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The Newsletter of the Pacific Institute for Research and Evaluation OCTOBER 2017  



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PIRE News Staff
  • Joey Dacanay – Designer & Production
  • Jill Dougherty – Editor & Production
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Contributors to this Issue
  • Katie Carr
  • Elinam Dellor
  • Laura Finan
  • Elise Trott Jaramillo
  • Diane McKnight
  • Ted Miller
  • Roland Moore
  • Bernie Murphy
  • Julie Murphy
  • Eduardo Romano
  • Sue Thomas
  • Rebecca Yau


July 2017 – September 2017

(Articles listed are either accepted and published or in publication)

Alexandridis, AA, McCort, A, Ringwalt, CL, Sachdeva, N, Sanford, C, Marshall, SW, Mack, K, Dasgupta, N, 2017 A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina Injury Prevention, doi: 10.1136/injuryprev 2017 042396 Impact Factor: 1.693 Abstract

Background: In response to increasing opioid overdoses, US prevention efforts have focused on prescriber education and supply, demand and harm reduction strategies. Limited evidence informs which interventions are effective. We evaluated Project Lazarus, a centralised statewide intervention designed to prevent opioid overdose. Methods: Observational intervention study of seven strategies. 74 of 100 North Carolina counties implemented the intervention. Dichotomous variables were constructed for each strategy by county-month. Exposure data were: process logs, surveys, addiction treatment interviews, prescription drug monitoring data. Outcomes were: unintentional and undetermined opioid overdose deaths, overdose-related emergency department (ED) visits. Interrupted time-series Poisson regression was used to estimate rates during preintervention (2009-2012) and intervention periods (2013-2014). Adjusted IRR controlled for prescriptions, county health status and time trends. Time-lagged regression models considered delayed impact (0-6 months). Results: In adjusted immediate-impact models, provider education was associated with lower overdose mortality (IRR 0.91; 95%?CI 0.81 to 1.02) but little change in overdose-related ED visits. Policies to limit ED opioid dispensing were associated with lower mortality (IRR 0.97; 95%?CI 0.87 to 1.07), but higher ED visits (IRR 1.06; 95%?CI 1.01 to 1.12). Expansions of medication-assisted treatment (MAT) were associated with increased mortality (IRR 1.22; 95%?CI 1.08 to 1.37) but lower ED visits in time-lagged models. Conclusions: Provider education related to pain management and addiction treatment, and ED policies limiting opioid dispensing showed modest immediate reductions in mortality. MAT expansions showed beneficial effects in reducing ED-related overdose visits in time-lagged models, despite an unexpected adverse association with mortality.

Ally, Elizabeth Z., Laranjeira, Ronaldo, Viana, Maria C., Pinsky, Ilana, Caetano, Raul, Mitsuhiro, Sandro, Madruga, Clarice S., 2016 Intimate partner violence trends in Brazil: data from two waves of the Brazilian National Alcohol and Drugs Survey Revista Brasileira de Psiquiatria, 38 (2), 98-105. doi: 10.1590/1516-4446-2015-1798 Impact Factor: 2.049 Abstract

Objective: To compare intimate partner violence (IPV) prevalence rates in 2006 and 2012 in a nationally representative household sample in Brazil. The associations between IPV and substance use were also investigated. Methods: IPV was assessed using the Conflict Tactic Scale-R in two waves (2006/2012) of the Brazilian Alcohol and Drugs Survey. Weighted prevalence rates and adjusted logistic regression models were calculated. Results: Prevalence rates of IPV victimization decreased significantly, especially among women (8.8 to 6.3%). The rates of IPV perpetration also decreased significantly (10.6 to 8.4% for the overall sample and 9.2 to 6.1% in men), as well as the rates of bidirectional violence (by individuals who were simultaneously victims and perpetrators of violence) (3.2 to 2.4% for the overall sample). Alcohol increased the likelihood of being a victim (odds ratio [OR] = 1.6) and perpetrator (OR = 2.4) of IPV. Use of illicit drugs increased up to 4.5 times the likelihood of being a perpetrator. Conclusions: In spite of the significant reduction in most types of IPV between 2006 and 2012, violence perpetrated by women was not significantly reduced, and the current national rates are still high. Further, this study suggests that use of alcohol and other psychoactive drugs plays a major role in IPV. Prevention initiatives must take drug misuse into consideration.

Berey, Benjamin, Loparco, Cassidy, Leeman, Robert, Grube, Joel, 2017 The Myriad Influences of Alcohol Advertising on Adolescent Drinking Current Addiction Reports, 4 (2), 172-183. Impact Factor: N/A Abstract

This review investigates effects of alcohol advertising on adolescent drinking. Prior reviews focused on behavioral outcomes and long-term effects. In contrast, the present review focuses on subgroups with greater exposure to alcohol advertising, research methods to study alcohol advertising, potential mechanisms underlying relationships between adolescent exposure to alcohol advertising, and increased drinking and points to prevention/intervention strategies that may reduce effects of alcohol advertising. Alcohol advertising influences current and future drinking. Further, evidence suggests that adolescents may be targeted specifically. Alcohol advertisements may influence behavior by shifting alcohol expectancies, norms regarding alcohol use, and positive attitudes. Media literacy programs may be an effective intervention strategy. Adolescents are exposed to large quantities of alcohol advertisements, which violate guidelines set by the alcohol industry. However, media literacy programs may be a promising strategy for adolescents to increase critical thinking and create more realistic expectations regarding alcohol.

Bersamin, M. M., Fisher, D. A., Gaidus, A. J., Gruenewald, P. J., 2016 School-based health centers’ presence: The role of school and community factors American Journal of Preventive Medicine, 51 (6), 926-932. doi: http://dx.doi.org/10.1016/j.amepre.2016.06.025 Impact Factor: 4.46 Abstract

Introduction: School-based health centers (SBHCs) offer an efficient mechanism for delivering health services to large numbers of underserved youth; however, their availability varies across communities. Data on sociocontextual variables were analyzed to investigate factors that inhibit and facilitate SBHCs. Methods: Secondary data from 2012 to 2015 state databases were linked to examine the association between SBHCs’ presence in California high schools and demand, resource, and political conservatism at the school and community levels that may influence where SBHCs are located and the number of provided health services. Data were analyzed in 2015 using hierarchical binary and Poisson models. Results: Presence of a local non-school-based family planning clinic was the strongest correlate of SBHC presence. School size, percentage non-white, and percentage receiving free or reduced-price lunches were positively associated with SBHC presence. Percentage who voted Republican in the 2012 general election and teen pregnancy rates were negatively associated with SBHC presence. None of the predictors were associated with number of services provided by SBHCs. Conclusions: School and community factors appear to play a role in supporting or impeding the establishment of SBHCs. In addition to variables tapping communities’ need for and resources available to support SBHCs, political conservatism appears to affect SBHC availability. SBHC advocates can use this information to understand where opportunities for growth might exist, identify collaborative partners, and prepare for challenges to supporting new SBHCs. Researchers may also use this information in evaluation studies to control for school-level confounders and develop appropriate comparison samples through matching procedures.

Caetano, Raul, 2015 A decade after NESARC: What has it told us? Addiction, 110 (3), 375-377. doi: 10.1111/add.12627 Impact Factor: 4.97 Abstract

The National Epidemiologic Study of Alcohol Related Conditions (NESARC) is a random sample survey of the United States population conducted in two waves by researchers at the Laboratory of Epidemiology and Biometry of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). NESARC I (2001–02) interviewed 43 093 individuals in the United States aged 18 years and older. NESARC II (2004–05) re-interviewed 34 653 respondents from wave I. This editorial will identify some important contributions made by the various analyses of data collected in NESARC; it will discuss controversial decisions about methods employed in the survey; and it will discuss how some of those controversies could potentially have been addressed.

Caetano, Raul, Kaplan, Mark S., Huguet, Nathalie, Conner, Kenneth, McFarland, Bentson H., Giesbrecht, Norman, Nolte, Kurt B., 2015 Precipitating circumstances of suicide and alcohol intoxication among U.S. Ethnic groups Alcoholism: Clinical and Experimental Research, 39 (8), 1510-1517. doi: 10.1111/acer.12788 Impact Factor: 2.53 Abstract

Background: Our goal was to assess the prevalence of 9 different types of precipitating circumstances among suicide decedents, and examine the association between circumstances and postmortem blood alcohol concentration (BAC = 0.08 g/dl) across U.S. ethnic groups. Methods: Data come from the restricted 2003 to 2011 National Violent Death Reporting System, with postmortem information on 59,384 male and female suicide decedents for 17 U.S. states. Results: Among men, precipitating circumstances statistically associated with a BAC = 0.08 g/dl were physical health and job problems for Blacks, and experiencing a crisis, physical health problems, and intimate partner problem for Hispanics. Among women, the only precipitating circumstance associated with a BAC = 0.08 g/dl was substance abuse problems other than alcohol for Blacks. The number of precipitating circumstances present before the suicide was negatively associated with a BAC = 0.08 g/dl for Whites, Blacks, and Hispanics. Conclusions: Selected precipitating circumstances were associated with a BAC = 0.08 g/dl, and the strongest determinant of this level of alcohol intoxication prior to suicide among all ethnic groups was the presence of an alcohol problem.

Caetano, Raul, Mills, Britain, Madruga, Clarice, Pinsky, Ilana, Laranjeira, Ronaldo, 2015 Discrepant trends in income, drinking, and alcohol problems in an emergent economy: Brazil 2006 to 2012 Alcoholism, Clinical And Experimental Research, 39 (5), 863-871. doi: 10.1111/acer.12692 Impact Factor: 2.53 Abstract

Background: To examine the association between increases in income and self-reported alcohol consumption, binge drinking, and alcohol problems in 2006 and 2012 in Brazil. Methods: Participants were interviewed as part of 2 multistage representative cluster samples of the Brazilian household population between November 2005 and April 2006 and between November 2011 and March 2012. The number of current drinkers during these 2 intervals (n = 1,379 and n = 1,907, respectively) comprised the sample analyzed. Four past-year outcome variables-standard drinks per week, binge drinking, presence of alcohol-related social/health problems, and DSM-5 alcohol use disorder (AUD)-were estimated across income, age, and gender groups. Regression models were estimated to evaluate these and other sociodemographic effects on drinking and problem outcomes and to test for possible wave by income interactions. Results: Response rates were 66.4% in 2006 and 77% in 2012. Income increases were seen in virtually all age-gender subgroups and were particularly pronounced for younger age groups and older women. Both genders reported increased drinks per week (men: 12.82, 2006; 15.78, 2012; p < 0.01; women: 4.89, 2006; 7.66, 2012; p < 0.001) and proportion binge drinking (men: 57%, 2006; 66%, 2012; p < 0.05; women: 39%, 2006; 48%, 2012; p < 0.05), although this was not seen in all gender and age groups. Social/health problem prevalence decreased among men (37%, 2006; 26%, 2012; p < 0.001) and remained the same among women (13%, 2006; 14%, 2012). DSM-5 AUD decreased among men (34%, 2006; 24%, 2012; p < 0.01) and remained stable among women (14%, 2006; 16%, 2012). Conclusions: Brazilian economic development between 2006 and 2012 led to a rise in income in several gender and age groups. Although not always directly associated with an observed increase in alcohol consumption, the rise in income may have created a sense of optimism that inhibited a rise in alcohol-related problems.

Caetano, Raul, Vaeth, Patrice A. C., Canino, Glorisa, 2016 Prevalence and predictors of drinking, binge drinking, and related health and social problems in Puerto Rico The American Journal on Addictions, 25 (6), 478-485. doi: 10.1111/ajad.12418 Impact Factor: 1.77 Abstract

Background: This paper examines prevalence and predictors of drinking, binge drinking, and alcohol-related social and health problems in Puerto Rico. Methods: Respondents constitute a multi-stage household probability sample (N = 1,510) from San Juan, Puerto Rico. The response rate was 83%. Results: Men compared to women (Coeff: .34; 95 CI = .19–.50; p < .001), those with more liberal norms (Coeff: 1.05; 95 CI = .87–1.23; p < .001) and those with more positive attitudes about drinking (Coeff: 1.06; 95 CI= .63–1.49; p < .001) have a higher average number of weekly drinks. Those in the 40–49 age group have a lower mean number of weekly drinks than those in the 18–29 age group (Coeff.: -.23; 95 CI = -.42–.03; p < .02). Those with income between $30,001 and $40,000 a year compared to those with less than $10,000, (OR: .28; 95 CI = .08–1.93; p < .039) report fewer social/health problems. Protestants compared to Catholics (AOR: 1.94; 95 CI = 1.08–3.47; p < .026), those with more liberal drinking norms (AOR: 3.62; 95 CI = 1.87–6.99; p < .001) and more positive attitudes about drinking (AOR: 3.41; 95 CI = 1.04–11.09; p < .001), and those who consume a higher number of drink per week (AOR: 1.03; 95 CI = 1.01–1.05; p < .001) and binge (AOR: 3.52; 95 CI = 2.14–5.80; p < .001) are more likely to report social and health problems associated with alcohol use. Discussion and Conclusions: The finding that male gender is not associated with binge drinking and social and health problems was not expected. Puerto Ricans appear to drink less than the general population and Hispanics and Puerto Ricans on the U.S. mainland. Scientific Significance: Up to date epidemiological findings provide information about high risk groups and correlates of alcohol problems in the population. These are now available for Puerto Rico and can be used in the design of prevention interventions.

