My research is focused on understanding how place affects health.
To understand why this is both interesting and important you need to know:
(1) Place affects health. Where individuals live, work, go to school shapes their individual health.
(2) Social determinants of health (e.g. income, employment) affect chronic disease behaviors. These include the ability to exercise, access nutritious food, receive mental health care.
(3) Social determinants of health affect chronic disease outcomes (e.g. cardiovascular disease, cancer, or obesity).
(4) Socially marginalized populations including individuals of low socioeconomic status and racially marginalized communities have the highest risk for many chronic disease behaviors and outcomes. This disproportionate risk is largely due to the contextual health influences of the physical and social environment.
Methodologically, I am currently working to develop a specific epidemiologic framework for utilizing electronic health records, survey, and geographic data with Geographic Information Systems (GIS) and spatial methods to reduce health disparities among socially marginalized populations. Merging clinical data with data on social determinants of health in a spatial epidemiology framework effectively allows us to ask and answer questions about how place affects health.
Instructor, Epidemiology and Population Health
Honors & Awards
K99/R00 Pathway to Independence Award, National Heart, Lung, and Blood Institute (NHLBI) (September 2022 - August 2027)
Butler-Williams Scholars Program, National Institute on Aging (NIA) (August 2022)
Health Disparities Research Institute, National Institute on Minority Health and Health Disparities (NIMHD) (August 2022)
Inaugural Postdoc Justice, Equity, Diversity, and Inclusion (JEDI) Champion Award, Stanford University (2021)
New Extramural Health Disparities Research, National Heart, Lung, and Blood Institute (NHLBI); NIH Loan Repayment Program (2020-2022)
Young Investigator Educational Grant, ACTRIMS-ECTRIMS (2020)
Big Data Scientist Training Enhancement (BD-STEP) Program Fellowship, U.S. Department of Veterans Affairs (2019-2022)
Charles E. Irwin New Investigator Award, Society for Adolescent Health and Medicine (2019)
Administrative Supplement to Promote Diversity in Health-Related Research (1P50CA189190), National Cancer Institute (2016-2018)
Public Health Alumni Association Scholarship, University of California, Berkeley School of Public Health (2016, 2018)
Tobacco Regulation and Addiction Center Fellowship, American Heart Association (2014-2015)
Best Applied Research Presentation, Delta Omega Research Competition, Johns Hopkins Bloomberg School of Public Health (2013)
Boards, Advisory Committees, Professional Organizations
Co-chair, Diversity, Equity, and Inclusion Committee, Society for Epidemiologic Research (2021 - Present)
Committee Member, Diversity, Equity, and Inclusion Committee, Society for Epidemiologic Research (2020 - Present)
Committee Member, Diversity, Equity, and Inclusion Committee, Department of Epidemiology and Population Health (2020 - Present)
Committee Member, National Cancer Institute CSBC/PS-ON/BD-STEP Junior Investigator Meeting (2020)
Cardiovascular Diseases, Medications, and ALS: A Population-Based Case-Control Study.
We investigated the associations between antecedent all-cause CVD diagnoses, cause-specific CVD diagnosis, and CVD medication prescriptions with the risk of developing amyotrophic lateral sclerosis (ALS).We conducted a population-based case-control study of U.S. Medicare enrollees from 2006 to 2013. The final sample included 3,714 incident ALS cases and 18,570 controls (matched on age, sex, enrollment length, and county). Information was collected from Medicare Parts A, B, and D administrative claims data on hypertension, ischemic heart disease, heart failure, acute myocardial infarction, atrial fibrillation, prescriptions of angiotensin-converting enzyme inhibitors, angiotensin II receptors blockers, calcium channel blockers, beta blockers, and antiarrhythmics. Associations were evaluated using conditional logistic regression adjusting for age, sex, race/ethnicity, geographical location, alcohol and tobacco use, and socioeconomic status.The odds ratio (OR) for having one or more ICD-9 codes for any cardiovascular disease diagnosis at least 24 months prior to the date of ALS diagnosis was 0.85 (95% conﬁdence interval [CI]: 0.78-0.92). Cardiovascular conditions that were inversely associated with ALS included heart failure (OR = 0.79; 95% CI 0.70-0.89), atrial fibrillation (OR = 0.81; 95% CI 0.77-0.92), and hypertension (OR = 0.91; 95% CI 0.84-0.98). Exposures to several classes of cardiovascular medications were inversely associated with ALS risk even after adjusting for confounding by indication, including ACE inhibitors (OR = 0.84, 95% CI 0.77-0.91), calcium channel blockers (OR = 0.64, 95% CI 0.59-0.70), and beta blockers (OR = 0.76, 95% CI 0.71-0.83).These findings merit additional research, including animal studies and pilot clinical trials, to further evaluate and evidence the effects of ACEIs, CCBs, and BBs on the risk of developing and clinical expression of ALS.
View details for DOI 10.1159/000526982
View details for PubMedID 36481735
Telemedicine Utilization Among Patients With Multiple Sclerosis in the US Veterans Health Administration, 2010-2020.
