Yehuda Neumark

Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys

Background Alcohol, tobacco, and illegal drug use cause considerable morbidity and mortality, but good cross-national epidemiological data are limited. This paper describes such data from the first 17 countries participating in the World Health Organizations (WHOs) World Mental Health (WMH) Survey Initiative. Methods and Findings Household surveys with a combined sample size of 85,052 were carried out in the Americas (Colombia, Mexico, United States), Europe (Belgium, France, Germany, Italy, Netherlands, Spain, Ukraine), Middle East and Africa (Israel, Lebanon, Nigeria, South Africa), Asia (Japan, Peoples Republic of China), and Oceania (New Zealand). The WHO Composite International Diagnostic Interview (CIDI) was used to assess the prevalence and correlates of a wide variety of mental and substance disorders. This paper focuses on lifetime use and age of initiation of tobacco, alcohol, cannabis, and cocaine. Alcohol had been used by most in the Americas, Europe, Japan, and New Zealand, with smaller proportions in the Middle East, Africa, and China. Cannabis use in the US and New Zealand (both 42%) was far higher than in any other country. The US was also an outlier in cocaine use (16%). Males were more likely than females to have used drugs; and a sex–cohort interaction was observed, whereby not only were younger cohorts more likely to use all drugs, but the male–female gap was closing in more recent cohorts. The period of risk for drug initiation also appears to be lengthening longer into adulthood among more recent cohorts. Associations with sociodemographic variables were consistent across countries, as were the curves of incidence of lifetime use. Conclusions Globally, drug use is not distributed evenly and is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones. Sex differences were consistently documented, but are decreasing in more recent cohorts, who also have higher levels of illegal drug use and extensions in the period of risk for initiation.

Racial/ethnic disparities in report of physician-provided smoking cessation advice : Analysis of the 2000 national health interview survey

OBJECTIVES We explored racial/ethnic disparities in reports of smoking cessation advice among smokers who had visited a physician in the previous year. Also, we examined the likelihood of receipt of such advice across Hispanic subgroups and levels of English proficiency. METHODS We analyzed data from the 2000 National Health Interview Survey. RESULTS Nearly half of the 5652 respondents reported receiving smoking cessation advice from their doctor. Compared with Hispanics, and after control for a range of other factors, respondents in the non-Hispanic White (adjusted odds ratio [OR]=1.57, 95% confidence interval [CI]=1.2, 2.0), non-Hispanic Black (adjusted OR=1.44, 95% CI=1.0, 2.0), and other non-Hispanic (adjusted OR=2.19, 95% CI=1.3, 3.6) groups were significantly more likely to report receiving advice. English proficiency was not associated with receipt of physician advice among Hispanic smokers. CONCLUSIONS Some 16 million smokers in the United States could not recall receiving advice to quit smoking from their physician in the preceding year. These missed opportunities, compounded by racial/ethnic disparities such as those observed between Hispanics and other groups and between Hispanic subgroups, suggest that considerably greater effort is needed to diminish the toll stemming from smoking and smoking-related diseases.

Limited English Proficiency Is a Barrier to Receipt of Advice about Physical Activity and Diet among Hispanics with Chronic Diseases in the United States

The prevalence of obesity, diabetes, and cardiovascular disease is reaching epidemic proportions among Hispanics in the United States. Health care providers play an important role in motivating patients to make healthful lifestyle changes to reduce the burden of such conditions. Data from the US 2000 National Health Interview Survey was analyzed to determine differences in report of physician-provided physical activity and/or dietary advice by level of English proficiency among obese Hispanics or those who reported having diabetes or cardiovascular disease and who contacted a physician during the past year (n=1,186). Only one third of the sample reported receiving advice to increase their physical activity or to improve their dietary habits; one fifth reported receipt of advice about both. English-proficient Hispanics were about 50% more likely to report receiving advice on physical activity (adjusted odd ratio [AOR]=1.5; 95% confidence interval [CI]: 1.1 to 2.1), diet (AOR=1.5; 95% CI: 1.1 to 2.2) or both (AOR=1.6; 95% CI: 1.1 to 2.3), as compared with limited English-proficient Hispanics, after controlling for health insurance coverage and number of visits to a physician during the last year. Sex, age, region of residence, level of education, annual family income, and smoking status were not significantly associated with receiving physical activity and/or dietary advice. In order to address racial health disparities, and lower the burden of chronic illness, culturally sensitive strategies must be implemented to enhance delivery of effective health-promotion messages by physicians, particularly among at-risk communities.