Caetano, Raul, Vaeth, Patrice A. C., Canino, Glorisa, 2017 Family cohesion and pride, drinking and alcohol use disorder in Puerto Rico The American Journal Of Drug And Alcohol Abuse, 43 (1), 87-94. Impact Factor: 1.82 Abstract

Background: The extended multigenerational family is a core value of Hispanic culture. Family cohesion/pride can have protective effects on drinking- and drug-use-related behavior among Hispanics. Objectives: To examine the association between family cohesion/pride, drinking, binge drinking, and DSM-5 alcohol use disorder (AUD) in Puerto Rico. Methods: Data are from a household random sample of 1510 individuals 18–64 years of age in San Juan, Puerto Rico. Results: Bivariate analyses showed that family cohesion/pride was not associated with the average number of drinks consumed per week but was associated with binge drinking among men. Family cohesion/pride was also associated with DSM-5 AUD. Results of the multivariate analyses were consistent with these bivariate results for DSM-5 AUD. Respondents with low (OR = 2.2, 95CL = 1.21–3.98; p< .01) and medium (OR = 1.88; 95CL = 1.12–3.14; p< .01) family cohesion/pride were more likely than those with high family cohesion/pride to have a positive diagnosis of DSM-5 AUD. More liberal drinking norms and positive attitudes toward drinking were also strong predictors of the average number of drinks consumed per week. More liberal drinking norms also predicted binge drinking, and DSM-5 AUD. Conclusions: Higher family cohesion/pride may have a protective effect against DSM-5 AUD. This may have practical implications for clinical and prevention programs. As long as high cohesion is not enabling drinking, these programs can enhance and support family cohesion/pride to help clients in treatment and recovery and prevent drinking problems.

Caetano, Raul, Vaeth, Patrice A. C., Mills, Britain, Canino, Glorisa, 2016 Employment status, depression, drinking, and alcohol use disorder in Puerto Rico Alcoholism: Clinical and Experimental Research, 40 (4), 806-815. doi: 10.1111/acer.13020 Impact Factor: 2.53 Abstract

Background: Our aim was to examine the association between employment status, depression, drinking, binge drinking, and DSM-5 alcohol use disorder in Puerto Rico. Methods: Data are from a 2013 to 2014 household random sample of individuals 18 to 64 years of age in San Juan, Puerto Rico. Results: Bivariate analyses showed that depression was 5 times higher among unemployed males than among those employed full time (21% vs. 4%) and 2 times higher among unemployed females compared to those employed part time or full time (18% vs. 7% and 9%). Employment status was not associated with weekly volume of drinking, but nonparticipation in the workforce was protective against drinking (odds ratio [OR] = 2.17; 95% confidence interval [CI]: 1.03 to 4.57; p < 0.05) and binge drinking (OR = 0.62; 95% CI = 0.39 to 0.97; p < 0.05). This association could be due to the fact that those not in the work force may not be working due to sickness or disability. Male gender was a factor of risk for being a current drinker (OR = 2; 95% CI = 1.53 to 2.6; p < 0.001) and binge drinking (OR = 1.69; 95% CI = 1.29 to 2.2; p < 0.001). Male gender was protective against depression (OR = 0.32; 95% CI = 0.14 to 0.73; p < 0.01), but males employed only part time were almost 5 times more likely than females employed full time to be depressed (OR = 4.66; 95% CI = 1.25 to 17.38; p < 0.05). Conclusions: Employment status in Puerto Rico is associated with depression and with current drinking, but not with other alcohol-related outcomes. Perhaps Puerto Rico is a 'wet' environment, where drinking is already at a relatively high level that is not affected by employment status. Perhaps the chronic high rate of unemployment in the island has also created familial (e.g., support) and personal level accommodations (e.g., participation in the informal economy) that do not include increased drinking.

Caetano, Raul, Vaeth, Patrice A. C., Santiago, Katyana, Canino, Glorisa, 2016 The dimensionality of DSM5 alcohol use disorder in Puerto Rico Addictive Behaviors, 6220-24. doi: 10.1016/j.addbeh.2016.06.011 Impact Factor: 2.79 Abstract

Aims: To test the dimensionality and measurement properties of lifetime DSM-5 AUD criteria in a sample of adults from the metropolitan area of San Juan, Puerto Rico. Design: Cross-sectional study with survey data collected in 2013–2014. Setting: General population. Participants: Random household sample of the adult population 18 to 64 years of age in San Juan, Puerto Rico (N = 1510; lifetime drinker N = 1107). Measurement: DSM-5 alcohol use disorder (2 or more criteria present in 12 months). Results: Lifetime reports of AUD criteria were consistent with a one-dimensional model. Scalar measurement invariance was observed across gender, but measurement parameters for tolerance varied across age, with younger ages showing a lower threshold and steeper loading. Conclusions: Results provide support for a unidimensional DSM-5 AUD construct in a sample from a Latin American country.

Carlson, Nancy N., Holcomb-McCoy, Cheryl, Miller, Ted R., 2017 School counselors’ knowledge and involvement concerning gifted and talented students Journal of Counselor Leadership and Advocacy, 4 (2), 89-101. doi: 10.1080/2326716x.2017.1294122 Impact Factor: N/A Abstract

This study explored school counselors' self-reported knowledge and involvement with gifted and talented (GT) students. A survey instrument was developed and completed by 328 school counselors. Principal factor analysis with oblimin rotation identified two dimensions underlying the construct of knowledge and three dimensions underlying the construct of involvement, one of which was "advocacy." General GT knowledge was associated with all aspects of involvement, and identification knowledge was associated with advocacy.

Chartier, Karen G., Miller, Kierste, Harris, T. Robert, Caetano, Raul, 2016 A 10-year study of factors associated with alcohol treatment use and non-use in a U.S. population sample Drug and Alcohol Dependence, 160205-211. doi: 10.1016/j.drugalcdep.2016.01.005 Impact Factor: 3.349 Abstract

Background: This study seeks to identify changes in perceived barriers to alcohol treatment and predictors of treatment use between 1991–92 and 2001–02, to potentially help understand reported reductions in treatment use at this time. Social, economic, and health trends during these 10 years provide a context for the study. Methods: Subjects were Whites, Blacks, and Hispanics. The data were from the National Longitudinal Alcohol Epidemiologic Survey (NLAES) and the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). We conducted two analyses that compared the surveys on: (1) perceived treatment barriers for subjects who thought they should get help for their drinking, and (2) variables predicting past-year treatment use in an alcohol use disorder subsample using a multi-group multivariate regression model. Results: In the first analysis, those barriers that reflected negative beliefs and fears about seeking treatment as well as perceptions about the lack of need for treatment were more prevalent in 2001–02. The second analysis showed that survey year moderated the relationship between public insurance coverage and treatment use. This relationship was not statistically significant in 1991–92 but was significant and positive in 2001–02, although the effect of this change on treatment use was small. Conclusions: Use of alcohol treatment in the U.S. may be affected by a number of factors, such as trends in public knowledge about treatment, social pressures to reduce drinking, and changes in the public financing of treatment.

Cochran, Gerald, Field, Craig, DiClemente, Carlo, Caetano, Raul, 2016 Latent Classes Among Recipients of a Brief Alcohol Intervention: A Replication Analysis Behavioral Medicine, 42 (1), 29-38. Impact Factor: 2.390 Abstract

The purpose of this study was to identify differential improvement in alcohol use among injured patients following brief intervention. Latent class analysis was conducted to identify patient profiles based on alcohol-related risk from two clinical trials (Texas: N= 737; Maryland: N= 250) conducted in Level-1 trauma centers. Drinking was analyzed to detect improvements at 6 and 12 months. The four classes that emerged from Maryland participants were similar to four of the five classes from Texas. Increases in both studies for days abstinent were reported by classes characterized by multiple risks and minimal risks. Decreases in volume consumed for both studies were also reported by classes characterized by multiple risks and minimal risks. By classifying patients according to alcohol-related risk, providers may be able to build on positive prognoses for drinking improvements or adapt interventions to better serve those likely to improve less.

Conner, Kenneth R., Lathrop, Sarah, Caetano, Raul, Silenzio, Vincent, Nolte, Kurt B., 2016 Blood Alcohol Concentrations in Suicide and Motor Vehicle Crash Decedents Ages 18 to 54 Alcoholism, Clinical And Experimental Research, 40 (4), 772-775. doi: 10.1111/acer.13002 Impact Factor: 2.53 Abstract

Background: Using postmortem data, we examined the hypotheses that high (and very high) blood alcohol concentrations (BACs) are more common among motor vehicle crash decedents (MVCs) than among suicide decedents, whereas low alcohol levels are more common among suicides. Methods: We examined BAC in 224 suicide decedents and 166 MVCs ages 18 to 54 in the state of New Mexico in 2012. Comparisons between the groups were made based on differing BAC levels using 0.080 g/dl categories including low (0.001 to 0.079 g/dl), high (0.080 to 0.159 g/dl), and very high BAC (=0.160 g/dl), and based on 0.100 g/dl categories including low (0.001 to 0.099 g/dl), high (0.100 to 0.199 g/dl), and very high BAC (=0.200 g/dl), with these groups compared with a no-alcohol reference (0.000 g/dl) in separate analyses. Multivariate logistic regressions compared suicides with MVCs that adjusted for age, sex, and race/ethnicity. Results: Support for the hypothesis that suicides are more likely to have a low BAC level was supported in the analysis using the 0.100 g/dl categorizations. Neither analysis supported the hypothesis that MVCs are more likely to have high (or very high) BACs compared with suicides. Among both injury groups with positive BACs, low BACs were least common. Conclusions: Low BAC levels may be more likely to be observed among suicides compared with MVCs, a possible reflection of the more varied role that alcohol plays in suicide compared with MVC. Nonetheless, high (and very high) BAC is the predominant scenario in both suicides and MVCs with positive BAC.

Cunradi, Carol B., Moore, Roland S., Battle, Robynn S., 2017 Prevalence and Correlates of Current and Former Smoking among Urban Transit Workers Safety and Health at Work, (Preprints), Impact Factor: N/A Abstract

Transit workers constitute a blue-collar occupational group that have elevated smoking rates relative to other sectors of employed adults in the United States. This study analyzed cross-sectional tobacco survey data from 935 workers (60% African American; 37% female) employed at an urban public transit agency in California. Prevalence of current and former smoking was 20.3% and 20.6%, respectively. Younger workers were less likely than older workers to be current or former smokers. Having a complete home smoking ban was associated with decreased likelihood of being a smoker [odds ratio (OR)=0.04, 95% confidence interval (CI)=0.01–0.17], as were neutral views about whether it is easy for a smoker to take a smoking break during their shift (OR=0.50, 95% CI 0.28–0.88). Current smoking among the sample is > 50% higher than the adult statewide prevalence. Potential points of intervention identified in this study include perceived ease of worksite smoking breaks and establishing home smoking bans. Tailored cessation efforts focusing on older transit workers more likely to smoke are needed to reduce tobacco-related disparities in this workforce.

Ehlers, Cindy L., Kim, Corinne, Gilder, David A., Stouffer, Gina M., Caetano, Raul, Yehuda, Rachel, 2016 Lifetime history of traumatic events in a young adult Mexican American sample: Relation to substance dependence, affective disorder, acculturation stress, and PTSD Journal of Psychiatric Research, 8379-85. doi: 10.1016/j.jpsychires.2016.08.009 Impact Factor: 3.301 Abstract

Mexican Americans comprise one of the most rapidly growing populations in the United States, and within this population, trauma and post-traumatic stress disorder (PTSD) are associated with physical and mental health problems. Therefore, efforts to delineate factors that may uniquely contribute to increased likelihood of trauma, PTSD, and substance use disorders over the lifetime in Mexican Americans are important to address health disparities and to develop treatment and prevention programs. Six hundred fourteen young adults (age 18–30 yrs) of Mexican American heritage, largely second generation, were recruited from the community and assessed with the Semi-Structured Assessment for the Genetics of Alcoholism and an acculturation stress scale. More males (51.2%) reported experiencing traumas than females (41.1%), however, a larger proportion of females received a PTSD diagnosis (15%) than males (8%). Alcohol dependence and affective disorders, but not anxiety disorders, antisocial disorders, nicotine, marijuana, or stimulant dependence, were significantly comorbid with PTSD. Endorsing higher levels of acculturation stress was also significantly associated with both trauma exposure and a diagnosis of PTSD. Logistic regression revealed that female gender, having an affective disorder, alcohol dependence, higher levels of acculturation stress, and lower levels of education were all predictors of PTSD status. Additionally, alcohol dependence generally occurred after the PTSD diagnosis in early adulthood in this high-risk population. These studies suggest that treatment and prevention efforts should particularly focus on young adult second generation Mexican American women with higher levels of acculturation stress, who may be at higher risk for PTSD, affective disorder, and alcohol dependence following trauma exposure.