Neurology. Clinical practice
2022; 12 (6): e133-e142
Telemedicine may help to bridge the specialty care access gap for patients with MS (PwMS) restricted by distance or disability. The objective of this study is to assess the frequency and longitudinal patterns of telemedicine utilization among PwMS and controls.We conducted a population-based nested case-control study within the Veterans Health Administration (VHA) from January 1, 2010, to December 31, 2020. MS cases and controls were individually matched on sex, age, and Veterans Affair (VA) service region (Veterans Integrated Service Network). MS case and control participants sample sizes by year included 2010: 19,387/86,379; 2016: 19,752/88,535; and 2020: 16,451/78,315. Telemedicine encounter codes were used to identify telemedicine utilization among MS cases and controls in the VHA for 2010, 2016, and 2020. Telemedicine encounters were categorized according to mode (video, phone, and supplementary remote) and type of care provided.Patients in the VHA have had increasing utilization of telemedicine over the past decade. Among PwMS, mean telemedicine encounters increased steadily from 2010 to 2020 (5.6-10.5 encounters/patient, respectively). Across all years, MS cases were significantly more likely than controls to use telemedicine. The odds ratios (ORs) (95% confidence interval [CI]) of any telemedicine utilization comparing MS cases with controls in 2010, 2016, and 2020, respectively, were 1.5 (CI: 1.3-1.5), 1.9 (CI: 1.8-2.0), and 1.7 (CI: 1.6-1.8). Compared with non-Hispanic White veterans, non-Hispanic Black veterans were more likely to use telemedicine (adjusted OR = 1.5; [CI: 1.40-1.60]). The most common and least common modes of telemedicine among cases and controls were telephone and supplementary remote, respectively. Comparing 2010 with 2020, the largest increases in telemedicine utilization exhibited among MS cases were among primary care, specialty care, specialty neurology care, and other types of health care. States with the highest increases in telemedicine utilization were AL, CA, CO, FL, GA, KS, IL, NY, and SC. PwMS tended to live in counties with more adverse social determinants of health compared with controls.PwMS were significantly more likely to use telemedicine than their matched controls. There were significant increases in telemedicine utilization between 2010 and 2020. The VHA has a robust telemedicine system of care that has grown to supplement in person care more so than other US health care systems. Future work is needed to assess the determinants of telemedicine utilization.
View details for DOI 10.1212/CPJ.0000000000200078
View details for PubMedID 36540144
View details for PubMedCentralID PMC9757110
Increasing Representation of Epidemiologists from Around the World in the Society of Epidemiologic Research: the Case of Mexico.
American journal of epidemiology
Mexico has a population of 129 million and is considered one of the most unequal countries in the world, suffering from widespread health disparities. There is a pressing need to strengthen epidemiologic capacity in Mexico, to help solve the complex health problems the country faces and to reduce health inequities. However, the representation of Mexican epidemiologists in the largest epidemiologic society in North America is low despite the close distance to the US. In this commentary, we discuss the barriers to higher representation of Mexican epidemiologists within the Society for Epidemiologic Research (SER), including language barriers, costs, and regional necessities. We also discuss opportunities to expand Mexican SER representation and collaboration, but overall, we hope that this is a call towards expanding SER global participation and starting a conversation on a common agenda for epidemiologic research.
View details for DOI 10.1093/aje/kwac127
View details for PubMedID 35896787
Adolescent individual, school, and neighborhood influences on young adult hypertension risk.
2022; 17 (4): e0266729
BACKGROUND: Geographic and contextual socioeconomic risk factors in adolescence may be more strongly associated with young adult hypertension than individual-level risk factors. This study examines the association between individual, neighborhood, and school-level influences during adolescence on young adult blood pressure.METHODS: Data were analyzed from the National Longitudinal Study of Adolescent to Adult Health (1994-1995 aged 11-18 and 2007-2008 aged 24-32). We categorized hypertension as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg. Secondary outcomes included continuous systolic and diastolic blood pressure. We fit a series of cross-classified multilevel models to estimate the associations between young adulthood hypertension with individual-level, school-level, and neighborhood-level factors during adolescence (i.e., fixed effects) and variance attributable to each level (i.e., random effects). Models were fit using Bayesian estimation procedures. For linear models, intra-class correlations (ICC) are reported for random effects.RESULTS: The final sample included 13,911 participants in 128 schools and 1,917 neighborhoods. Approximately 51% (7,111) young adults were hypertensive. Individual-level characteristics-particularly older ages, Non-Hispanic Black race, Asian race, male sex, BMI, and current smoking-were associated with increased hypertension. Non-Hispanic Black (OR = 1.21; 95% CI: 1.03-1.42) and Asian (OR = 1.28; 95% CI: 1.02-1.62) students had higher odds of hypertension compared to non-Hispanic White students. At the school level, hypertension was associated with the percentage of non-Hispanic White students (OR for 10% higher = 1.06; 95% CI: 1.01-1.09). Adjusting for individual, school, and neighborhood predictors attenuated the ICC for both the school (from 1.4 null to 0.9 fully-adjusted) and neighborhood (from 0.4 to 0.3).CONCLUSION: We find that adolescents' schools and individual-level factors influence young adult hypertension, more than neighborhoods. Unequal conditions in school environments for adolescents may increase the risk of hypertension later in life. Our findings merit further research to better understand the mechanisms through which adolescents' school environments contribute to adult hypertension and disparities in hypertension outcomes later in life.
View details for DOI 10.1371/journal.pone.0266729
View details for PubMedID 35482649
Differences in COVID-19 Risk by Race and County-Level Social Determinants of Health among Veterans.
