Melvin D. Livingston

Effects of State Medical Marijuana Laws on Adolescent Marijuana Use

OBJECTIVES Medical marijuana laws (MMLs) have been suggested as a possible cause of increases in marijuana use among adolescents in the United States. We evaluated the effects of MMLs on adolescent marijuana use from 2003 through 2011. METHODS We used data from the Youth Risk Behavior Survey and a difference-in-differences design to evaluate the effects of passage of state MMLs on adolescent marijuana use. The states examined (Montana, Rhode Island, Michigan, and Delaware) had passed MMLs at different times over a period of 8 years, ensuring that contemporaneous history was not a design confound. RESULTS In 40 planned comparisons of adolescents exposed and not exposed to MMLs across states and over time, only 2 significant effects were found, an outcome expected according to chance alone. Further examination of the (nonsignificant) estimates revealed no discernible pattern suggesting an effect on either self-reported prevalence or frequency of marijuana use. CONCLUSIONS Our results suggest that, in the states assessed here, MMLs have not measurably affected adolescent marijuana use in the first few years after their enactment. Longer-term results, after MMLs are more fully implemented, might be different.

Perceived racial/ethnic discrimination, problem behaviors, and mental health among minority urban youth

Objectives. We examined perceived frequency and intensity of racial/ethnic discrimination and associations with high-risk behaviors/conditions among adolescents. Design. With surveys from 2490 racial/ethnic minority adolescents primarily with low socioeconomic status, we used regression analysis to examine associations between racial/ethnic discrimination and behavioral health outcomes (alcohol use, marijuana use, physical aggression, delinquency, victimization, depression, suicidal ideation, and sexual behaviors). Results. Most adolescents (73%) experienced racial/ethnic discrimination and 42% of experiences were ‘somewhat-’ or ‘very disturbing.’ Adolescents reporting frequent and disturbing racial/ethnic discrimination were at increased risk of all measured behaviors, except alcohol and marijuana use. Adolescents who experienced any racial/ethnic discrimination were at increased risk for victimization and depression. Regardless of intensity, adolescents who experienced racial/ethnic discrimination at least occasionally were more likely to report greater physical aggression, delinquency, suicidal ideation, younger age at first oral sex, unprotected sex during last intercourse, and more lifetime sexual partners. Conclusion. Most adolescents had experienced racial/ethnic discrimination due to their race/ethnicity. Even occasional experiences of racial/ethnic discrimination likely contribute to maladaptive behavioral and mental health outcomes among adolescents. Prevention and coping strategies are important targets for intervention.

Area-Level Socioeconomic Position and Repeat Mammography Screening Use: Results from the 2005 National Health Interview Survey

Background: Despite a considerable number of studies describing the relationship between area-level socioeconomic conditions and mammography screening, definitive conclusions have yet to be drawn. The aim of this study was to examine the relationship between area-level socioeconomic position (SEP) and repeat mammography screening, using nationwide U.S. census SEP data linked to a nationally representative sample of women who participated in the 2005 National Health Interview Survey (NHIS). Methods: An area-level SEP index using 2000 U.S. census tract data was constructed and categorized into quartiles, including information on unemployment, poverty, housing values, annual family income, education, and occupation. Repeat mammography utilization (dichotomous variable) was defined as having three mammograms over the course of 6 years (24-month interval), which must have included a recent mammogram (in past 2 years). Results were obtained by ordinary multivariable logistic regression for survey data. Women ages 46 to 79 years (n = 7,352) were included in the analysis. Results: In a model adjusted for sociodemographics, health care factors, and known correlates of mammography screening, women living in more disadvantaged areas had lower odds of engaging in repeat mammography than women living in the most advantaged areas [OR comparing quartile 4 (most disadvantaged) to quartile 1 (most advantaged) = 0.63; 95% confidence interval, 0.50–0.80]. Conclusion: The results of this nationwide study support the hypothesis that area-level SEP is independently associated with mammography utilization. Impact: These findings underscore the importance of addressing area-level social inequalities, if uptake of mammography screening guidelines is to be realized across all social strata. Cancer Epidemiol Biomarkers Prev; 20(11); 2331–44. ©2011 AACR.