Emerson, Marc A., Moore, Roland S., Caetano, Raul, 2017 Association between lifetime posttraumatic stress disorder and past year alcohol use disorder among American Indians/Alaska Natives and non-Hispanic Whites Alcoholism: Clinical and Experimental Research, 41 (3), 576-584. doi: 10.1111/acer.13322 Impact Factor: 2.53 Abstract

Background: Posttraumatic stress disorder (PTSD) and alcohol use disorder disproportionately impact certain populations including American Indians/Alaska Natives (AIAN). While PTSD and alcohol use disorder have been studied both separately and in tandem, less is known about the association in AIAN. The objective was to examine the association between lifetime PTSD and past year alcohol use disorder among AIAN and non-Hispanic Whites (NHW). Methods: Data come from the 2012 to 2013 U.S. National Epidemiologic Survey on Alcohol and Related Conditions-III. We used logistic regression to estimate odds of AUD among adults with and without PTSD by race. Results: A total of 19,705 participants, of whom 511 were AIAN and 19,194 were NHW, were included in this study. The percentage of PTSD among AIAN was 22.9% (n = 117) compared to 11.7% (n = 2,251) in NHW (p-value < 0.0001). The percentage of past year alcohol use disorder among AIAN was 20.2% (n = 103) compared to 14.2% (n = 2,725) in NHW (p-value < 0.0001). The percentage of comorbid past year alcohol use disorder with lifetime PTSD among AIAN was 6.5% (n = 33) compared to 2.4% (n = 457) in NHW (p-value < 0.0001). Regarding the joint distribution of PTSD and AUD, AIAN men have greater than 3 times the percentage compared to NHW men (9.5% vs. 3.1%). When stratifying by race (after adjusting for age, sex, depression, and education), among AIAN, the odds of past year alcohol use disorder with (vs. without) lifetime PTSD were 1.76 (95% CI 1.07, 2.90) and among NHW, the odds were 1.59 (95% CI 1.41, 1.80). Conclusions: PTSD is significantly associated with alcohol use disorder in the study populations. Despite a lack of pre-PTSD measures of alcohol use disorder, these findings show a trend indicating that AIAN exposed to PTSD are more burdened with alcohol use disorder compared to NHW in the general U.S. population.

Fell, James C., Scherer, M., 2017 Administrative license suspension: Does length of suspension matter? Traffic Injury Prevention, 18 (6), 577-584. doi: 10.1080/15389588.2017.1293257 Impact Factor: 1.14 Abstract

Administrative license revocation (ALR) laws, which provide that the license of a driver with a blood alcohol concentration at or over the illegal limit is subject to an immediate suspension by the state department of motor vehicles, are an example of a traffic law in which the sanction rapidly follows the offense. The power of ALR laws has been attributed to how swiftly the sanction is applied, but does the length of suspension matter? Objectives: Our objectives were to (a) determine the relationship of the ALR suspension length to the prevalence of drinking drivers relative to sober drivers in fatal crashes and (b) estimate the extent to which the relationship is associated to the general deterrent effect compared to the specific deterrent effect of the law. Methods: Data comparing the impact of ALR law implementation and ALR law suspension periods were analyzed using structural equation modeling techniques on the ratio of drinking drivers to nondrinking drivers in fatal crashes from the Fatality Analysis Reporting System (FARS). Results: States with an ALR law with a short suspension period (1-30 days) had a significantly lower drinking driver ratio than states with no ALR law. States with a suspension period of 91-180 days had significantly lower ratios than states with shorter suspension periods, while the three states with suspension lengths of 181 days or longer had significantly lower ratios than states with shorter suspension periods. Discussion: The implementation of any ALR law was associated with a 13.1% decrease in the drinking/nondrinking driver fatal crash ratio but only a 1.8% decrease in the intoxicated/nonintoxicated fatal crash ratio. The ALR laws and suspension lengths had a significant general deterrent effect, but no specific deterrent effect. Practical Implications: States might want to keep (or adopt) ALR laws for their general deterrent effects and pursue alternatives for specific deterrent effects. States with short ALR suspension periods should consider lengthening them to 91 days or longer.

Ferreira-Borges, Carina, Dias, Sonia, Babor, Thomas, Esser, Marissa B., Parry, Charles D. H., 2015 Alcohol and public health in Africa: Can we prevent alcohol-related harm from increasing? Addiction, 110 (9), 1373-1379. doi: 10.1111/add.12916 Impact Factor: 4.97 Abstract

Aims: According to the World Health Organization (WHO), the total amount of alcohol consumed in the African region is expected to increase due to the growth of new alcohol consumers, especially young people and women. With the changing alcohol environment, increases in the alcohol-attributable burden of disease are inevitable. To our knowledge, there has not been a comprehensive analysis of the factors that could be driving those increases. The objective of this study was to examine the evidence from peer reviewed literature regarding the factors that could be instrumental in this process, in order to inform strategic policy-related decisions. Method: A narrative review was conducted using a thematic analysis approach. We searched papers published between January 2000 and July 2014 in PubMed, the WHO's Global Health Library and African Journals Online. Results: Our analysis identified seven factors (demographics, rapid urbanization, economic development, increased availability, corporate targeting, weak policy infrastructure and trade agreements) which are potentially tied to changes in alcohol consumption in Africa. Driven largely by globalization, a potential convergence of these various factors is likely to be associated with continued growth in alcohol consumption and alcohol-related morbidity and mortality. Conclusions: To address the emerging risk factors associated with increased alcohol consumption, African governments need to take a more active role in protecting the public's health. In particular, important strategic shifts are needed to increase implementation of intersectoral strategies, community involvement in the policy dialogue, health services re-orientation and better regulation of the alcohol beverage industry.

Field, Craig, Cabriales, José, Woolard, Robert, Tyroch, Alan, Caetano, Raul, Castro, Yessenia, 2015 Cultural adaptation of a brief motivational intervention for heavy drinking among Hispanics in a medical setting BMC Public Health, 15 (1), 1-12. Impact Factor: 2.265 Abstract

Hispanics, particularly men of Mexican origin, are more likely to engage in heavy drinking and experience alcohol-related problems, but less likely to obtain treatment for alcohol problems than non-Hispanic men. Our previous research indicates that heavy-drinking Hispanics who received a brief motivational intervention (BMI) were significantly more likely than Hispanics receiving standard care to reduce subsequent alcohol use. Among Hispanics who drink heavily the BMI effectively reduced alcohol use but did not impact alcohol-related problems or treatment utilization. We hypothesized that an adapted BMI that integrates cultural values and addresses acculturative stress among Hispanics would be more effective. We describe here the protocol for the design and implementation of a randomized (approximately 300 patients per condition) controlled trial evaluating the comparative effectiveness of a culturally adapted (CA) BMI in contrast to a non-adapted BMI (NA-BMI) in a community hospital setting among men of Mexican origin. Study participants will include men who were hospitalized due to an alcohol related injury or screened positive for heavy drinking. By accounting for risk and protective factors of heavy drinking among Hispanics, we hypothesize that CA-BMI will significantly decrease alcohol use and alcohol problems, and increase help-seeking and treatment utilization. This is likely the first study to directly address alcohol related health disparities among non-treatment seeking men of Mexican origin by comparing the benefits of a CA-BMI to a NA-BMI. This study stands to not only inform interventions used in medical settings to reduce alcohol-related health disparities, but may also help reduce the public health burden of heavy alcohol use in the United States.

Gaither, T. W., Sanford, T. A., Miller, T. R., Awad, M. A., Osterberg, E. C., Murphy, G. P., Lawrence, B. A., Breyer, B. N., 2017 Estimated total costs from non-fatal and fatal bicycle crashes in the USA: 1997-2013 Injury Prevention, doi: 10.1136/injuryprev-2016-042281 Impact Factor: 1.693 Abstract

Introduction: Emergency department visits and hospital admissions resulting from adult bicycle trauma have increased dramatically. Annual medical costs and work losses of these incidents last were estimated for 2005 and quality-of-life losses for 2000. Methods: We estimated costs associated with adult bicycle injuries in the USA using 1997-2013 non-fatal incidence data from the National Electronic Injury Surveillance System with cost estimates from the Consumer Product Safety Commission's Injury Cost Model, and 1999-2013 fatal incidence data from the National Vital Statistics System costed by similar methods. RESULTS: Approximately 3.8 million non-fatal adult bicycle injuries were reported during the study period and 9839 deaths. In 2010 dollars, estimated adult bicycle injury costs totalled $24.4 billion in 2013. Estimated injury costs per mile bicycled fell from $2.85 in 2001 to $2.35 in 2009. From 1999 to 2013, total estimated costs were $209 billion due to non-fatal bicycle injuries and $28 billion due to fatal injuries. Inflation-free annual costs in the study period increased by 137% for non-fatal injuries and 23% for fatal injuries. The share of non-fatal costs associated with injuries to riders age 45 and older increased by 1.6% (95% CI 1.4% to 1.9%) annually. The proportion of costs due to incidents that occurred on a street or highway steadily increased by 0.8% (95% CI 0.4% to 1.3%) annually. Conclusions: Inflation-free costs per case associated with non-fatal bicycle injuries are increasing. The growth in costs is especially associated with rising ridership, riders 45 and older, and street/highway crashes.

GBD Cancer Collaboration,,, Miller, T., 2017 Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: A systematic analysis for the Global Burden of Disease Study JAMA Oncology, 3 (4), 524-548. doi: 10.1001/jamaoncol.2016.5688 Impact Factor: .423 Abstract

Importance: Cancer is the second leading cause of death worldwide. Current estimates on the burden of cancer are needed for cancer control planning. Objective: To estimate mortality, incidence, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 32 cancers in 195 countries and territories from 1990 to 2015. Evidence Review: Cancer mortality was estimated using vital registration system data, cancer registry incidence data (transformed to mortality estimates using separately estimated mortality to incidence [MI] ratios), and verbal autopsy data. Cancer incidence was calculated by dividing mortality estimates through the modeled MI ratios. To calculate cancer prevalence, MI ratios were used to model survival. To calculate YLDs, prevalence estimates were multiplied by disability weights. The YLLs were estimated by multiplying age-specific cancer deaths by the reference life expectancy. DALYs were estimated as the sum of YLDs and YLLs. A sociodemographic index (SDI) was created for each location based on income per capita, educational attainment, and fertility. Countries were categorized by SDI quintiles to summarize results. Findings: In 2015, there were 17.5 million cancer cases worldwide and 8.7 million deaths. Between 2005 and 2015, cancer cases increased by 33%, with population aging contributing 16%, population growth 13%, and changes in age-specific rates contributing 4%. For men, the most common cancer globally was prostate cancer (1.6 million cases). Tracheal, bronchus, and lung cancer was the leading cause of cancer deaths and DALYs in men (1.2 million deaths and 25.9 million DALYs). For women, the most common cancer was breast cancer (2.4 million cases). Breast cancer was also the leading cause of cancer deaths and DALYs for women (523000 deaths and 15.1 million DALYs). Overall, cancer caused 208.3 million DALYs worldwide in 2015 for both sexes combined. Between 2005 and 2015, age-standardized incidence rates for all cancers combined increased in 174 of 195 countries or territories. Age-standardized death rates (ASDRs) for all cancers combined decreased within that timeframe in 140 of 195 countries or territories. Countries with an increase in the ASDR due to all cancers were largely located on the African continent. Of all cancers, deaths between 2005 and 2015 decreased significantly for Hodgkin lymphoma (-6.1% [95% uncertainty interval (UI), -10.6% to -1.3%]). The number of deaths also decreased for esophageal cancer, stomach cancer, and chronic myeloid leukemia, although these results were not statistically significant. Conclusion and Relevance: As part of the epidemiological transition, cancer incidence is expected to increase in the future, further straining limited health care resources. Appropriate allocation of resources for cancer prevention, early diagnosis, and curative and palliative care requires detailed knowledge of the local burden of cancer. The GBD 2015 study results demonstrate that progress is possible in the war against cancer. However, the major findings also highlight an unmet need for cancer prevention efforts, including tobacco control, vaccination, and the promotion of physical activity and a healthy diet.