International journal of environmental research and public health
1800; 18 (24)
COVID-19 disparities by area-level social determinants of health (SDH) have been a significant public health concern and may also be impacting U.S. Veterans. This retrospective analysis was designed to inform optimal care and prevention strategies at the U.S. Department of Veterans Affairs (VA) and utilized COVID-19 data from the VAs EHR and geographically linked county-level data from 18 area-based socioeconomic measures. The risk of testing positive with Veterans' county-level SDHs, adjusting for demographics, comorbidities, and facility characteristics, was calculated using generalized linear models. We found an exposure-response relationship whereby individual COVID-19 infection risk increased with each increasing quartile of adverse county-level SDH, such as the percentage of residents in a county without a college degree, eligible for Medicaid, and living in crowded housing.
View details for DOI 10.3390/ijerph182413140
View details for PubMedID 34948748
Creation and validation of a polysocial score for mortality among community-dwelling older adults in the USA: the health and retirement study.
Age and ageing
BACKGROUND: the interrelatedness between social determinants of health impedes researchers to identify important social factors for health investment. A new approach is needed to quantify the aggregate effect of social factors and develop person- centred social interventions.METHODS: participants ([n=7,383], 54.5% female) were aged 65years or above who complete an additional psychosocial questionnaire in the health and retirement study in 2006 or 2008. Social determinants of health encompassed five social domains: economic stability, neighbourhood and physical environment, education, community and social context, and healthcare system. We used the forward stepwise logistic regression to derive a polysocial score model for 5-year mortality. Indices of goodness-of-fit, discrimination and reclassification were used to assess model performance. We used logistic regression to identify the association between polysocial score and mortality. Subgroup analyses were conducted to examine sex- and race-specific association.RESULTS: polysocial score was created using 14 social determinants of health. In the training cohort, the C-statistic was 0.71 for the reference model (only age, sex and race/ethnicity) and increased to 0.75 for the continuous and categorical polysocial score. Compared with the reference model, the integrated discrimination index for adding the continuous or categorical polysocial score was both 0.03 (P values < 0.001). Participants with an intermediate (odds ratio [OR]=0.69; 95% confidence interval [CI], 0.51-0.82) or high (OR=0.48; 95% CI, 0.38-0.60) polysocial score had lower odds of death than those in the low category in the fully adjusted model, respectively.CONCLUSIONS: the polysocial approach may offer possible solutions to monitor social environments and suggestions for older people to improve their social status for specific health outcomes.
View details for DOI 10.1093/ageing/afab174
View details for PubMedID 34473824
Prevalence and Sociodemographic Correlates of Unmet Need for Mental Health Counseling Among Adults During the COVID-19 Pandemic.
Psychiatric services (Washington, D.C.)
OBJECTIVE: This study aimed to determine the prevalence and correlates of unmet need for mental health counseling among U.S. adults during the COVID-19 pandemic.METHODS: Data from the December 9-21, 2020, cross-sectional Household Pulse Survey (N=69,944) were analyzed.RESULTS: Overall, 12.8% of adults reported an unmet need for mental health counseling in the past month, including 25.2% of adults with a positive screen for depression or anxiety. Among adults with a positive screen, risk factors associated with an unmet need for mental health counseling included female sex, younger age, income below the federal poverty line, higher education, and household job loss during the pandemic, while protective factors included Asian and Black race.CONCLUSIONS: Over one-quarter of U.S. adults with a positive screen for depression or anxiety experienced an unmet need for mental health counseling during the pandemic. Policy makers should consider increasing funding for mental health services as part of pandemic relief legislation.
View details for DOI 10.1176/appi.ps.202100111
View details for PubMedID 34189929
Association Between Income Inequality and County-Level COVID-19 Cases and Deaths in the US.