The Effect of an Increased Minimum Wage on Infant Mortality and Birth Weight

OBJECTIVES To investigate the effects of state minimum wage laws on low birth weight and infant mortality in the United States. METHODS We estimated the effects of state-level minimum wage laws using a difference-in-differences approach on rates of low birth weight (< 2500 g) and postneonatal mortality (28-364 days) by state and month from 1980 through 2011. All models included state and year fixed effects as well as state-specific covariates. RESULTS Across all models, a dollar increase in the minimum wage above the federal level was associated with a 1% to 2% decrease in low birth weight births and a 4% decrease in postneonatal mortality. CONCLUSIONS If all states in 2014 had increased their minimum wages by 1 dollar, there would likely have been 2790 fewer low birth weight births and 518 fewer postneonatal deaths for the year.

Efforts to adjust for confounding by neighborhood using complex survey data.

In social epidemiology, one often considers neighborhood or contextual effects on health outcomes, in addition to effects of individual exposures. This paper is concerned with the estimation of an individual exposure effect in the presence of confounding by neighborhood effects, motivated by an analysis of National Health Interview Survey (NHIS) data. In the analysis, we operationalize neighborhood as the secondary sampling unit of the survey, which consists of small groups of neighboring census blocks. Thus the neighborhoods are sampled with unequal probabilities, as are individuals within neighborhoods. We develop and compare several approaches for the analysis of the effect of dichotomized individual-level education on the receipt of adequate mammography screening. In the analysis, neighborhood effects are likely to confound the individual effects, due to such factors as differential availability of health services and differential neighborhood culture. The approaches can be grouped into three broad classes: ordinary logistic regression for survey data, with either no effect or a fixed effect for each cluster; conditional logistic regression extended for survey data; and generalized linear mixed model (GLMM) regression for survey data. Standard use of GLMMs with small clusters fails to adjust for confounding by cluster (e.g. neighborhood); this motivated us to develop an adaptation. We use theory, simulation, and analyses of the NHIS data to compare and contrast all of these methods. One conclusion is that all of the methods perform poorly when the sampling bias is strong; more research and new methods are clearly needed.

Heterogeneous population effects of an alcohol excise tax increase on sexually transmitted infections morbidity.

Background and Aims Alcohol taxes reduce population-level excessive alcohol use and alcohol-related morbidity and mortality, yet little is known about the distribution of the effects of alcohol taxation across race/ethnicity and age subgroups. We examined the race/ethnicity- and age group-specific effects of an excise alcohol tax increase on a common and routinely collected alcohol-related morbidity indicator, sexually transmitted infections. Methods We used an interrupted time series design to examine the effect of a 2009 alcohol tax increase in Illinois, USA on new cases of two common sexually transmitted infections (chlamydia and gonorrhea) reported to the US National Notifiable Disease Surveillance System from January 2003 to December 2011 (n = 108 repeated monthly observations). We estimated the effects of the tax increase on infection rates in the general population and within specific race/ethnicity and age subgroups using mixed models accounting for temporal trends and median income. Results Following the Illinois alcohol tax increase, state-wide rates of gonorrhea decreased 21% [95% confidence Interval (CI) = −25.7, −16.7] and chlamydia decreased 11% [95% CI = −17.8, −4.4], resulting in an estimated 3506 fewer gonorrhea infections and 5844 fewer chlamydia infections annually. The null hypothesis of homogenous effects by race/ethnicity and age was rejected (P < 0.0001). Significant reductions were observed among non-Hispanic blacks: gonorrhea rates decreased 25.6% (95% CI = −30.0, −21.0) and chlamydia rates decreased 14.7% (95% CI = −20.9, −8.0). Among non-Hispanics, point estimates suggest decreases were highest among 25–29-year-olds. Conclusions Increased alcohol taxes appear to reduce sexually transmitted infections, especially among subpopulations with high disease burdens, such as non-Hispanic blacks.

Prevention Trial in the Cherokee Nation: Design of a Randomized Community Trial

Despite advances in prevention science and practice in recent decades, the U.S. continues to struggle with significant alcohol-related risks and consequences among youth, especially among vulnerable rural and Native American youth. The Prevention Trial in the Cherokee Nation is a partnership between prevention scientists and Cherokee Nation Behavioral Health to create, implement, and evaluate a new, integrated community-level intervention designed to prevent underage drinking and associated negative consequences among Native American and other youth living in rural high-risk underserved communities. The intervention builds directly on results of multiple previous trials of two conceptually distinct approaches. The first is an updated version of CMCA, an established community environmental change intervention, and the second is CONNECT, our newly developed population-wide intervention based on screening, brief intervention, and referral to treatment (SBIRT) research. CMCA direct-action community organizing is used to engage local citizens to address community norms and practices related to alcohol use and commercial and social access to alcohol among adolescents. The new CONNECT intervention expands traditional SBIRT to be implemented universally within schools. Six key research design elements optimize causal inference and experimental evaluation of intervention effects, including a controlled interrupted time-series design, purposive selection of towns, random assignment to study condition, nested cohorts as well as repeated cross-sectional observations, a factorial design crossing two conceptually distinct interventions, and multiple comparison groups. The purpose of this paper is to describe the strong partnership between prevention scientists and behavioral health leaders within the Cherokee Nation, and the intervention and research design of this new community trial.