GBD Causes of Death Collaborators,,, Miller, T., 2017 Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: A systematic analysis for the Global Burden of Disease Study 2016 The Lancet, 390 (10100), 1151-1210. doi: 10.1016/s0140-6736(17)32152-9 Impact Factor: 47.831 Abstract

Background: Monitoring levels and trends in premature mortality is crucial to understanding how societies can address prominent sources of early death. The Global Burden of Disease 2016 Study (GBD 2016) provides a comprehensive assessment of cause-specific mortality for 264 causes in 195 locations from 1980 to 2016. This assessment includes evaluation of the expected epidemiological transition with changes in development and where local patterns deviate from these trends. Methods: We estimated cause-specific deaths and years of life lost (YLLs) by age, sex, geography, and year. YLLs were calculated from the sum of each death multiplied by the standard life expectancy at each age. We used the GBD cause of death database composed of: vital registration (VR) data corrected for under-registration and garbage coding; national and subnational verbal autopsy (VA) studies corrected for garbage coding; and other sources including surveys and surveillance systems for specific causes such as maternal mortality. To facilitate assessment of quality, we reported on the fraction of deaths assigned to GBD Level 1 or Level 2 causes that cannot be underlying causes of death (major garbage codes) by location and year. Based on completeness, garbage coding, cause list detail, and time periods covered, we provided an overall data quality rating for each location with scores ranging from 0 stars (worst) to 5 stars (best). We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to generate estimates for each location, year, age, and sex. We assessed observed and expected levels and trends of cause-specific deaths in relation to the Socio-demographic Index (SDI), a summary indicator derived from measures of average income per capita, educational attainment, and total fertility, with locations grouped into quintiles by SDI. Relative to GBD 2015, we expanded the GBD cause hierarchy by 18 causes of death for GBD 2016. Findings: The quality of available data varied by location. Data quality in 25 countries rated in the highest category (5 stars), while 48, 30, 21, and 44 countries were rated at each of the succeeding data quality levels. Vital registration or verbal autopsy data were not available in 27 countries, resulting in the assignment of a zero value for data quality. Deaths from non-communicable diseases (NCDs) represented 72·3% (95% uncertainty interval [UI] 71·2–73·2) of deaths in 2016 with 19·3% (18·5–20·4) of deaths in that year occurring from communicable, maternal, neonatal, and nutritional (CMNN) diseases and a further 8·43% (8·00–8·67) from injuries. Although age-standardised rates of death from NCDs decreased globally between 2006 and 2016, total numbers of these deaths increased; both numbers and age-standardised rates of death from CMNN causes decreased in the decade 2006–16—age-standardised rates of deaths from injuries decreased but total numbers varied little. In 2016, the three leading global causes of death in children under-5 were lower respiratory infections, neonatal preterm birth complications, and neonatal encephalopathy due to birth asphyxia and trauma, combined resulting in 1·80 million deaths (95% UI 1·59 million to 1·89 million). Between 1990 and 2016, a profound shift toward deaths at older ages occurred with a 178% (95% UI 176–181) increase in deaths in ages 90–94 years and a 210% (208–212) increase in deaths older than age 95 years. The ten leading causes by rates of age-standardised YLL significantly decreased from 2006 to 2016 (median annualised rate of change was a decrease of 2·89%); the median annualised rate of change for all other causes was lower (a decrease of 1·59%) during the same interval. Globally, the five leading causes of total YLLs in 2016 were cardiovascular diseases; diarrhoea, lower respiratory infections, and other common infectious diseases; neoplasms; neonatal disorders; and HIV/AIDS and tuberculosis. At a finer level of disaggregation within cause groupings, the ten leading causes of total YLLs in 2016 were ischaemic heart disease, cerebrovascular disease, lower respiratory infections, diarrhoeal diseases, road injuries, malaria, neonatal preterm birth complications, HIV/AIDS, chronic obstructive pulmonary disease, and neonatal encephalopathy due to birth asphyxia and trauma. Ischaemic heart disease was the leading cause of total YLLs in 113 countries for men and 97 countries for women. Comparisons of observed levels of YLLs by countries, relative to the level of YLLs expected on the basis of SDI alone, highlighted distinct regional patterns including the greater than expected level of YLLs from malaria and from HIV/AIDS across sub-Saharan Africa; diabetes mellitus, especially in Oceania; interpersonal violence, notably within Latin America and the Caribbean; and cardiomyopathy and myocarditis, particularly in eastern and central Europe. The level of YLLs from ischaemic heart disease was less than expected in 117 of 195 locations. Other leading causes of YLLs for which YLLs were notably lower than expected included neonatal preterm birth complications in many locations in both south Asia and southeast Asia, and cerebrovascular disease in western Europe. Interpretation: The past 37 years have featured declining rates of communicable, maternal, neonatal, and nutritional diseases across all quintiles of SDI, with faster than expected gains for many locations relative to their SDI. A global shift towards deaths at older ages suggests success in reducing many causes of early death. YLLs have increased globally for causes such as diabetes mellitus or some neoplasms, and in some locations for causes such as drug use disorders, and conflict and terrorism. Increasing levels of YLLs might reflect outcomes from conditions that required high levels of care but for which effective treatments remain elusive, potentially increasing costs to health systems.

GBD Child and Adolescent Health Collaboration,,, Miller, T., 2017 Child and adolescent health from 1990 to 2015: Findings from the Global Burden of Diseases, Injuries, and Risk Factors 2015 Study JAMA Pediatrics, 171 (6), 573-592. doi: 10.1001/jamapediatrics.2017.0250 Impact Factor: 2.035 Abstract

Importance: Comprehensive and timely monitoring of disease burden in all age groups, including children and adolescents, is essential for improving population health. Objective: To quantify and describe levels and trends of mortality and nonfatal health outcomes among children and adolescents from 1990 to 2015 to provide a framework for policy discussion. Evidence Review: Cause-specific mortality and nonfatal health outcomes were analyzed for 195 countries and territories by age group, sex, and year from 1990 to 2015 using standardized approaches for data processing and statistical modeling, with subsequent analysis of the findings to describe levels and trends across geography and time among children and adolescents 19 years or younger. A composite indicator of income, education, and fertility was developed (Socio-demographic Index [SDI]) for each geographic unit and year, which evaluates the historical association between SDI and health loss. Findings: Global child and adolescent mortality decreased from 14.18 million (95% uncertainty interval [UI], 14.09 million to 14.28 million) deaths in 1990 to 7.26 million (95% UI, 7.14 million to 7.39 million) deaths in 2015, but progress has been unevenly distributed. Countries with a lower SDI had a larger proportion of mortality burden (75%) in 2015 than was the case in 1990 (61%). Most deaths in 2015 occurred in South Asia and sub-Saharan Africa. Global trends were driven by reductions in mortality owing to infectious, nutritional, and neonatal disorders, which in the aggregate led to a relative increase in the importance of noncommunicable diseases and injuries in explaining global disease burden. The absolute burden of disability in children and adolescents increased 4.3% (95% UI, 3.1%-5.6%) from 1990 to 2015, with much of the increase owing to population growth and improved survival for children and adolescents to older ages. Other than infectious conditions, many top causes of disability are associated with long-term sequelae of conditions present at birth (eg, neonatal disorders, congenital birth defects, and hemoglobinopathies) and complications of a variety of infections and nutritional deficiencies. Anemia, developmental intellectual disability, hearing loss, epilepsy, and vision loss are important contributors to childhood disability that can arise from multiple causes. Maternal and reproductive health remains a key cause of disease burden in adolescent females, especially in lower-SDI countries. In low-SDI countries, mortality is the primary driver of health loss for children and adolescents, whereas disability predominates in higher-SDI locations; the specific pattern of epidemiological transition varies across diseases and injuries. Conclusions and Relevance: Consistent international attention and investment have led to sustained improvements in causes of health loss among children and adolescents in many countries, although progress has been uneven. The persistence of infectious diseases in some countries, coupled with ongoing epidemiologic transition to injuries and noncommunicable diseases, require all countries to carefully evaluate and implement appropriate strategies to maximize the health of their children and adolescents and for the international community to carefully consider which elements of child and adolescent health should be monitored.

GBD Chronic Respiratory Disease Collaborators,,, Miller, T., 2017 Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: A systematic analysis for the Global Burden of Disease Study 2015 The Lancet Respiratory Medicine, 5 (9), 691-706. doi: 10.1016/s2213-2600(17)30293-x Impact Factor: 19.287 Abstract

Background: Chronic obstructive pulmonary disease (COPD) and asthma are common diseases with a heterogeneous distribution worldwide. Here, we present methods and disease and risk estimates for COPD and asthma from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2015 study. The GBD study provides annual updates on estimates of deaths, prevalence, and disability-adjusted life years (DALYs), a summary measure of fatal and non-fatal disease outcomes, for over 300 diseases and injuries, for 188 countries from 1990 to the most recent year. Methods: We estimated numbers of deaths due to COPD and asthma using the GBD Cause of Death Ensemble modelling (CODEm) tool. First, we analysed data from vital registration and verbal autopsy for the aggregate category of all chronic respiratory diseases. Subsequently, models were run for asthma and COPD relying on covariates to predict rates in countries that have incomplete or no vital registration data. Disease estimates for COPD and asthma were based on systematic reviews of published papers, unpublished reports, surveys, and health service encounter data from the USA. We used the Global Initiative of Chronic Obstructive Lung Disease spirometry-based definition as the reference for COPD and a reported diagnosis of asthma with current wheeze as the definition of asthma. We used a Bayesian meta-regression tool, DisMod-MR 2.1, to derive estimates of prevalence and incidence. We estimated population-attributable fractions for risk factors for COPD and asthma from exposure data, relative risks, and a theoretical minimum exposure level. Results were stratified by Socio-demographic Index (SDI), a composite measure of income per capita, mean years of education over the age of 15 years, and total fertility rate. Findings: In 2015, 3·2 million people (95% uncertainty interval [UI] 3·1 million to 3·3 million) died from COPD worldwide, an increase of 11·6% (95% UI 5·3 to 19·8) compared with 1990. There was a decrease in age-standardised death rate of 41·9% (37·7 to 45·1) but this was counteracted by population growth and ageing of the global population. From 1990 to 2015, the prevalence of COPD increased by 44·2% (41·7 to 46·6), whereas age-standardised prevalence decreased by 14·7% (13·5 to 15·9). In 2015, 0·40 million people (0·36 million to 0·44 million) died from asthma, a decrease of 26·7% (-7·2 to 43·7) from 1990, and the age-standardised death rate decreased by 58·8% (39·0 to 69·0). The prevalence of asthma increased by 12·6% (9·0 to 16·4), whereas the age-standardised prevalence decreased by 17·7% (15·1 to 19·9). Age-standardised DALY rates due to COPD increased until the middle range of the SDI before reducing sharply. Age-standardised DALY rates due to asthma in both sexes decreased monotonically with rising SDI. The relation between with SDI and DALY rates due to asthma was attributed to variation in years of life lost (YLLs), whereas DALY rates due to COPD varied similarly for YLLs and years lived with disability across the SDI continuum. Smoking and ambient particulate matter were the main risk factors for COPD followed by household air pollution, occupational particulates, ozone, and secondhand smoke. Together, these risks explained 73·3% (95% UI 65·8 to 80·1) of DALYs due to COPD. Smoking and occupational asthmagens were the only risks quantified for asthma in GBD, accounting for 16·5% (14·6 to 18·7) of DALYs due to asthma. Interpretation Asthma was the most prevalent chronic respiratory disease worldwide in 2015, with twice the number of cases of COPD. Deaths from COPD were eight times more common than deaths from asthma. In 2015, COPD caused 2·6% of global DALYs and asthma 1·1% of global DALYs. Although there are laudable international collaborative efforts to make surveys of asthma and COPD more comparable, no consensus exists on case definitions and how to measure disease severity for population health measurements like GBD. Comparisons between countries and over time are important, as much of the chronic respiratory burden is either preventable or treatable with affordable interventions.

GBD Collaborators on Eastern Mediterranean Region and Diabetes,,, Miller, T., 2017 High fasting plasma glucose, diabetes, and its risk factors in the Eastern Mediterranean Region, 1990-2013: Findings from the Global Burden of Disease Study 2013 Diabetes Care, 40 (1), 22-29. doi: 10.2337/dc16-1075 Impact Factor: 8.934 Abstract

Objective: The prevalence of diabetes in the Eastern Mediterranean Region (EMR) is among the highest in the world. We used findings from the Global Burden of Disease 2013 study to calculate the burden of diabetes in the EMR. RESEARCH DESIGN AND Methods: The burden of diabetes and burden attributable to high fasting plasma glucose (HFPG) were calculated for each of the 22 countries in the EMR between 1990 and 2013. A systematic analysis was performed on mortality and morbidity data to estimate prevalence, deaths, and disability-adjusted life years (DALYs). Results: The diabetes death rate increased by 60.7%, from 12.1 per 100,000 population (95% uncertainty interval [UI]: 11.2-13.2) in 1990 to 19.5 per 100,000 population (95% UI: 17.4-21.5) in 2013. The diabetes DALY rate increased from 589.9 per 100,000 (95% UI: 498.0-698.0) in 1990 to 883.5 per 100,000 population (95% UI: 732.2-1,051.5) in 2013. In 2013, HFPG accounted for 4.9% (95% UI: 4.4-5.3) of DALYs from all causes. Total DALYs from diabetes increased by 148.6% during 1990-2013; population growth accounted for a 62.9% increase, and aging and increase in age-specific DALY rates accounted for 31.8% and 53.9%, respectively. Conclusions: Our findings show that diabetes causes a major burden in the EMR, which is increasing. Aging and population growth do not fully explain this increase in the diabetes burden. Programs and policies are urgently needed to reduce risk factors for diabetes, increase awareness of the disease, and improve diagnosis and control of diabetes to reduce its burden.

GBD DALYs and HALE Collaborators,,, Miller, T., 2017 Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016 The Lancet, 390 (10100), 1260-1344. doi: 10.1016/s0140-6736(17)32130-x Impact Factor: 47.831 Abstract

Background: Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI). Methods: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate. Findings: The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9–78·6) for females and 72·0 years (68·8–75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0–49·5]) and for males was in Lesotho (41·5 years [39·0–44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97–6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74–6·27) for males and 6·49 years (6·08–6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61–1·93) for males and 1·96 years (1·69–2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (–2·3% [–5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally. Interpretation At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support.