JAMA network open
2021; 4 (5): e218799
Importance: Socioeconomically marginalized communities have been disproportionately affected by the COVID-19 pandemic. Income inequality may be a risk factor for SARS-CoV-2 infection and death from COVID-19.Objective: To evaluate the association between county-level income inequality and COVID-19 cases and deaths from March 2020 through February 2021 in bimonthly time epochs.Design, Setting, and Participants: This ecological cohort study used longitudinal data on county-level COVID-19 cases and deaths from March 1, 2020, through February 28, 2021, in 3220 counties from all 50 states, Puerto Rico, and the District of Columbia.Main Outcomes and Measures: County-level daily COVID-19 case and death data from March 1, 2020, through February 28, 2021, were extracted from the COVID-19 Data Repository by the Center for Systems Science and Engineering at Johns Hopkins University in Baltimore, Maryland.Exposure: The Gini coefficient, a measure of unequal income distribution (presented as a value between 0 and 1, where 0 represents a perfectly equal geographical region where all income is equally shared and 1 represents a perfectly unequal society where all income is earned by 1 individual), and other county-level data were obtained primarily from the 2014 to 2018 American Community Survey 5-year estimates. Covariates included median proportions of poverty, age, race/ethnicity, crowding given by occupancy per room, urbanicity and rurality, educational level, number of physicians per 100 000 individuals, state, and mask use at the county level.Results: As of February 28, 2021, on average, each county recorded a median of 8891 cases of COVID-19 per 100 000 individuals (interquartile range, 6935-10 666 cases per 100 000 individuals) and 156 deaths per 100 000 individuals (interquartile range, 94-228 deaths per 100 000 individuals). The median county-level Gini coefficient was 0.44 (interquartile range, 0.42-0.47). There was a positive correlation between Gini coefficients and county-level COVID-19 cases (Spearman rho=0.052; P<.001) and deaths (Spearman rho=0.134; P<.001) during the study period. This association varied over time; each 0.05-unit increase in Gini coefficient was associated with an adjusted relative risk of COVID-19 deaths: 1.25 (95% CI, 1.17-1.33) in March and April 2020, 1.20 (95% CI, 1.13-1.28) in May and June 2020, 1.46 (95% CI, 1.37-1.55) in July and August 2020, 1.04 (95% CI, 0.98-1.10) in September and October 2020, 0.76 (95% CI, 0.72-0.81) in November and December 2020, and 1.02 (95% CI, 0.96-1.07) in January and February 2021 (P<.001 for interaction). The adjusted association of the Gini coefficient with COVID-19 cases also reached a peak in July and August 2020 (relative risk, 1.28 [95% CI, 1.22-1.33]).Conclusions and Relevance: This study suggests that income inequality within US counties was associated with more cases and deaths due to COVID-19 in the summer months of 2020. The COVID-19 pandemic has highlighted the vast disparities that exist in health outcomes owing to income inequality in the US. Targeted interventions should be focused on areas of income inequality to both flatten the curve and lessen the burden of inequality.
View details for DOI 10.1001/jamanetworkopen.2021.8799
View details for PubMedID 33938935
Differences in COVID-19 Testing and Test Positivity Among Veterans, United States, 2020.
Public health reports (Washington, D.C. : 1974)
OBJECTIVE: COVID-19 disproportionately affects racial/ethnic minority groups in the United States. We evaluated characteristics associated with obtaining a COVID-19 test from the Veterans Health Administration (VHA) and receiving a positive test result for COVID-19.METHODS: We conducted a retrospective cohort analysis of 6 292 800 veterans in VHA care at 130 VHA medical facilities. We assessed the number of tests for SARS-CoV-2 administered by the VHA (n = 822 934) and the number of positive test results (n = 82 094) from February 8 through December 28, 2020. We evaluated associations of COVID-19 testing and test positivity with demographic characteristics of veterans, adjusting for facility characteristics, comorbidities, and county-level area-based socioeconomic measures using nested generalized linear models.RESULTS: In fully adjusted models, veterans who were female, Black/African American, Hispanic/Latino, urban, and low income and had a disability had an increased likelihood of obtaining a COVID-19 test, and veterans who were Asian had a decreased likelihood of obtaining a COVID-19 test. Compared with veterans who were White, veterans who were Black/African American (risk ratio [RR] = 1.23; 95% CI, 1.19-1.27) and Native Hawaiian/Other Pacific Islander (RR = 1.13; 95% CI, 1.05-1.21) had an increased likelihood of receiving a positive test result. Hispanic/Latino veterans had a 43% higher likelihood of receiving a positive test result than non-Hispanic/Latino veterans did.CONCLUSIONS: Although veterans have access to subsidized health care at the VHA, the increased risk of receiving a positive test result for COVID-19 among Black and Hispanic/Latino veterans, despite receiving more tests than White and non-Hispanic/Latino veterans, suggests that other factors (eg, social inequities) are driving disparities in COVID-19 prevalence.
View details for DOI 10.1177/00333549211009498
View details for PubMedID 33826875
Addressing the mental health impact of COVID-19 through population health.
Clinical psychology review
2021; 85: 102006
The COVID-19 pandemic has and will continue to result in negative mental health outcomes such as depression, anxiety and traumatic stress in people and populations throughout the world. A population mental health perspective informed by clinical psychology, psychiatry and dissemination and implementation science is ideally suited to address the broad, multi-faceted and long-lasting mental health impact of the pandemic. Informed by a systematic review of the burgeoning empirical research on the COVID-19 pandemic and research on prior coronavirus pandemics, we link pandemic risk factors, negative mental health outcomes and appropriate intervention strategies. We describe how social risk factors and pandemic stressors will contribute to negative mental health outcomes, especially among vulnerable populations. We evaluate the scalability of primary, secondary and tertiary interventions according to mental health target, population, modality, intensity and provider type to provide a unified strategy for meeting population mental health needs. Traditional models, in which evidence-based therapies delivered are delivered in-person, by a trained expert, at a specialty care location have proved difficult to scale. The use of non-traditional models, tailoring preventive interventions to populations based on their needs, and ongoing coordinated evaluation of intervention implementation and effectiveness will be critical to refining our efforts to increase reach.
View details for DOI 10.1016/j.cpr.2021.102006
View details for PubMedID 33714167
Mental disorder prevalence among populations impacted by coronavirus pandemics: A multilevel meta-analytic study of COVID-19, MERS & SARS.