Hand Washing Among School Children in Bogotá, Colombia

OBJECTIVES We assessed hand-washing behaviors and intentions among school children in Bogotá, Colombia, to help identify and overcome barriers to proper hygiene practices. METHODS Data on hand-washing behavior and intentions and individual and contextual factors were collected from 2042 sixth- through eighth-grade students in 25 schools in Bogotá via anonymous questionnaires. A member of the school administration or teaching staff completed a questionnaire about the school environment. Site inspections of bathroom facilities were conducted. RESULTS Only 33.6% of the sample reported always or very often washing hands with soap and clean water before eating and after using the toilet. About 7% of students reported regular access to soap and clean water at school. A high level of perceived control was the strongest predictor of positive hand-washing intentions (adjusted odds ratio [AOR]=6.0; 95% confidence interval [CI]=4.8, 7.5). Students with proper hand-washing behavior were less likely to report previous-month gastrointestinal symptoms (OR=0.8; 95% CI=0.6, 0.9) or previous-year school absenteeism (OR=0.7; 95% CI=0.6, 0.9). CONCLUSIONS Scarcity of adequate facilities in most schools in Bogotá prevents children from adopting proper hygienic behavior and thwarts health promotion efforts. The current renovation program of public schools in Bogotá provides a unique opportunity to meet the challenges of providing a supportive environment for adoption of healthy behaviors.

Early cannabis use and estimated risk of later onset of depression spells: Epidemiologic evidence from the population-based world health organization world mental health survey initiative

Early-onset cannabis use is widespread in many countries and might cause later onset of depression. Sound epidemiologic data across countries are missing. The authors estimated the suspected causal association that links early-onset (age <17 years) cannabis use with later-onset (age > or =17 years) risk of a depression spell, using data on 85,088 subjects from 17 countries participating in the population-based World Health Organization World Mental Health Survey Initiative (2001-2005). In all surveys, multistage household probability samples were evaluated with a fully structured diagnostic interview for assessment of psychiatric conditions. The association between early-onset cannabis use and later risk of a depression spell was studied using conditional logistic regression with local area matching of cases and controls, controlling for sex, age, tobacco use, and other mental health problems. The overall association was modest (controlled for sex and age, risk ratio = 1.5, 95% confidence interval: 1.4, 1.7), was statistically robust in 5 countries, and showed no sex difference. The association did not change appreciably with statistical adjustment for mental health problems, except for childhood conduct problems, which reduced the association to nonsignificance. This study did not allow differentiation of levels of cannabis use; this issue deserves consideration in future research.

The drinking of earlier and more recent Russian immigrants to Israel: comparison to other Israelis.

OBJECTIVES Russia has a high level of per capita alcohol consumption, while the level in Israel is low. Since 1989, over 820,000 Russian Jews immigrated to Israel. In the 1970s and early 1980s, a smaller wave of immigration from Russia to Israel occurred (approximately 170,000). The drinking of earlier immigrants was compared to recent immigrants and other Israelis. METHODS Data came from a 1995 national survey of Israeli household residents. Of 4984 Israeli respondents, 292 were Russian immigrants who arrived since 1989 and 131 were Russians who immigrated earlier. Groups were compared with logistic regression. RESULTS Recent Russian immigrants were more likely to drink in the last 12 months, to drink frequently and to get drunk than other Israelis. The earlier Russian immigrants were not more likely than other Israelis to report drinking in the last 12 months or frequent drinking, but were more likely to report 30-day drinking and getting drunk. In direct comparison of recent and earlier Russians, recent immigrants reported more frequent drinking than earlier immigrants. CONCLUSIONS The results for drinking and frequency of drinking are consistent with acculturation effects as well as other explanations. Further investigation in studies with appropriate designs will be necessary to clarify the meaning of these results.