GBD Disease and Injury Incidence and Prevalence Collaborators,,, Miller, T., 2017 Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016 The Lancet, 390 (10100), 1211-1259. doi: 10.1016/s0140-6736(17)32154-2 Impact Factor: 47.831 Abstract

Background: As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016. Methods: We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER). Findings: Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8–75·9 million [7·2%, 6·0–8·3]), 45·1 million (29·0–62·8 million [5·6%, 4·0–7·2]), 36·3 million (25·3–50·9 million [4·5%, 3·8–5·3]), 34·7 million (23·0–49·6 million [4·3%, 3·5–5·2]), and 34·1 million (23·5–46·0 million [4·2%, 3·2–5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3–3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0–11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100?000, 95% UI 6862–11943) and highest rate (Yemen, 14?774 YLDs per 100?000, 11?018–19?228). Interpretation: The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.

GBD Eastern Mediterranean Region Adolescent Health Collaborators,,, Miller, T., 2017 Adolescent health in the Eastern Mediterranean Region: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-1003-4 Impact Factor: 2.327 Abstract

Objectives: The 22 countries of the East Mediterranean Region (EMR) have large populations of adolescents aged 10–24 years. These adolescents are central to assuring the health, development, and peace of this region. We described their health needs. Methods: Using data from the Global Burden of Disease Study 2015 (GBD 2015), we report the leading causes of mortality and morbidity for adolescents in the EMR from 1990 to 2015. We also report the prevalence of key health risk behaviors and determinants. Results: Communicable diseases and the health consequences of natural disasters reduced substantially between 1990 and 2015. However, these gains have largely been offset by the health impacts of war and the emergence of non-communicable diseases (including mental health disorders), unintentional injury, and self-harm. Tobacco smoking and high body mass were common health risks amongst adolescents. Additionally, many EMR countries had high rates of adolescent pregnancy and unmet need for contraception. Conclusions: Even with the return of peace and security, adolescents will have a persisting poor health profile that will pose a barrier to socioeconomic growth and development of the EMR.

GBD Eastern Mediterranean Region Cancer Collaborators,,, Miller, T., 2017 Burden of cancer in the Eastern Mediterranean Region, 2005–2015: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-0999-9 Impact Factor:2.327 Abstract

Objectives: To estimate incidence, mortality, and disability-adjusted life years (DALYs) caused by cancer in the Eastern Mediterranean Region (EMR) between 2005 and 2015. Methods: Vital registration system and cancer registry data from the EMR region were analyzed for 29 cancer groups in 22 EMR countries using the Global Burden of Disease Study 2015 methodology. Results: In 2015, cancer was responsible for 9.4% of all deaths and 5.1% of all DALYs. It accounted for 722,646 new cases, 379,093 deaths, and 11.7 million DALYs. Between 2005 and 2015, incident cases increased by 46%, deaths by 33%, and DALYs by 31%. The increase in cancer incidence was largely driven by population growth and population aging. Breast cancer, lung cancer, and leukemia were the most common cancers, while lung, breast, and stomach cancers caused most cancer deaths. Conclusions: Cancer is responsible for a substantial disease burden in the EMR, which is increasing. There is an urgent need to expand cancer prevention, screening, and awareness programs in EMR countries as well as to improve diagnosis, treatment, and palliative care services.

GBD Eastern Mediterranean Region Cardiovascular Disease Collaborators,,, Miller, T., 2017 Burden of cardiovascular diseases in the Eastern Mediterranean Region, 1990–2015: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-1012-3 Impact Factor: 2.327 Abstract

Objectives: To report the burden of cardiovascular diseases (CVD) in the Eastern Mediterranean Region (EMR) during 1990–2015. Methods: We used the 2015 Global Burden of Disease study for estimates of mortality and disability-adjusted life years (DALYs) of different CVD in 22 countries of EMR. Results: A total of 1.4 million CVD deaths (95% UI: 1.3–1.5) occurred in 2015 in the EMR, with the highest number of deaths in Pakistan (465,116) and the lowest number of deaths in Qatar (723). The age-standardized DALY rate per 100,000 decreased from 10,080 in 1990 to 8606 in 2015 (14.6% decrease). Afghanistan had the highest age-standardized DALY rate of CVD in both 1990 and 2015. Kuwait and Qatar had the lowest age-standardized DALY rates of CVD in 1990 and 2015, respectively. High blood pressure, high total cholesterol, and high body mass index were the leading risk factors for CVD. Conclusions: The age-standardized DALY rates in the EMR are considerably higher than the global average. These findings call for a comprehensive approach to prevent and control the burden of CVD in the region.

GBD Eastern Mediterranean Region Diabetes and CKD Collaborators,,, Miller, T., 2017 Diabetes mellitus and chronic kidney disease in the Eastern Mediterranean Region: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-1014-1 Impact Factor: 2.327 Abstract

Objectives: We used findings from the Global Burden of Disease 2015 study to update our previous publication on the burden of diabetes and chronic kidney disease due to diabetes (CKD-DM) during 1990-2015. Methods: We extracted GBD 2015 estimates for prevalence, mortality, and disability-adjusted life years (DALYs) of diabetes (including burden of low vision due to diabetes, neuropathy, and amputations and CKD-DM for 22 countries of the EMR from the GBD visualization tools. Results: In 2015, 135,230 (95% UI 123,034-148,184) individuals died from diabetes and 16,470 (95% UI 13,977-18,961) from CKD-DM, 216 and 179% increases, respectively, compared to 1990. The total number of people with diabetes was 42.3 million (95% UI 38.6-46.4 million) in 2015. DALY rates of diabetes in 2015 were significantly higher than the expected rates based on Socio-demographic Index (SDI). Conclusions: Our study showed a large and increasing burden of diabetes in the region. There is an urgency in dealing with diabetes and its consequences, and these efforts should be at the forefront of health prevention and promotion.

GBD Eastern Mediterranean Region HIV/AIDS Collaborators,,, Miller, T., 2017 Trends in HIV/AIDS morbidity and mortality in Eastern Mediterranean countries, 1990–2015: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-1023-0 Impact Factor: 2.327 Abstract

Objectives: We used the results of the Global Burden of Disease 2015 study to estimate trends of HIV/AIDS burden in Eastern Mediterranean Region (EMR) countries between 1990 and 2015. Methods: Tailored estimation methods were used to produce final estimates of mortality. Years of life lost (YLLs) were calculated by multiplying the mortality rate by population by age-specific life expectancy. Years lived with disability (YLDs) were computed as the prevalence of a sequela multiplied by its disability weight. Results: In 2015, the rate of HIV/AIDS deaths in the EMR was 1.8 (1.4-2.5) per 100,000 population, a 43% increase from 1990 (0.3; 0.2-0.8). Consequently, the rate of YLLs due to HIV/AIDS increased from 15.3 (7.6-36.2) per 100,000 in 1990 to 81.9 (65.3-114.4) in 2015. The rate of YLDs increased from 1.3 (0.6-3.1) in 1990 to 4.4 (2.7-6.6) in 2015. Conclusions: HIV/AIDS morbidity and mortality increased in the EMR since 1990. To reverse this trend and achieve epidemic control, EMR countries should strengthen HIV surveillance, and scale up HIV antiretroviral therapy and comprehensive prevention services.

GBD Eastern Mediterranean Region Intentional Injuries Collaborators,,, Miller, T., 2017 Intentional injuries in the Eastern Mediterranean Region, 1990–2015: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-1005-2 Impact Factor: 2.327 Abstract

Objectives: We used GBD 2015 findings to measure the burden of intentional injuries in the Eastern Mediterranean Region (EMR) between 1990 and 2015. Methods: The Global Burden of Disease (GBD) study defines intentional injuries as a combination of self-harm (including suicide), interpersonal violence, collective violence (war), and legal intervention. We estimated number of deaths, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) for each type of intentional injuries. Results: In 2015, 28,695 individuals (95% UI: 25,474–37,832) died from self-harm, 35,626 (95% UI: 20,947–41,857) from interpersonal violence, and 143,858 (95% UI: 63,554–223,092) from collective violence and legal interventions. In 2015, collective violence and legal intervention was the fifth-leading cause of DALYs in the EMR and the leading cause in Syria, Yemen, Iraq, Afghanistan, and Libya; they account for 49.7% of total DALYs in Syria. Conclusions: Our findings call for increased efforts to stabilize the region and assist in rebuilding the health systems, as well as increasing transparency and employing preventive strategies to reduce self-harm and interpersonal injuries.

GBD Eastern Mediterranean Region Maternal Mortality Collaborators,,, Miller, T., 2017 Maternal mortality and morbidity burden in the Eastern Mediterranean Region: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-1004-3 Impact Factor: 2.327 Abstract

Objectives: Assessing the burden of maternal mortality is important for tracking progress and identifying public health gaps. This paper provides an overview of the burden of maternal mortality in the Eastern Mediterranean Region (EMR) by underlying cause and age from 1990 to 2015. Methods: We used the results of the Global Burden of Disease 2015 study to explore maternal mortality in the EMR countries. Results: The maternal mortality ratio in the EMR decreased 16.3% from 283 (241–328) maternal deaths per 100,000 live births in 1990 to 237 (188–293) in 2015. Maternal mortality ratio was strongly correlated with socio-demographic status, where the lowest-income countries contributed the most to the burden of maternal mortality in the region. Conclusion: Progress in reducing maternal mortality in the EMR has accelerated in the past 15 years, but the burden remains high. Coordinated and rigorous efforts are needed to make sure that adequate and timely services and interventions are available for women at each stage of reproductive life.

GBD Eastern Mediterranean Region Mental Health Collaborators,,, Miller, T., 2017 The burden of mental disorders in the Eastern Mediterranean Region, 1990–2015: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-1006-1 Impact Factor: 2.327 Abstract

Objectives: Mental disorders are among the leading causes of nonfatal burden of disease globally. Methods: We used the global burden of diseases, injuries, and risk factors study 2015 to examine the burden of mental disorders in the Eastern Mediterranean region (EMR). We defined mental disorders according to criteria proposed in the diagnostic and statistical manual of mental disorders IV and the 10th International Classification of Diseases. Results: Mental disorders contributed to 4.7% (95% uncertainty interval (UI) 3.7–5.6%) of total disability-adjusted life-years (DALYs), ranking as the ninth leading cause of disease burden. Depressive disorders and anxiety disorders were the third and ninth leading causes of nonfatal burden, respectively. Almost all countries in the EMR had higher age-standardized mental disorder DALYs rates compared to the global level, and in half of the EMR countries, observed mental disorder rates exceeded the expected values. Conclusions: The burden of mental disorders in the EMR is higher than global levels, particularly for women. To properly address this burden, EMR governments should implement nationwide quality epidemiological surveillance of mental disorders and provide adequate prevention and treatment services.

GBD Eastern Mediterranean Region Neonatal, Infant, and under-5 Mortality Collaborators,,, Miller, T., 2017 Neonatal, infant, and under-5 mortality and morbidity burden in the Eastern Mediterranean Region: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, online ahead of print. doi: 10.1007/s00038-017-0998-x Impact Factor: 2.327 Abstract

Objectives: Although substantial reductions in under-5 mortality have been observed during the past 35 years, progress in the Eastern Mediterranean Region (EMR) has been uneven. This paper provides an overview of child mortality and morbidity in the EMR based on the Global Burden of Disease (GBD) study. Methods: We used GBD 2015 study results to explore under-5 mortality and morbidity in EMR countries. Results: In 2015, 755,844 (95% uncertainty interval (UI) 712,064–801,565) children under 5 died in the EMR. In the early neonatal category, deaths in the EMR decreased by 22.4%, compared to 42.4% globally. The rate of years of life lost per 100,000 population under 5 decreased 54.38% from 177,537 (173,812–181,463) in 1990 to 80,985 (76,308–85,876) in 2015; the rate of years lived with disability decreased by 0.57% in the EMR compared to 9.97% globally. Conclusions: Our findings call for accelerated action to decrease child morbidity and mortality in the EMR. Governments and organizations should coordinate efforts to address this burden. Political commitment is needed to ensure that child health receives the resources needed to end preventable deaths.

GBD Eastern Mediterranean Region Transportation Injuries Collaborators,,, Miller, T., 2017 Transport injuries and deaths in the Eastern Mediterranean Region: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-0987-0 Impact Factor: 2.327 Abstract

Objectives: Transport injuries (TI) are ranked as one of the leading causes of death, disability, and property loss worldwide. This paper provides an overview of the burden of TI in the Eastern Mediterranean Region (EMR) by age and sex from 1990 to 2015. Methods: Transport injuries mortality in the EMR was estimated using the Global Burden of Disease mortality database, with corrections for ill-defined causes of death, using the cause of death ensemble modeling tool. Morbidity estimation was based on inpatient and outpatient datasets, 26 cause-of-injury and 47 nature-of-injury categories. Results: In 2015, 152,855 (95% uncertainty interval: 137,900-168,100) people died from TI in the EMR countries. Between 1990 and 2015, the years of life lost (YLL) rate per 100,000 due to TI decreased by 15.5%, while the years lived with disability (YLD) rate decreased by 10%, and the age-standardized disability-adjusted life years (DALYs) rate decreased by 16%. Conclusions: Although the burden of TI mortality and morbidity decreased over the last two decades, there is still a considerable burden that needs to be addressed by increasing awareness, enforcing laws, and improving road conditions.