General hospital psychiatry
2021; 70: 124–33
Through a systematic review and meta-analysis of research on COVID-19, severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS) pandemics, we investigated whether mental disorder prevalence: (a) was elevated among populations impacted by coronavirus pandemics (relative to unselected populations reported in the literature), and (b) varied by disorder (undifferentiated psychiatric morbidity, anxiety, depressive, posttraumatic stress disorders [PTSD]) and impacted population (community, infected/recovered, healthcare provider, quarantined).From 68 publications (N = 87,586 participants), 808 estimates were included in a series of multilevel meta-analyses/regressions including random effects to account for estimates nested within studies.Median summary point prevalence estimates varied by disorder and population. Psychiatric morbidity (20-56%), PTSD (10-26%) and depression (9-27%) were most prevalent in most populations. The highest prevalence of each disorder was found among infected/recovered adults (18-56%), followed by healthcare providers (11-28%) and community adults (11-20%). Prevalence estimates were often notably higher than reported for unselected samples. Sensitivity analyses demonstrated that overall prevalence estimates moderately varied by pandemic, study location, and mental disorder measure type.Coronavirus pandemics are associated with multiple mental disorders in several impacted populations. Needed are investigations of causal links between specific pandemic-related stressors, threats, and traumas and mental disorders.
View details for DOI 10.1016/j.genhosppsych.2021.03.006
View details for PubMedID 33894561
Differences in COVID-19 Risk by Race and County-Level Social Determinants of Health Among Veterans
View details for DOI 10.1101/2021.10.20.21265149v1
- Author reply. General hospital psychiatry 2021
Racial and ethnic disparities for SARS-CoV-2 positivity in the United States: a generalizing pandemic
View details for DOI 10.1101/2021.04.27.21256215
Screen time for children and adolescents during the COVID-19 pandemic.
Obesity (Silver Spring, Md.)
The coronavirus 2019 (COVID-19) pandemic has led to laws and policies including national school closures, lockdown or shelter in place laws, and social distancing recommendations that may translate to higher overall screen time among children and adolescents for the duration of these laws and policies. These policies may need to be periodically re-instated to control future COVID-19 recurrences or other national emergencies. Excessive screen time is associated with cardiovascular disease risk factors such as obesity, high blood pressure, and insulin resistance because it increases sedentary time and is associated with snacking.
View details for DOI 10.1002/oby.22917
View details for PubMedID 32463530
Disentangling individual, school, and neighborhood effects on screen time among adolescents and young adults in the United States.
To examine the association between individual, neighborhood, and school-level influences on individual screen time among adolescents and young adults (AYAs) in the National Longitudinal Study of Adolescent to Adult Health.We classified screen time continuously as self-reported total hours per week of television, videos, and video/computer games at baseline and categorical as extended screen time (≥14 h per week). We fit cross-classified multilevel models (CCMM) and examined the individual-, school- and neighborhood-level demographic and socioeconomic factors associated with screen time. Models were fit using MLwiN with Bayesian estimation procedures.AYAs reported an average of 22.8 (SD = 19.4) and 21.9 (SD = 20.3) hours of screen time, respectively. At the individual level, younger age, male sex, Black/multiracial race, receipt of public assistance, and lower parental education were associated with higher screen time. At the school level, being out of session (i.e., school and national holidays including summer), having a higher proportion of non-White students, and having a lower proportion of parents with a college education were associated with higher individual screen time.We found that individual-level factors most influence youth screen time, with smaller contributions from school factors.
View details for DOI 10.1016/j.ypmed.2020.106357
View details for PubMedID 33301823
Mental Disorder Prevalence Among Populations Impacted by Coronavirus Pandemics: A Multilevel Meta-Analytic Study of COVID-19, MERS & SARS
View details for DOI 10.1101/2020.12.18.20248499
Association of Alternative Tobacco Product Initiation With Ownership of Tobacco Promotional Materials Among Adolescents and Young Adults.
JAMA network open
2019; 2 (5): e194006
Importance: Use of alternative tobacco products (ATPs) such as electronic cigarettes, chewing tobacco, pipes, cigars, cigarillos, little cigars, and hookah is rapidly increasing. Although marketing restrictions exist for cigarettes, marketing of ATPs is not yet fully regulated, and studies have not assessed the association between ownership of ATP promotional materials and subsequent ATP or cigarette initiation among adolescents and young adults.Objective: To estimate the association between marketing receptivity measured at baseline and ATP and any tobacco initiation 1 year later, including cigarettes, among adolescents and young adults.Design, Setting, and Participants: Longitudinal cohort study of adolescents and young adults aged 13 to 19 years recruited at high schools in California from July 2014 to October 2015, with follow-up 1 year later. Data were analyzed from January to March 2018.Exposures: Ownership of ATP-specific promotional material and ownership of any tobacco promotional materials (eg, samples, coupons, branded caps, t-shirts, or posters) assessed in wave 1.Main Outcomes and Measures: Outcomes were (1) ATP initiation and (2) either ATP or cigarette initiation in wave 2.Results: Of 757 participants (mean [SD] age at wave 1, 16.1 [1.1] years; 481 [63.5%] female; 166 [21.9%] Asian or Pacific Islander, 202 [26.7%] white, and 276 [36.4%] Latino), 129 (17.0%) initiated ATP use and 141 (18.6%) initiated ATP or cigarette use 1 year later. In unadjusted models, wave 2 ATP initiation was found to be significantly associated with wave 1 ownership of ATP promotional materials (odds ratio, 2.23; 95% CI, 1.26-3.97). After adjustment for wave 1 demographic covariates, the association between ownership of ATP promotional material and ATP initiation 1 year later yielded similar results (odds ratio, 2.13; 95% CI, 1.16-3.91). Results of models assessing a combined outcome variable of either ATP or cigarette ever use were not statistically significant.Conclusions and Relevance: Ownership of ATP promotional materials was associated with subsequent initiation of ATPs. The results of this study are consistent with the suggestion that current marketing restrictions for cigarettes, including restrictions of the distribution of samples, coupons, and other promotional material, should extend to ATPs.
