P < 0.05). CONCLUSIONS There appears to be an increase in alcohol-related adverse events from drinking around the time of ones birthday among young adults in Canada.

Prevalence and Mental Health Correlates of Illegal Cannabis Use Among Bisexual Women

ABSTRACT This study reports the prevalence of cannabis use among bisexual women in Ontario, Canada, and identifies correlations among levels of cannabis use (no use, some use, active use) and measures of mental health and social support. Analysis focused on 262 bisexual women from a bisexual mental health study using respondent-driven sampling. Among networked bisexual women in Ontario, Canada, the weighted prevalence of past-year cannabis use was 33.6%, with 13.8% of bisexual women using cannabis twice or more per week. Cannabis use was positively associated with social support, gay community involvement, outness to family, and depression. There was no significant association between cannabis use and anxiety, posttraumatic stress disorder, antibisexual experiences, or suicidal ideation. Bisexual womens rate of past-year cannabis use is more than 5 times that for Canadian women in general, and is consistent with rates for bisexual women found in U.S. studies.

Protocol: a cluster randomised control trial study exploring stigmatisation and recovery-based perspectives regarding mental illness and substance use problems among primary healthcare providers across Toronto, Ontario

Introduction Primary care settings are often the first and only point of contact for persons with mental health and/or substance use problems. However, staff experience and training in this area are often limited. These factors as well as a multitude of other components such as structural and systemic stigma experienced by staff can lead to clients being stigmatised, leading to poorer outcomes. By developing a comprehensive intervention for primary care staff working at community health centres (CHCs) aimed at reducing stigma towards people with mental health and substance use problems (MHSUP), we sought to test an innovative and contact-based intervention consisting of staff training, raising awareness, a recovery-focused art programme and an analysis of internal policies and procedures. All of these components can inform and support staff so they can provide better care for people who are experiencing MHSUP. CHC staff members and clients will be included in this project as active participants. Methods and analysis This mixed-methods project will consist of repeated surveys of staff and clients, as well as in-depth, semistructured interviews with a sample of clients and staff. A cluster randomised control trial design will test the effectiveness of an antistigma intervention for CHCs in Toronto, Canada. Six CHCs—three receiving the intervention and three controls—will be included in the study. Using a variety of measures, including the Opening Minds Scale for Health Care Providers (OMS-HC), Mental Illness: Clinicians Attitudes (MICA) Scale, Modified Bogardus Social Distance Scale, Perceived Devaluation-Discrimination Scale, Discrimination Experience subscale of the Internalized Stigma of Mental Illness (ISMI) Scale and the Recovery Assessment Scale (RAS), we hope to gain a thorough understanding of staff members’ attitudes and beliefs and clients’ perceptions of staff beliefs and behaviours. In-depth interviews will reveal important themes related to clients’ experiences of stigma both within and outside the healthcare setting. Ethics and dissemination If demonstrated to be successful, this intervention can be used as a model for future initiatives aimed at reducing MHSUP-related stigma among healthcare providers in an organisational context. Adapting this work in other settings is a key strategic goal of this project. The project will also advance knowledge about stigma reduction and the experience of encountering stigma within a healthcare setting. Trial registration NCT03043417; Post-results.

Impacts of Canada’s minimum age for tobacco sales (MATS) laws on youth smoking behaviour, 2000–2014

Background Recently, the US Institute of Medicine has proposed that raising the minimum age for tobacco purchasing/sales to 21 years would likely lead to reductions in smoking behavior among young people. Surprisingly few studies, however, have assessed the potential impacts of minimum-age tobacco restrictions on youth smoking. Objective To estimate the impacts of Canadian minimum age for tobacco sales (MATS) laws on youth smoking behaviour. Design A regression-discontinuity design, using seven merged cycles of the Canadian Community Health Survey, 2000–2014. Participants Survey respondents aged 14–22 years (n=98 320). Exposure Current Canadian MATS laws are 18 years in Alberta, Saskatchewan, Manitoba, Quebec, the Yukon and Northwest Territories, and 19 years of age in the rest of the country. Main outcomes Current, occasional and daily smoking status; smoking frequency and intensity; and average monthly cigarette consumption. Results In comparison to age groups slightly younger than the MATS, those just older had significant and abrupt increases immediately after the MATS in the prevalence of current smokers (absolute increase: 2.71%; 95% CI 0.70% to 4.80%; P=0.009) and daily smokers (absolute increase: 2.43%; 95% CI 0.74% to 4.12%; P=0.005). Average past-month cigarette consumption within age groups increased immediately following the MATS by 18% (95% CI 3% to 39%; P=0.02). There was no evidence of significant increases in smoking intensity for daily or occasional smokers after release from MATS restrictions. Conclusion The study provides relevant evidence supporting the effectiveness of Canadian MATS laws for limiting smoking among tobacco-restricted youth.