GBD Eastern Mediterranean Region Vision Loss Collaborators,,, Miller, T., 2017 Burden of vision loss in the Eastern Mediterranean Region, 1990–2015: Findings from the Global Burden of Disease 2015 Study International Journal of Public Health, doi: 10.1007/s00038-017-1000-7 Impact Factor: 2.327 Abstract

Objectives: To report the estimated trend in prevalence and years lived with disability (YLDs) due to vision loss (VL) in the Eastern Mediterranean region (EMR) from 1990 to 2015. Methods: The estimated trends in age-standardized prevalence and the YLDs rate due to VL in 22 EMR countries were extracted from the Global Burden of Disease (GBD) 2015 study. The association of Socio-demographic Index (SDI) with changes in prevalence and YLDs of VL was evaluated using a multilevel mixed model. Results: The age-standardized prevalence of VL in the EMR was 18.2% in 1990 and 15.5% in 2015. The total age-standardized YLDs rate attributed to all-cause VL in EMR was 536.9 per 100,000 population in 1990 and 482.3 per 100,000 population in 2015. For each 0.1 unit increase in SDI, the age-standardized prevalence and YLDs rate of VL showed a reduction of 1.5% (p < 0.001) and 23.9 per 100,000 population (p < 0.001), respectively. Conclusions: The burden of VL is high in the EMR; however, it shows a descending trend over the past 25 years. EMR countries need to establish comprehensive eye care programs in their health care systems.

GBD Health Financing Collaborator Network,,, Miller, T., 2017 Evolution and patterns of global health financing 1995-2014: Development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries The Lancet, 389 (10083), 1981-2004. doi: 10.1016/s0140-6736(17)30874-7 Impact Factor: 47.831 Abstract

Background: An adequate amount of prepaid resources for health is important to ensure access to health services and for the pursuit of universal health coverage. Previous studies on global health financing have described the relationship between economic development and health financing. In this study, we further explore global health financing trends and examine how the sources of funds used, types of services purchased, and development assistance for health disbursed change with economic development. We also identify countries that deviate from the trends. Methods: We estimated national health spending by type of care and by source, including development assistance for health, based on a diverse set of data including programme reports, budget data, national estimates, and 964 National Health Accounts. These data represent health spending for 184 countries from 1995 through 2014. We converted these data into a common inflation-adjusted and purchasing power-adjusted currency, and used non-linear regression methods to model the relationship between health financing, time, and economic development. Findings: Between 1995 and 2014, economic development was positively associated with total health spending and a shift away from a reliance on development assistance and out-of-pocket (OOP) towards government spending. The largest absolute increase in spending was in high-income countries, which increased to purchasing power-adjusted $5221 per capita based on an annual growth rate of 3·0%. The largest health spending growth rates were in upper-middle-income (5·9) and lower-middle-income groups (5·0), which both increased spending at more than 5% per year, and spent $914 and $267 per capita in 2014, respectively. Spending in low-income countries grew nearly as fast, at 4·6%, and health spending increased from $51 to $120 per capita. In 2014, 59·2% of all health spending was financed by the government, although in low-income and lower-middle-income countries, 29·1% and 58·0% of spending was OOP spending and 35·7% and 3·0% of spending was development assistance. Recent growth in development assistance for health has been tepid; between 2010 and 2016, it grew annually at 1·8%, and reached US$37·6 billion in 2016. Nonetheless, there is a great deal of variation revolving around these averages. 29 countries spend at least 50% more than expected per capita, based on their level of economic development alone, whereas 11 countries spend less than 50% their expected amount. Interpretation Health spending remains disparate, with low-income and lower-middle-income countries increasing spending in absolute terms the least, and relying heavily on OOP spending and development assistance. Moreover, tremendous variation shows that neither time nor economic development guarantee adequate prepaid health resources, which are vital for the pursuit of universal health coverage.

GBD Health Financing Collaborator Network,,, Miller, T., 2017 Future and potential spending on health 2015-40: Development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries The Lancet, 389 (10083), 2005-2030. doi: 10.1016/s0140-6736(17)30873-5 Impact Factor: 47.83 Abstract

Background: The amount of resources, particularly prepaid resources, available for health can affect access to health care and health outcomes. Although health spending tends to increase with economic development, tremendous variation exists among health financing systems. Estimates of future spending can be beneficial for policy makers and planners, and can identify financing gaps. In this study, we estimate future gross domestic product (GDP), all-sector government spending, and health spending disaggregated by source, and we compare expected future spending to potential future spending. Methods: We extracted GDP, government spending in 184 countries from 1980–2015, and health spend data from 1995–2014. We used a series of ensemble models to estimate future GDP, all-sector government spending, development assistance for health, and government, out-of-pocket, and prepaid private health spending through 2040. We used frontier analyses to identify patterns exhibited by the countries that dedicate the most funding to health, and used these frontiers to estimate potential health spending for each low-income or middle-income country. All estimates are inflation and purchasing power adjusted. Findings: We estimated that global spending on health will increase from US$9·21 trillion in 2014 to $24·24 trillion (uncertainty interval [UI] 20·47–29·72) in 2040. We expect per capita health spending to increase fastest in upper-middle-income countries, at 5·3% (UI 4·1–6·8) per year. This growth is driven by continued growth in GDP, government spending, and government health spending. Lower-middle income countries are expected to grow at 4·2% (3·8–4·9). High-income countries are expected to grow at 2·1% (UI 1·8–2·4) and low-income countries are expected to grow at 1·8% (1·0–2·8). Despite this growth, health spending per capita in low-income countries is expected to remain low, at $154 (UI 133–181) per capita in 2030 and $195 (157–258) per capita in 2040. Increases in national health spending to reach the level of the countries who spend the most on health, relative to their level of economic development, would mean $321 (157–258) per capita was available for health in 2040 in low-income countries. Interpretation: Health spending is associated with economic development but past trends and relationships suggest that spending will remain variable, and low in some low-resource settings. Policy change could lead to increased health spending, although for the poorest countries external support might remain essential.

GBD Healthcare Access and Quality Collaborators,,, Miller, T., 2017 Healthcare access and quality index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: A novel analysis from the Global Burden of Disease Study 2015 The Lancet, 390 (10091), 231-266. doi: 10.1016/s0140-6736(17)30818-8 Impact Factor: 47.831 Abstract

Background: National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods: We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings: Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation: This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world.

GBD Mortality Collaborators,,, Miller, T., 2017 Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970-2016: A systematic analysis for the Global Burden of Disease Study 2016 The Lancet, 390 (10100), 1084-1150. doi: 10.1016/s0140-6736(17)31833-0 Impact Factor: 47.831 Abstract

Background: Detailed assessments of mortality patterns, particularly age-specific mortality, represent a crucial input that enables health systems to target interventions to specific populations. Understanding how all-cause mortality has changed with respect to development status can identify exemplars for best practice. To accomplish this, the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) estimated age-specific and sex-specific all-cause mortality between 1970 and 2016 for 195 countries and territories and at the subnational level for the five countries with a population greater than 200 million in 2016. Methods: We have evaluated how well civil registration systems captured deaths using a set of demographic methods called death distribution methods for adults and from consideration of survey and census data for children younger than 5 years. We generated an overall assessment of completeness of registration of deaths by dividing registered deaths in each location-year by our estimate of all-age deaths generated from our overall estimation process. For 163 locations, including subnational units in countries with a population greater than 200 million with complete vital registration (VR) systems, our estimates were largely driven by the observed data, with corrections for small fluctuations in numbers and estimation for recent years where there were lags in data reporting (lags were variable by location, generally between 1 year and 6 years). For other locations, we took advantage of different data sources available to measure under-5 mortality rates (U5MR) using complete birth histories, summary birth histories, and incomplete VR with adjustments; we measured adult mortality rate (the probability of death in individuals aged 15–60 years) using adjusted incomplete VR, sibling histories, and household death recall. We used the U5MR and adult mortality rate, together with crude death rate due to HIV in the GBD model life table system, to estimate age-specific and sex-specific death rates for each location-year. Using various international databases, we identified fatal discontinuities, which we defined as increases in the death rate of more than one death per million, resulting from conflict and terrorism, natural disasters, major transport or technological accidents, and a subset of epidemic infectious diseases; these were added to estimates in the relevant years. In 47 countries with an identified peak adult prevalence for HIV/AIDS of more than 0·5% and where VR systems were less than 65% complete, we informed our estimates of age-sex-specific mortality using the Estimation and Projection Package (EPP)-Spectrum model fitted to national HIV/AIDS prevalence surveys and antenatal clinic serosurveillance systems. We estimated stillbirths, early neonatal, late neonatal, and childhood mortality using both survey and VR data in spatiotemporal Gaussian process regression models. We estimated abridged life tables for all location-years using age-specific death rates. We grouped locations into development quintiles based on the Socio-demographic Index (SDI) and analysed mortality trends by quintile. Using spline regression, we estimated the expected mortality rate for each age-sex group as a function of SDI. We identified countries with higher life expectancy than expected by comparing observed life expectancy to anticipated life expectancy on the basis of development status alone. Findings: Completeness in the registration of deaths increased from 28% in 1970 to a peak of 45% in 2013; completeness was lower after 2013 because of lags in reporting. Total deaths in children younger than 5 years decreased from 1970 to 2016, and slower decreases occurred at ages 5–24 years. By contrast, numbers of adult deaths increased in each 5-year age bracket above the age of 25 years. The distribution of annualised rates of change in age-specific mortality rate differed over the period 2000 to 2016 compared with earlier decades: increasing annualised rates of change were less frequent, although rising annualised rates of change still occurred in some locations, particularly for adolescent and younger adult age groups. Rates of stillbirths and under-5 mortality both decreased globally from 1970. Evidence for global convergence of death rates was mixed; although the absolute difference between age-standardised death rates narrowed between countries at the lowest and highest levels of SDI, the ratio of these death rates—a measure of relative inequality—increased slightly. There was a strong shift between 1970 and 2016 toward higher life expectancy, most noticeably at higher levels of SDI. Among countries with populations greater than 1 million in 2016, life expectancy at birth was highest for women in Japan, at 86·9 years (95% UI 86·7–87·2), and for men in Singapore, at 81·3 years (78·8–83·7) in 2016. Male life expectancy was generally lower than female life expectancy between 1970 and 2016, and the gap between male and female life expectancy increased with progression to higher levels of SDI. Some countries with exceptional health performance in 1990 in terms of the difference in observed to expected life expectancy at birth had slower progress on the same measure in 2016. Interpretation: Globally, mortality rates have decreased across all age groups over the past five decades, with the largest improvements occurring among children younger than 5 years. However, at the national level, considerable heterogeneity remains in terms of both level and rate of changes in age-specific mortality; increases in mortality for certain age groups occurred in some locations. We found evidence that the absolute gap between countries in age-specific death rates has declined, although the relative gap for some age-sex groups increased. Countries that now lead in terms of having higher observed life expectancy than that expected on the basis of development alone, or locations that have either increased this advantage or rapidly decreased the deficit from expected levels, could provide insight into the means to accelerate progress in nations where progress has stalled.

GBD Risk Factors Collaborators,,, Miller, T., 2017 Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016 The Lancet, 390 (10100), 1345-1422. doi: 10.1016/s0140-6736(17)32366-8 Impact Factor: 47.831 Abstract

Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context. Methods: We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22?717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined. Findings: Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9–11·6) decline in deaths and a 10·8% (8·3–13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7–17·5) of deaths and 6·2% (3·9–8·7) of DALYs, and population growth for 12·4% (10·1–14·9) of deaths and 12·4% (10·1–14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9–29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks. Interpretation: Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade.