View details for DOI 10.1001/jamanetworkopen.2019.4006
View details for PubMedID 31099874
Tobacco Retail Density and Initiation of Alternative Tobacco Product Use Among Teens.
The Journal of adolescent health : official publication of the Society for Adolescent Medicine
The rise of noncigarette, alternative tobacco product (ATP) use among adolescents may be due in part to an increase in retail availability of ATPs. We examined whether proximity and density of tobacco retailers near students' homes are associated with a higher likelihood of initiating ATP use over time.Using data from 728 adolescents (aged 13-19 years at baseline) residing in 191 different neighborhoods and attending 10 different California high schools, longitudinal multilevel and cross-classified random effect models evaluated individual-level, neighborhood-level, and school-level risk factors for ATP initiation after 1 year. Covariates were obtained from the American Community Survey and the California Department of Education.The sample was predominantly female (63.5%) and was racially and ethnically diverse. Approximately one third of participants (32.5%) reported ever ATP use at baseline, with 106 (14.5%) initiating ATP use within 1 year. The mean number of tobacco retailers per square mile within a tract was 5.66 (standard deviation = 6.3), and the average distance from each participant's residence to the nearest tobacco retailer was .61 miles (standard deviation = .4). Living in neighborhoods with greater tobacco retailer density at baseline was associated with higher odds of ATP initiation (odds ratio = 1.22, 95% confidence interval = 1.07-2.12), controlling for individual and school factors.Tobacco retailers clustered in students' home neighborhood may be an environmental influence on adolescents' ATP use. Policy efforts to reduce adolescent ATP use should aim to reduce the density of tobacco retailers and limit the proximity of tobacco retailers near adolescents' homes and schools.
View details for DOI 10.1016/j.jadohealth.2019.09.004
View details for PubMedID 31784411
Protecting Youth From the Risks of Electronic Cigarettes.
The Journal of adolescent health : official publication of the Society for Adolescent Medicine
The rapid increase in e-cigarette use among adolescents and young adults has led to drastic changes in patterns of nicotine consumption worldwide. The use of e-cigarettes, many of which contain high levels of nicotine, is especially harmful in this age group and is associated with increased use of cigarettes and other substances among youth. While the risks of short- and long-term e-cigarette use and secondhand aerosol exposure remain only partially understood, e-cigarettes should not be recommended for smoking cessation for youth in any circumstances given the lack of evidence for effectiveness and potential harmful physical and mental health effects. The perceptions of low e-cigarette risk of adolescents and young adults combined with few market regulations and the appeal of youth-friendly flavors, have created ideal conditions for the e-cigarette industry to thrive and place millions of youth at risk of developing an addiction to nicotine. Policies and regulations aiming to prevent youth-directed marketing and sales of e-cigarette and all nicotine delivery products are needed to protect young people. Public health-led education campaigns and educational curricula are also needed to help inform youth and families about the risks of e-cigarette use. While more research is required to determine the best ways to help youth quit e-cigarette use, adolescent health providers can play a key role in screening and counseling youth about e-cigarette use and should be adequately trained and supported to care for youth with e-cigarette addiction.
View details for DOI 10.1016/j.jadohealth.2019.10.007
View details for PubMedID 31780385
Biomarkers of Secondhand Smoke Exposure in Waterpipe Tobacco Venue Employees in Istanbul, Moscow, and Cairo.
Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco
2018; 20 (4): 482–91
Most smoke-free legislation to reduce secondhand smoke (SHS) exposure exempts waterpipe (hookah) smoking venues. Few studies have examined SHS exposure in waterpipe venues and their employees.We surveyed 276 employees of 46 waterpipe tobacco venues in Istanbul, Moscow, and Cairo. We interviewed venue managers and employees and collected biological samples from employees to measure exhaled carbon monoxide (CO), hair nicotine, saliva cotinine, urine cotinine, urine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), and urine 1-hydroxypyrene glucuronide (1-OHPG). We estimated adjusted geometric mean ratios (GMR) of each SHS biomarker by employee characteristics and indoor air SHS measures.There were 73 nonsmoking employees and 203 current smokers of cigarettes or waterpipe. In nonsmokers, the median (interquartile) range concentrations of SHS biomarkers were 1.1 (0.2, 40.9) µg/g creatinine urine cotinine, 5.5 (2, 15) ng/mL saliva cotinine, 0.95 (0.36, 5.02) ng/mg hair nicotine, 1.48 (0.98, 3.97) pg/mg creatinine urine NNAL, 0.54 (0.25, 0.97) pmol/mg creatinine urine 1-OHPG, and 1.67 (1.33, 2.33) ppm exhaled CO. An 8-hour increase in work hours was associated with higher urine cotinine (GMR: 1.68, 95% CI: 1.20, 2.37) and hair nicotine (GMR: 1.22, 95% CI: 1.05, 1.43). Lighting waterpipes was associated with higher saliva cotinine (GMR: 2.83, 95% CI: 1.05, 7.62).Nonsmoking employees of waterpipe tobacco venues were exposed to high levels of SHS, including measurable levels of carcinogenic biomarkers (tobacco-specific nitrosamines and PAHs).Smoke-free regulation should be extended to waterpipe venues to protect nonsmoking employees and patrons from the adverse health effects of SHS.