The association of depression and all-cause and cause-specific mortality: an umbrella review of systematic reviews and meta-analyses

BackgroundDepression is a prevalent and disabling mental disorder that frequently co-occurs with a wide range of chronic conditions. Evidence has suggested that depression could be associated with excess all-cause mortality across different settings and populations, although the causality of these associations remains unclear.MethodsWe conducted an umbrella review of systematic reviews and meta-analyses of observational studies. PubMed, PsycINFO, and Embase electronic databases were searched through January 20, 2018. Systematic reviews and meta-analyses that investigated associations of depression and all-cause and cause-specific mortality were selected for the review. The evidence was graded as convincing, highly suggestive, suggestive, or weak based on quantitative criteria that included an assessment of heterogeneity, 95% prediction intervals, small-study effects, and excess significance bias.ResultsA total of 26 references providing 2 systematic reviews and data for 17 meta-analytic estimates met inclusion criteria (19 of them on all-cause mortality); data from 246 unique studies (N = 3,825,380) were synthesized. All 17 associations had P < 0.05 per random effects summary effects, but none of them met criteria for convincing evidence. Associations of depression and all-cause mortality in patients after acute myocardial infarction, in individuals with heart failure, in cancer patients as well as in samples from mixed settings met criteria for highly suggestive evidence. However, none of the associations remained supported by highly suggestive evidence in sensitivity analyses that considered studies employing structured diagnostic interviews. In addition, associations of depression and all-cause mortality in cancer and post-acute myocardial infarction samples were supported only by suggestive evidence when studies that tried to adjust for potential confounders were considered.ConclusionsEven though associations between depression and mortality have nominally significant results in all assessed settings and populations, the evidence becomes weaker when focusing on studies that used structured interviews and those that tried to adjust for potential confounders. A causal effect of depression on all-cause and cause-specific mortality remains unproven, and thus interventions targeting depression are not expected to result in lower mortality rates at least based on current evidence from observational studies.

Monoamine Oxidase-A Genetic Variants and Childhood Abuse Predict Impulsiveness in Borderline Personality Disorder

Objective Impulsivity is a core feature of borderline personality disorder (BPD) and antisocial personality disorder (ASPD) that likely arises from combined genetic and environmental influences. The interaction of the low activity variant of the monoamine oxidase-A (MAOA-L) gene and early childhood adversity has been shown to predict aggression in clinical and non-clinical populations. Although impulsivity is a risk factor for aggression in BPD and ASPD, little research has investigated potential gene-environment (G×E) influences impacting its expression in these conditions. Moreover, G×E interactions may differ by diagnosis. Methods Full factorial analysis of variance was employed to investigate the influence of monoamine oxidase-A (MAO-A) genotype, childhood abuse, and diagnosis on Barratt Impulsiveness Scale-11 (BIS-11) scores in 61 individuals: 20 subjects with BPD, 18 subjects with ASPD, and 23 healthy controls. Results A group×genotype×abuse interaction was present (F(2,49)=4.4, p=0.018), such that the interaction of MAOA-L and childhood abuse predicted greater BIS-11 motor impulsiveness in BPD. Additionally, BPD subjects reported higher BIS-11 attentional impulsiveness versus ASPD participants (t(1,36)=2.3, p=0.025). Conclusion These preliminary results suggest that MAOA-L may modulate the impact of childhood abuse on impulsivity in BPD. Results additionally indicate that impulsiveness may be expressed differently in BPD and ASPD.