GBD Sustainable Development Goals Collaborators,,, Miller, T., 2017 Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: An analysis from the Global Burden of Disease Study 2016 The Lancet, 390 (10100), 1423-1459. doi: 10.1016/s0140-6736(17)32336-x Impact Factor: 47.831 Abstract

Background: The UN's Sustainable Development Goals (SDGs) are grounded in the global ambition of “leaving no one behind”. Understanding today's gains and gaps for the health-related SDGs is essential for decision makers as they aim to improve the health of populations. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016), we measured 37 of the 50 health-related SDG indicators over the period 1990–2016 for 188 countries, and then on the basis of these past trends, we projected indicators to 2030. Methods: We used standardised GBD 2016 methods to measure 37 health-related indicators from 1990 to 2016, an increase of four indicators since GBD 2015. We substantially revised the universal health coverage (UHC) measure, which focuses on coverage of essential health services, to also represent personal health-care access and quality for several non-communicable diseases. We transformed each indicator on a scale of 0–100, with 0 as the 2·5th percentile estimated between 1990 and 2030, and 100 as the 97·5th percentile during that time. An index representing all 37 health-related SDG indicators was constructed by taking the geometric mean of scaled indicators by target. On the basis of past trends, we produced projections of indicator values, using a weighted average of the indicator and country-specific annualised rates of change from 1990 to 2016 with weights for each annual rate of change based on out-of-sample validity. 24 of the currently measured health-related SDG indicators have defined SDG targets, against which we assessed attainment. Findings: Globally, the median health-related SDG index was 56·7 (IQR 31·9–66·8) in 2016 and country-level performance markedly varied, with Singapore (86·8, 95% uncertainty interval 84·6–88·9), Iceland (86·0, 84·1–87·6), and Sweden (85·6, 81·8–87·8) having the highest levels in 2016 and Afghanistan (10·9, 9·6–11·9), the Central African Republic (11·0, 8·8–13·8), and Somalia (11·3, 9·5–13·1) recording the lowest. Between 2000 and 2016, notable improvements in the UHC index were achieved by several countries, including Cambodia, Rwanda, Equatorial Guinea, Laos, Turkey, and China; however, a number of countries, such as Lesotho and the Central African Republic, but also high-income countries, such as the USA, showed minimal gains. Based on projections of past trends, the median number of SDG targets attained in 2030 was five (IQR 2–8) of the 24 defined targets currently measured. Globally, projected target attainment considerably varied by SDG indicator, ranging from more than 60% of countries projected to reach targets for under-5 mortality, neonatal mortality, maternal mortality ratio, and malaria, to less than 5% of countries projected to achieve targets linked to 11 indicator targets, including those for childhood overweight, tuberculosis, and road injury mortality. For several of the health-related SDGs, meeting defined targets hinges upon substantially faster progress than what most countries have achieved in the past. Interpretation: GBD 2016 provides an updated and expanded evidence base on where the world currently stands in terms of the health-related SDGs. Our improved measure of UHC offers a basis to monitor the expansion of health services necessary to meet the SDGs. Based on past rates of progress, many places are facing challenges in meeting defined health-related SDG targets, particularly among countries that are the worst off. In view of the early stages of SDG implementation, however, opportunity remains to take actions to accelerate progress, as shown by the catalytic effects of adopting the Millennium Development Goals after 2000. With the SDGs' broader, bolder development agenda, multisectoral commitments and investments are vital to make the health-related SDGs within reach of all populations.

GBD Tobacco Collaborators,,, Miller, T., 2017 Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: A systematic analysis from the Global Burden of Disease Study 2015 The Lancet, 389 (10082), 1885-1906. doi: 10.1016/s0140-6736(17)30819-x Impact Factor: 47.831 Abstract

Background: The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed. Methods: We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI). Findings: Worldwide, the age-standardised prevalence of daily smoking was 25.0% (95% uncertainty interval [UI] 24.2-25.7) for men and 5.4% (5.1-5.7) for women, representing 28.4% (25.8-31.1) and 34.4% (29.4-38.6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11.5% of global deaths (6.4 million [95% UI 5.7-7.0 million]) were attributable to smoking worldwide, of which 52.2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015. Interpretation: The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

Giesbrecht, Norman, Huguet, Nathalie, Ogden, Lauren, Kaplan, Mark S., McFarland, Bentson H., Caetano, Raul, Conner, Kenneth R., Nolte, Kurt B., 2015 Acute alcohol use among suicide decedents in 14 U.S. states: Impacts of off-premise and on-premise alcohol outlet density Addiction, 110 (2), 300-307. doi: 10.1111/add.12762 Impact Factor: 4.97 Abstract

Aims: To estimate the association between per capita alcohol retail outlet density and blood alcohol concentration (BAC) from 51 547 suicide decedents and to analyse the relationship between alcohol outlet density and socio-demographic characteristics among alcohol-positive suicide decedents in the United States by racial/ethnic groups and method of suicide. Design: Analysis of US data, 2003–11, National Violent Death Reporting System. Setting: Suicide decedents from 14 US states. Participants: A total of 51 347 suicide decedents tested for BAC. Measurements: BAC and levels were derived from coroner/medical examiner reports. Densities of county level on-premises and off-premises alcohol retail outlets were calculated using the 2010 Census. Findings: Multi-level logistic regression models suggested that higher off-premises alcohol outlet densities were associated with greater proportions of alcohol-related suicides among men—for suicides with alcohol present [BAC >0; adjusted odds ratio (AOR) = 1.08, 95% confidence interval (CI) = 1.03–1.13]. Interactions between outlet density and decedents' characteristics were also tested. There was an interaction between off-premises alcohol availability and American Indian/Alaska Native race (AOR = 1.36; 95% CI = 1.10–1.69) such that this subgroup had highest BAC positivity. On-premises density was also associated with BAC >0 (AOR = 1.07; 95% CI = 1.03–1.11) and BAC =0.08 (AOR = 1.05; 95% CI = 1.02–1.09) among male decedents. Conclusions: In the United States, the density of both on- and off-premises alcohol outlets in a county is associated positively with alcohol-related suicide, especially among American Indians/Alaska Natives.

Gilder, David A., Geisler, Jennifer R., Luna, Juan A., Calac, Daniel, Monti, Peter M., Spillane, Nichea S., Lee, Juliet P., Moore, Roland S., Ehlers, Cindy L., 2017 A pilot randomized trial of Motivational Interviewing compared to Psycho-Education for reducing and preventing underage drinking in American Indian adolescents Journal of Substance Abuse Treatment, 82 (1), 74-81. Impact Factor: 2.465 Abstract

Underage drinking is an important public health issue for American Indian and Alaska Native (AI/AN) adolescents, as it is for U.S. teens of all ethnicities. One of the demonstrated risk factors for the development of alcohol use disorders in AI/AN is early age of initiation of drinking. To address this issue a randomized trial to assess the efficacy of Motivational Interviewing (MI) compared to Psycho-Education (PE) to reduce and prevent underage drinking in AI/AN youth was developed and implemented. Sixty-nine youth received MI or PE and 87% were assessed at follow-up. For teens who were already drinking, participating in the intervention (MI or PE) was associated, at follow-up, with lower quantity×frequency (q×f) of drinking (p=0.011), fewer maximum drinks per drinking occasion (p=0.004), and fewer problem behaviors (p=0.009). The MI intervention resulted in male drinkers reporting a lower q×f of drinking (p=0.048) and female drinkers reporting less depression (p=0.011). In teens who had not started drinking prior to the intervention, 17% had initiated drinking at follow-up. As a group they reported increased quantity×frequency of drinking (p=0.008) and maximum drinks (p=0.047), but no change in problem behaviors. These results suggest that intervening against underage drinking using either MI or PE in AI/AN youth can result in reduced drinking, prevention of initiation of drinking, and other positive behavioral outcomes. Brief interventions that enhance motivation to change as well as Psycho-Education may provide a successful approach to reducing the potential morbidity of underage drinking in this high-risk group.

Gonzalez Suitt, Karla, Castro, Yessenia, Caetano, Raul, Field, Craig A., 2015 Predictive Utility of Alcohol Use Disorder Symptoms Across Race/Ethnicity Journal of Substance Abuse Treatment, 5661-67. doi: 10.1016/j.jsat.2015.03.001 Impact Factor: 2.465 Abstract

Research has shown differences in alcohol use and problems across race/ethnicity. This study examines whether there are differential effects of alcohol use disorder (AUD) symptoms on drinking outcomes across race/ethnicity. Data from 1483 patients admitted to a hospital for treatment of an injury were utilized (19% Black, 45% non-Latino White, and 36% Latino). AUD symptoms and race/ethnicity reported at baseline and their interaction were the predictor variables. Drinking patterns and associated problems measured at the 6- and 12-month follow-up were the outcome variables of interest. Linear regression was the analytic method employed. Endorsement of "spending a great deal of time to obtain, use, or recover from effects of drinking," "craving," "failure to fulfill major role obligations," and "alcohol use in physically hazardous situations" at baseline was associated with greater levels of subsequent alcohol use and alcohol-related problems at both 6- and 12-month follow-ups, regardless of race/ethnicity. Endorsement of "important social, occupational, or recreational activities given up because of drinking" was differentially associated with greater alcohol-related problems at both 6- and 12-month follow-ups dependent on race/ethnicity. Follow-up analyses indicated that this symptom was a significant predictor of alcohol problems among Latino and Black participants, but not non-Latino White participants. Brief interventions targeting these AUD symptoms could increase the effectiveness of brief motivational interventions among different racial/ethnic groups.

Gruenewald, P.J., Grube, J.W., Saltz, R., Paschall, M.J., 2017 Environmental approaches to prevention: Communities and contexts.

Gruenewald, P.J., Treno, A.J., Holder, H.D., LaScala, E.A., 2016 Community-based approaches to the prevention of substance use related problems. 1 doi: DOI:10.1093/oxfordhb/9780199381678.013.005 Abstract

Scientific research into the environmental prevention of alcohol and drug-use problems has a distinguished history, with the goal of identifying environmental factors that can be modified to reduce harmful alcohol and drug use. This chapter shows how effective community-based prevention programs have applied environmental prevention strategies to reduce substance use and abuse. Although not all environmental prevention strategies can be implemented at the community level, communities can use a number of these strategies to reduce heavy drinking, access to harmful legal products, and related problems. The authors contrast environmental prevention strategies with individual-based approaches to highlight differences and demonstrate synergies that exist between efforts to change substance use environments and programs that attempt to affect personal choices to use or abuse drugs. The authors highlight the global breadth of community-based prevention research efforts and contributions to broader based international efforts that benefit all societies, inform community-based prevention programs, and complement individual-based prevention strategies.

Jetelina, Katelyn K., Gonzalez, Jennifer M. Reingle, Vaeth, Patrice A. C., Mills, Britain A., Caetano, Raul, 2016 An investigation of the relationship between alcohol use and major depressive disorder across Hispanic national groups Alcoholism: Clinical and Experimental Research, 40 (3), 536-542. doi: 10.1111/acer.12979 Impact Factor: 2.53 Abstract

Background: There has been consistent epidemiological evidence of the association between drinking, alcohol dependence, and depression. However, most of the research has ignored potential diversity across Hispanic national subgroups. This study examines the prevalence of depression and explores its association with volume of drinking, age at first drink, binge drinking, and alcohol dependence across Mexican American, Puerto Rican, Cuban, and South/Central American Hispanic national groups. Methods: Data from more than 19,000 Hispanic adults were obtained from the 2010 to 2012 National Survey on Drug Use and Health. Survey logistic regression methods were used to test for differences in the relationship between major depressive disorder (MDD) and alcohol consumption across national groups. Results: The prevalence of MDD varied significantly across Hispanic national groups (?² = 67.06, p < 0.001). Puerto Ricans (14%) and Mexican Americans (9%) were most likely to have MDD. Mexican Americans had the highest prevalence of alcohol dependence, volume of consumption, and youngest age at first drink compared to Puerto Ricans, Cuban Americans, and Central/South Americans. Multivariate results suggest that the odds of alcohol dependence were nearly 4 times greater among Hispanics with MDD compared to Hispanics who did not meet the criteria for MDD. Hispanic national origin did not modify the association between MDD and alcohol use. Conclusions: Although significant differences in the prevalence rates of MDD and alcohol-use measures emerged across Hispanic national groups, there was no evidence that the relationships between these measures were different across Hispanic national groups. Further research should investigate the root causes of these variable MDD prevalence rates to inform detection and intervention efforts targeted toward specific national groups.

Johnson, Mark B., Kopetz, Catalina E., 2017 The unintended effects of providing risk information about drinking and driving Health Psychology, 36 (9), 872-880. doi: 10.1037/hea0000526 Impact Factor: 3.611 Abstract

Objective: Alcohol-impaired driving remains a serious public health concern despite the fact that drinking and driving risks are widely disseminated and well understood by the public. This research examines the motivational conditions under which providing risk information can exacerbate rather than decrease potential drinking drivers' willingness to drive while impaired. Method: In a hypothetical drinking and driving scenario, 3 studies investigated participants' self-reported likelihood of drinking and driving as a function of (a) accessibility of information regarding risk associated with drinking and driving, (b) motivation to drive, and (c) need for cognitive closure (NFC). Results: Across the 3 studies, participants self-reported a higher likelihood of driving when exposed to high-risk information (vs. low-risk information) if they were high in NFC. Risk information did decrease self-reported likelihood of driving among low-NFC participants (Studies 1-3). Furthermore, this effect was exacerbated when the relevant motivation (to get home conveniently) was high (Study 3). Conclusions: These findings have important implications for impaired-driving prevention efforts. They suggest that at least under some circumstances, risk information can have unintended negative effects on drinking and driving decisions. The results are consistent with the motivated cognition literature, which suggests that people process and use information in a manner that supports their most accessible and important motivation despite potentially negative consequences.