View details for DOI 10.1093/ntr/ntx125
View details for PubMedID 28582531
View details for PubMedCentralID PMC6350617
Secondhand Tobacco Smoke Exposure Associations With DNA Methylation of the Aryl Hydrocarbon Receptor Repressor
NICOTINE & TOBACCO RESEARCH
2017; 19 (4): 442–51
Cigarette smoking is inversely associated with DNA methylation of the aryl hydrocarbon receptor repressor (AHRR; cg05575921). However, the association between secondhand tobacco smoke (SHS) exposure and AHRR methylation is unknown.DNA methylation of AHRR cg05575921 in CD14+ monocyte samples, from 495 never-smokers and 411 former smokers (having quit smoking ≥15 years) from the Multi-Ethnic Study of Atherosclerosis (MESA), was cross-sectionally compared with concomitantly ascertained self-reported SHS exposure, urine cotinine concentrations, and estimates of air pollutants at participants' homes. Linear regression was used to test for associations, and covariates included age, sex, race, education, study site, and previous smoking exposure (smoking status, time since quitting, and pack-years).Recent indoor SHS exposure (hours per week) was inversely associated with cg05575921 methylation (β ± SE = -0.009 ± 0.003, p = .007). The inverse effect direction was consistent (but did not reach significance) in the majority of stratified analyses (by smoking status, sex, and race). Categorical analysis revealed high levels of recent SHS exposure (≥10 hours per week) inversely associated with cg05575921 methylation (β ± SE = -0.28 ± 0.09, p = .003), which remained significant (p < .05) in the majority of stratified analyses. cg05575921 methylation did not significantly (p < .05) associate with low to moderate levels of recent SHS exposure (1-9 hours per week), urine cotinine concentrations, years spent living with people smoking, years spent indoors (not at home) with people smoking, or estimated levels of air pollutants.High levels of recent indoor SHS exposure may be inversely associated with DNA methylation of AHRR in human monocytes.DNA methylation is a biochemical alteration that can occur in response to cigarette smoking; however, little is known about the effect of SHS on human DNA methylation. In the present study, we evaluated the association between SHS exposure and DNA methylation in human monocytes, at a site (AHRR cg05575921) known to have methylation inversely associated with current and former cigarette smoking compared to never smoking. Results from this study suggest high levels of recent SHS exposure inversely associate with DNA methylation of AHRR cg05575921 in monocytes from nonsmokers, albeit with weaker effects than active cigarette smoking.
View details for DOI 10.1093/ntr/ntw219
View details for Web of Science ID 000402066600008
View details for PubMedID 27613907
View details for PubMedCentralID PMC6075517
The relationship between smoking intensity and subclinical cardiovascular injury: The Multi-Ethnic Study of Atherosclerosis (MESA)
2017; 258: 119–30
Modern tobacco regulatory science requires an understanding of which biomarkers of cardiovascular injury are most sensitive to cigarette smoking exposure.We studied self-reported current smokers from the Multi-Ethnic Study of Atherosclerosis. Smoking intensity was defined by number of cigarettes/day and urinary cotinine levels. Subclinical cardiovascular injury was assessed using markers of inflammation [high-sensitivity C-reactive protein (hsCRP), interleukin 6 & 2 (IL-2 & IL-6), tumor necrosis factor alpha (TNF-α)], thrombosis (fibrinogen, D-dimer, homocysteine), myocardial injury (troponin T; TnT), endothelial damage (albumin: creatinine ratio), and vascular function [aortic & carotid distensibility, flow-mediated dilation (FMD)]. Biomarkers were modeled as absolute and percent change using multivariable-adjusted linear regression models adjusted for cardiovascular risk factors and smoking duration.Among 843 current smokers, mean age was 58 (9) years, 53% were men, 39% were African American, mean number of cigarettes per day was 13 (10), and median smoking duration was 39 (15) years. Cigarette count was significantly associated with higher hsCRP, IL-6 and fibrinogen (β coefficients: 0.013, 0.011, 0.60 respectively), while ln-transformed cotinine was associated with the same biomarkers (β coefficients: 0.12, 0.04, 5.3 respectively) and inversely associated with aortic distensibility (β coefficient: -0.13). There was a limited association between smoking intensity and homocysteine, D-dimer, and albumin:creatinine ratio in partially adjusted models only, while there was no association with IL-2, TNF-α, carotid distensibility, FMD, or TnT in any model. In percent change analyses, relationships were strongest with hsCRP.Smoking intensity was associated with early biomarkers of CVD, particularly, markers of systemic inflammation. Of these, hsCRP may be the most sensitive.
View details for DOI 10.1016/j.atherosclerosis.2017.01.021
View details for Web of Science ID 000397406500016
View details for PubMedID 28237909
View details for PubMedCentralID PMC5404388
Secondhand Smoke Exposure and Subclinical Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis.