Recreational Cannabis Legalization and Opioid-Related Deaths in Colorado, 2000–2015

Objectives To examine the association between Colorado’s legalization of recreational cannabis use and opioid-related deaths. Methods We used an interrupted time-series design (2000-2015) to compare changes in level and slope of monthly opioid-related deaths before and after Colorado stores began selling recreational cannabis. We also describe the percent change in opioid-related deaths by comparing the unadjusted model-smoothed number of deaths at the end of follow-up with the number of deaths just prior to legalization. Results Colorado’s legalization of recreational cannabis sales and use resulted in a 0.7 deaths per month (b = −0.68; 95% confidence interval = −1.34, −0.03) reduction in opioid-related deaths. This reduction represents a reversal of the upward trend in opioid-related deaths in Colorado. Conclusions Legalization of cannabis in Colorado was associated with short-term reductions in opioid-related deaths. As additional data become available, research should replicate these analyses in other states with legal recreational cannabis.

Effects of a 2009 Illinois Alcohol Tax Increase on Fatal Motor Vehicle Crashes

OBJECTIVES We examined the effects of a 2009 increase in alcohol taxes in Illinois on alcohol-related fatal motor vehicle crashes. METHODS We used an interrupted time-series design, with intrastate and cross-state comparisons and measurement derived from driver alcohol test results, for 104 months before and 28 months after enactment. Our analyses used autoregressive moving average and generalized linear mixed Poisson models. We examined both population-wide effects and stratifications by alcohol level, age, gender, and race. RESULTS Fatal alcohol-related motor vehicle crashes declined 9.9 per month after the tax increase, a 26% reduction. The effect was similar for alcohol-impaired drivers with positive alcohol levels lower than 0.15 grams per deciliter (-22%) and drivers with very high alcohol levels of 0.15 or more (-25%). Drivers younger than 30 years showed larger declines (-37%) than those aged 30 years and older (-23%), but gender and race stratifications did not significantly differ. CONCLUSIONS Increases in alcohol excise taxes, such as the 2009 Illinois act, could save thousands of lives yearly across the United States as part of a comprehensive strategy to reduce alcohol-impaired driving.

Association Between Sex Partner Meeting Venues and Sexual Risk Taking Among Urban Adolescents

PURPOSE To increase understanding of the association between sexual partner meeting venue types (school, through friends or family, organized groups, public places, or on the street) and sexual risk taking among urban youths. METHODS Data were from 17- to 18-year-old youths who reported having had sex (n = 1,656) by the time they participated in the 2008-2009 follow-up of a multicomponent alcohol preventive intervention, Project Northland Chicago. We used logistic regression to assess the association between partner meeting venue and sexual risk taking. RESULTS Approximately 20% of Chicago adolescents met their most recent sex partner on the street or in public places. Adolescents who met their partner in a public place, rather than in school, were more likely to report having ≥ 3 years age-discordant partner (women: odds ratio [OR] = 7.7, 95% confidence interval [CI] = 3.3-17.7; men: OR = 2.7, 95% CI = 1.1-6.6], alcohol use before sex (women: OR = 3.4, 95% CI = 1.8-6.5; men: OR = 2.4, 95% CI = 1.3-4.4), casual partner (women: OR = not significant; men: OR = 2.4, 95% CI = 1.3-4.5), anal sex (women: OR = not significant; men: OR = 2.4, 95% CI = 1.2-4.9), and unprotected sex (women: OR = 1.7, 95% CI = 1.0-2.7; men: OR = 1.9, 95% CI = 1.1-3.4). Meeting partners on the street was associated with increased probability of alcohol use before sex (women: OR = 2.2, 95% CI = 1.1-4.3; men: OR = 2.1, 95% CI = 1.0-4.6), age-discordant partnerships among women (OR = 14.2, 95% CI = 6.4-31.4), and casual sex partners among men (OR = 2.5, 95% CI = 1.4-4.8). CONCLUSIONS Targeting sexual risk taking with partners selected from public places or the street may improve adolescent HIV preventive interventions.