Socio-economic status and binge drinking in Israel

Modern Israeli society is comprised primarily of two nationality groups-Jews and Arabs, with disparate religious and cultural attitudes toward alcohol drinking. We recently described higher rates of past-month drinking among Jewish adults, although Arabs who drink were more likely to report binge drinking. The goal of the present study is to examine the relationship between binge drinking and socio-economic status (SES) among Arab and Jewish adults in Israel. Data from a 1995 nationally representative household survey on drug and alcohol use were analyzed. Participants included male and female Arabs (n=982) and Jews (n=4,972) aged 18-40 living in Israel. SES was assessed using education, household income, and occupation. The prevalence of binge drinking was highest among Arab men (21.4%) followed by Jewish men (15.2%), Arab women (7.3%), and Jewish women (4.0%). Prevalence rates and odds ratios (ORs) from logistic models controlling for age, gender, marital status and religiosity show that increased household income and occupation are associated with increased binge drinking among Arabs (OR>2.0) and decreased binge drinking among Jews (OR congruent with 0.6). Higher educational achievement was protective against binge drinking in both nationality groups. Varied results for income and occupation, and education indicate the need to examine the association between each SES indicator and alcohol consumption independently, especially in culturally diverse populations.

The Jerusalem Experience: Three Decades of Service, Research, and Training in Community-Oriented Primary Care

Community-oriented primary care (COPC) developed and was tested over nearly 3 decades in the Hadassah Community Health Center in Jerusalem, Israel. Integration of public health responsibility with individual-based clinical management of patients formed the cornerstone of the COPC approach. A family medicine practice and a mother and child preventive service provided the frameworks for this development. The health needs of the community were assessed, priorities determined, and intervention programs developed and implemented on the basis of detailed analysis of the factors responsible for defined health states. Ongoing health surveillance facilitated evaluation, and the effectiveness of interventions in different population groups was illustrated. The centers international COPC involvement has had effects on primary health care policy worldwide.

Smoking estimates from around the world: data from the first 17 participating countries in the World Mental Health Survey Consortium

Objective To contribute new multinational findings on basic descriptive features of smoking and cessation, based upon standardised community surveys of adults residing in seven low-income and middle-income countries and 10 higher-income countries from all regions of the world. Methods Data were collected using standardised interviews and community probability sample survey methods conducted as part of the WHO World Mental Health Surveys Initiative. Demographic and socioeconomic correlates of smoking are studied using cross-tabulation and logistic regression approaches. Within-country sample weights were applied with variance estimation appropriate for complex sample survey designs. Results Estimated prevalence of smoking experience (history of ever smoking) and current smoking varied across the countries under study. In all but four countries, one out of every four adults currently smoked. In higher-income countries, estimated proportions of former smokers (those who had quit) were roughly double the corresponding estimates for most low-income and middle-income countries. Characteristics of smokers varied within individual countries, and in relation to the World Banks low-medium-high gradient of economic development. In stark contrast to a sturdy male-female difference in the uptake of smoking seen in each country, there is no consistent sex-associated pattern in the odds of remaining a smoker (versus quitting). Conclusion The World Mental Health Surveys estimates complement existing global tobacco monitoring efforts. The observed global diversity of associations with smoking and smoking cessation underscore reasons for implementation of the Framework Convention on Tobacco Control provisions and prompt local adaptation of prevention and control interventions.

Effects of risk perception of marijuana use on marijuana use and intentions to use among adolescents in Bogotá, Colombia

BACKGROUND Perceived risk is a key concept of behavioral theories used to predict substance use among youth and a core component of drug use prevention interventions. The present study aimed to (1) assess degrees of risk perception of regular marijuana use, (2) identify factors associated with risk perception, and (3) explore the associations between perceived risk and marijuana use and intentions to use marijuana among school-attending adolescents in Bogotá, Colombia. METHODS Data from 2079 standardized questionnaires administered in 23 schools were analyzed in this study. Schools were selected in a multi-stage probability cluster sample to reflect the socio-economic characteristics of Bogotás student population. RESULTS Just over 11% of participants perceived regular marijuana use to be a low risk behavior. Older age (>16 years) (adjusted odds ratio=2.9; 95% confidence interval=1.4-6.0) and low level of knowledge regarding the physical and psychological harms of illegal drugs (AOR=2.9; 95%CI=2.0-4.3) were the strongest predictors of low risk perception, Low perceived risk was also significantly associated with ever having used marijuana (AOR=2.5; 95%CI=1.7-3.7), monthly marijuana use among ever marijuana users (AOR=2.7; 95%CI=1.4-5.0), and a positive intention to use marijuana within the next 12 months among non-users (AOR=2.1; 95%CI=1.4-3.5). CONCLUSIONS Consistent with previous findings, perceiving regular marijuana use as a risky behavior functions as a protective factor against the intention to use, use and occasional use of marijuana. Incorporation of this message into drug use prevention activities for non-users and early-stage users may enhance their effectiveness.