Journal of the American Heart Association
2016; 5 (12)
Few studies have evaluated the association between secondhand smoke (SHS) and subclinical cardiovascular disease among ethnically diverse populations. This study assesses the impact of SHS on inflammation and atherosclerosis (carotid intima-media thickness, coronary artery calcification, and peripheral arterial disease).We examined 5032 nonsmoking adults aged 45 to 84 years without prior cardiovascular disease participating in the Multi-Ethnic Study of Atherosclerosis (MESA) from 2000 to 2002. SHS exposure was determined by self-report, and urinary cotinine was measured in a representative subset (n=2893). The multi-adjusted geometric mean ratios (95% CIs) for high-sensitivity C-reactive protein and interleukin-6 comparing 407 participants with SHS ≥12 h/wk versus 3035 unexposed participants were 1.13 (1.02-1.26) and 1.04 (0.98-1.11), respectively. The multi-adjusted geometric mean ratio for carotid intima-media thickness was 1.02 (0.97-1.07). Fibrinogen and coronary artery calcification were not associated with SHS. The prevalence of peripheral arterial disease (ankle-brachial index ≤0.9 or ≥1.4) was associated with detectable urinary cotinine (odds ratio, 2.10; 95% CI, 1.09-4.04) but not with self-reported SHS. Urinary cotinine was not associated with inflammation or carotid intima-media thickness.Despite limited exposure assessment, this study supports the association of SHS exposure with inflammation and peripheral arterial disease.
View details for DOI 10.1161/JAHA.115.002965
View details for PubMedID 27993830
View details for PubMedCentralID PMC5210438
Compliance with smoke-free legislation within public buildings: a cross-sectional study in Turkey
BULLETIN OF THE WORLD HEALTH ORGANIZATION
2016; 94 (2): 92–102
To investigate public compliance with legislation to prohibit smoking within public buildings and the extent of tobacco smoking in outdoor areas in Turkey.Using a standardized observation protocol, we determined whether smoking occurred and whether ashtrays, cigarette butts and/or no-smoking signs were present in a random selection of 884 public venues in 12 cities in Turkey. We visited indoor and outdoor locations in bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. We used logistic regression models to determine the association between the presence of ashtrays or the absence of no-smoking signs and the presence of individuals smoking or cigarette butts.Most venues had no-smoking signs (629/884). We observed at least one person smoking in 145 venues, most frequently observed in bars/nightclubs (63/79), hospital dining areas (18/79), traditional coffee houses (27/120) and government-building dining areas (5/23). For 538 venues, we observed outdoor smoking close to public buildings. The presence of ashtrays was positively associated with indoor smoking and cigarette butts, adjusted odds ratio, aOR: 315.9; 95% confidence interval, CI: 174.9-570.8 and aOR: 165.4; 95% CI: 98.0-279.1, respectively. No-smoking signs were negatively associated with the presence of cigarette butts, aOR: 0.5; 95% CI: 0.3-0.8.Additional efforts are needed to improve the implementation of legislation prohibiting smoking in indoor public areas in Turkey, especially in areas in which we frequently observed people smoking. Possible interventions include removing all ashtrays from public places and increasing the number of no-smoking signs.
View details for DOI 10.2471/BLT.15.158238
View details for Web of Science ID 000372674200006
View details for PubMedID 26908959
View details for PubMedCentralID PMC4750436
Secondhand smoke in waterpipe tobacco venues in Istanbul, Moscow, and Cairo.
2015; 142: 568-74
The prevalence of waterpipe tobacco smoking has risen in recent decades. Controlled studies suggest that waterpipe secondhand smoke (SHS) contains similar or greater quantities of toxicants than cigarette SHS, which causes significant morbidity and mortality. Few studies have examined SHS from waterpipe tobacco in real-world settings. The purpose of this study was to quantify SHS exposure levels and describe the characteristics of waterpipe tobacco venues.In 2012-2014, we conducted cross-sectional surveys of 46 waterpipe tobacco venues (9 in Istanbul, 17 in Moscow, and 20 in Cairo). We administered venue questionnaires, conducted venue observations, and sampled indoor air particulate matter (PM2.5) (N=35), carbon monoxide (CO) (N=23), particle-bound polycyclic aromatic hydrocarbons (p-PAHs) (N=31), 4-methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) (N=43), and air nicotine (N=46).Venue characteristics and SHS concentrations were highly variable within and between cities. Overall, we observed a mean (standard deviation (SD)) of 5 (5) waterpipe smokers and 5 (3) cigarette smokers per venue. The overall median (25th percentile, 75th percentile) of venue mean air concentrations was 136 (82, 213) µg/m(3) for PM2.5, 3.9 (1.7, 22) ppm for CO, 68 (33, 121) ng/m(3) for p-PAHs, 1.0 (0.5, 1.9) ng/m(3) for NNK, and 5.3 (0.7, 14) µg/m(3) for nicotine. PM2.5, CO, and p-PAHs concentrations were generally higher in venues with more waterpipe smokers and cigarette smokers, although associations were not statistically significant.High concentrations of SHS constituents known to cause health effects indicate that indoor air quality in waterpipe tobacco venues may adversely affect the health of employees and customers.
View details for DOI 10.1016/j.envres.2015.08.012
View details for PubMedID 26298558
View details for PubMedCentralID PMC4609287