Kaplan, Mark S., Caetano, Raul, Giesbrecht, Norman, Huguet, Nathalie, Kerr, William C., McFarland, Bentson H., Nolte, Kurt B., 2017 The National Violent Death Reporting System: Use of the Restricted Access Database and Recommendations for the System's Improvement American Journal of Preventive Medicine, 53 (1), 130-133. doi: 10.1016/j.amepre.2017.01.043 Impact Factor: 4.46

Kaplan, M. S., Huguet, N., Caetano, R., Giesbrecht, N., Kerr, W. C., McFarland, B. H., 2015 Economic contraction, alcohol intoxication and suicide: analysis of the National Violent Death Reporting System Injury Prevention, 21 (1), 35-41. doi: 10.1136/injuryprev-2014-041215 Impact Factor: 1.693 Abstract

Objectives: Although there is a large and growing body of evidence concerning the impact of contracting economies on suicide mortality risk, far less is known about the role alcohol consumption plays in the complex relationship between economic conditions and suicide. The aims were to compare the postmortem alcohol intoxication rates among male and female suicide decedents before (2005-2007), during (2008-2009) and after (2010-2011) the economic contraction in the USA. Methods: Data from the restricted National Violent Death Reporting System (2005-2011) for male and female suicide decedents aged 20 years and older were analysed by Poisson regression analysis to test whether there was significant change in the fractions of suicide decedents who were acutely intoxicated at the time of death (defined as blood alcohol content >/=0.08 g/dL) prior, during and after the downturn. Results: The fraction of all suicide decedents with alcohol intoxication increased by 7% after the onset of the recession from 22.2% in 2005-2007 to 23.9% in 2008-2011. Compared with the years prior to the recession, male suicide decedents showed a 1.09-fold increased risk of alcohol intoxication within the first 2 years of the recession. Surprisingly, there was evidence of a lag effect among female suicide decedents, who had a 1.14-fold (95% CI 1.02 to 1.27) increased risk of intoxication in 2010-2011 compared with 2005-2007. Conclusions: These findings suggest that acute alcohol intoxication in suicide interacts with economic conditions, becoming more prevalent during contractions.

Kaplan, Mark S., Huguet, Nathalie, Caetano, Raul, Giesbrecht, Norman, Kerr, William C., McFarland, Bentson H., 2016 Heavy alcohol use among suicide decedents relative to a nonsuicide comparison group: Gender-specific effects of economic contraction Alcoholism: Clinical and Experimental Research, 40 (7), 1501-1506. doi: 10.1111/acer.13100 Impact Factor: 2.53 Abstract

Background: The primary objective of this gender-stratified study was to assess the rate of heavy alcohol use among suicide decedents relative to a nonsuicide comparison group during the 2008 to 2009 economic crisis. Methods: The National Violent Death Reporting System and the Behavioral Risk Factor Surveillance System were analyzed by gender-stratified multiple logistic regression to test whether change in acute intoxication (blood alcohol content = 0.08 g/dl) before (2005 to 2007), during (2008 to 2009), and after (2010 to 2011) the Great Recession mirrored change in heavy alcohol use in a living sample. Results: Among men, suicide decedents experienced a significantly greater increase (+8%) in heavy alcohol use at the onset of the recession (adjusted ratio of odds ratio = 1.15, 95% confidence interval = 1.10 to 1.20) (relative to the prerecession period) than did men in a nonsuicide comparison group (-2%). Among women, changes in rates of heavy alcohol use were similar in the suicide and nonsuicide comparison groups at the onset and after the recession. Conclusions: Acute alcohol use contributed to suicide among men during the recent economic downturn. Among women who died by suicide, acute alcohol use mirrored consumption in the general population. Women may show resilience (or men, vulnerability) to deleterious interaction of alcohol with financial distress.

Kelley-Baker, Tara, Waehrer, Geetha, Pollini, Robin A., 2017 Prevalence of self-reported prescription drug use in a national sample of U.S. drivers Journal of Studies on Alcohol and Drugs, 78 (1), 30–38. Impact Factor: 2.035 Abstract

Objective: Drug-involved driving has become an increasing concern. Although the focus has been on illegal drugs, there is evidence that prescribed medications can impair driving ability. The purpose of this study was to determine the self-reported prevalence of prescription drug use, including medical and nonmedical use, among a nationally representative sample of drivers and to report related driver characteristics. Method: As part of the 2013–2014 National Roadside Survey, drivers from 60 sites were randomly recruited and asked to complete a survey on prescription drug use. Results: Almost 20% of drivers reported using a prescription drug within the past 2 days, with the most common drug class being sedatives (8.0%), followed by antidepressants (7.7%), narcotics (7.5%), and stimulants (3.9%). Drivers who reported prescription drug use were significantly more likely to be female, older, non-Hispanic White, and report disability. Three of four drivers who reported medication use (78.2%) said the drug was prescribed for their use; the odds of using without a prescription were significantly higher for males, Black/African American, and Hispanic drivers, and lower for older drivers. Among those with a prescription, taking more than prescribed was most common for narcotics (6.8%), followed by sedatives (4.8%), stimulants (3.8%), and antidepressants (1.5%). Conclusions: These findings help to identify drivers using potentially impairing prescription drugs, both medically and nonmedically, and may inform the targeting of interventions to reduce impaired driving related to medications.

Kerr, William C., Kaplan, Mark S., Huguet, Nathalie, Caetano, Raul, Giesbrecht, Norman, McFarland, Bentson H., 2017 Economic Recession, Alcohol, and Suicide Rates: Comparative Effects of Poverty, Foreclosure, and Job Loss American Journal of Preventive Medicine, 52 (4), 469-475. doi: 10.1016/j.amepre.2016.09.021 Impact Factor: 4.46 Abstract

Introduction: Suicide rates and the proportion of alcohol-involved suicides rose during the 2008-2009 recession. Associations between county-level poverty, foreclosures, and unemployment and suicide rates and proportion of alcohol-involved suicides were investigated. Methods: In 2015, National Violent Death Reporting System data from 16 states in 2005-2011 were utilized to calculate suicide rates and a measure of alcohol involvement in suicides at the county level. Panel models with year and state fixed effects included county-level measures of unemployment, foreclosure, and poverty rates. Results: Poverty rates were strongly associated with suicide rates for both genders and all age groups, were positively associated with alcohol involvement in suicides for men aged 45-64 years, and negatively associated for men aged 20-44 years. Foreclosure rates were negatively associated with suicide rates for women and those aged =65 years but positively related for those aged 45-64 years. Unemployment rate effects on suicide rates were mediated by poverty rates in all groups. Conclusions: Population risk of suicide was most clearly associated with county-level poverty rates, indicating that programs addressing area poverty should be targeted for reducing suicide risk. Poverty rates were also associated with increased alcohol involvement for men aged 45-64 years, indicating a role for alcohol in suicide for this working-aged group. However, negative associations between economic indicators and alcohol involvement were found for four groups, suggesting that non-economic factors or more general economic effects not captured by these indicators may have played a larger role in alcohol-related suicide increases.

Keyes, Katherine M., Vo, Thomas, Wall, Melanie M., Caetano, Raul, Suglia, Shakira F., Martins, Silvia S., Galea, Sandro, Hasin, Deborah, 2015 Racial/ethnic differences in use of alcohol, tobacco, and marijuana: Is there a cross-over from adolescence to adulthood? Social Science & Medicine, 124132-141. doi: 10.1016/j.socscimed.2014.11.035 Impact Factor: 2.814 Abstract

Black adolescents in the US are less likely to use alcohol, marijuana, and tobacco compared with non-Hispanic Whites, but little is known about the consistency of these racial/ethnic differences in substance use across the lifecourse. Understanding lifecourse patterning of substance use is critical to inform prevention and intervention efforts. Data were drawn from four waves of the National Longitudinal Study of Adolescent Health (Add Health; Wave 1 (mean age = 16): N = 14,101; Wave 4 (mean age = 29): N = 11,365). Outcomes included alcohol (including at-risk drinking, defined as 5+/4+ drinks per drinking occasion or 14+/7+ drinks per week on average for men and women, respectively), cigarette, and marijuana use in 30-day/past-year. Random effects models stratified by gender tested differences-in-differences for wave by race interactions, controlling for age, parents' highest education/income, public assistance, and urbanicity. Results indicate that for alcohol, Whites were more likely to use alcohol and engage in at-risk alcohol use at all waves. By mean age 29.9, for example, White men were 2.1 times as likely to engage in at-risk alcohol use (95% C.I. 1.48–2.94). For cigarettes, Whites were more likely to use cigarettes and smoked more at Waves 1 through 3; there were no differences by Wave 4 for men and a diminished difference for women, and difference-in-difference models indicated evidence of convergence. For marijuana, there were no racial/ethnic differences in use for men at any wave. For women, by Wave 4 there was convergence in marijuana use and a cross-over in frequency of use among users, with Black women using more than White women. In summary, no convergence or cross-over for racial/ethnic differences through early adulthood in alcohol use; convergence for cigarette as well as marijuana use. Lifecourse patterns of health disparities secondary to heavy substance use by race and ethnicity may be, at least in part, due to age-related variation in cigarette and marijuana use.

Lipperman-Kreda, Sharon, Gruenewald, Paul J., Grube, Joel W., Bersamin, Melina, 2017 Adolescents, alcohol, and marijuana: Context characteristics and problems associated with simultaneous use Drug and Alcohol Dependence, 17955-60. doi: 10.1016/j.drugalcdep.2017.06.023 Impact Factor: 3.349 Abstract

We investigated contexts of simultaneous use of alcohol and marijuana and the impact of simultaneous use on problems among adolescents. Ecological momentary assessment data were obtained over two weekends from 150 adolescents in California (47% female, M age=16.36years), using smartphone surveys administered early and late in the evening and again the following morning. We assessed whether, in what context, and with whom adolescents drank alcohol and used other substances over 3 evening hours. We assessed problems they experienced each evening on the following morning. Results showed that greater adult supervision in every context was associated with a 55% lower risk of simultaneous use (RRR=0.45, p=.05). Contexts with no other underage drinkers were associated with 99% lower risk of simultaneous use (RRR=0.01, p=.005). Each occasion of simultaneous use was related to 110% increase in the number of problems (IRR=2.10, p=.005), with 83%, 221% and 311% greater odds of violence (OR=1.83, p=.05), driving under the influence or riding with a drunk driver (OR=3.21, p=.05), or being drunk (OR=4.11, p=.005). Additional analyses showed that these problems may be attributed largely to the alcohol consumed in each context. Results demonstrate that it is essential to consider situational and social characteristics of substance use contexts to better understand adolescent simultaneous use of alcohol and drugs and problems.

Madruga, Clarice S., De Saibro, Patricia, Ferri, Cleusa P., Caetano, Raul, Laranjeira, Ronaldo, Pinsky, liana, 2015 Correlated factors and prevalence of alcohol treatment in Brazil: A national survey Addictive Disorders & Their Treatment, 14 (1), 40-46. doi: 10.1097/ADT.0000000000000043 Impact Factor: N/A Abstract

Background: The knowledge of the motivations underlying treatment seeking is essential for the development of campaigns and evidence-based treatment strategies. This study aimed to estimate the rate of alcohol treatment use among Brazilians with alcohol disorders. We also investigated factors associated with willingness to stop drinking and motivation to engage into treatment programs. Method: This is a cross-sectional study using data from the first Brazilian National Alcohol Survey. A subsample of 1590 alcohol users was selected from the original survey, which interviewed 3007 individuals from the Brazilian household population. Prevalence of alcohol disorders and treatment factors were estimated. Mutually adjusted odds ratios with 95% confidence intervals were calculated using the appropriate STATA survey commands. These odds ratios estimate the associations between sociodemographic characteristics and selected alcohol-related problems. Results: Alcohol abuse and/or dependence was identified in 19.2% of the subsample of alcohol users. Nearly half of the participants with alcohol problems were not willing to stop drinking. Less than 10% of the participants with alcohol abuse/dependence that reported willingness to stop drinking have ever treated their alcohol problem, and AA meetings and specialized clinics were the most common treatment options mentioned. Willingness to quit drinking was positively associated with being male, participants who reported the negative impacts of alcohol and psychological problems caused by alcohol. Being advised to stop drinking by a doctor was also significantly associated with willingness to quit. Engagement into treatment was associated with self-reported physical problems, psychological problems, and with being advised to quit by a doctor. Conclusions: This study found very low rates of treatment engagement among participants with alcohol disorders. Our results should help develop treatment strategies more in tune with patients’ motivations to change. There is an urgent need to implement alcohol brief interventions in primary care in Brazil.

Madruga, Clarice S., Viana, Maria Carmen, Abdalla, Renata Rigacci, Caetano, Raul, Laranjeira, Ronaldo, 2017 Pathways from witnessing parental violence during childhood to involvement in intimate partner violence in adult life: The roles of depression and substance use Drug and Alcohol Review, 36 (1), 107-114. doi: 10.1111/dar.12514 Impact Factor: 2.405 Abstract

Introduction and Aims: The aims of this study were to determine the prevalence of witnessing parental violence (WPV) during childhood and of current intimate partner violence (IPV) victimisation and aggression in a Brazilian sample, in order to verify pathways between WPV and involvement in IPV as an adult. Design and Methods: The mediating roles of substance use and depression were investigated. Data came from the Second Brazilian National Alcohol and Drugs Survey, a multi-cluster probabilistic household survey, which gathered information on the use of psychoactive substances, current depressive disorder, history of childhood direct and indirect exposure to domestic violence and IPV in a nationally representative sample. A subsample of 2120 individuals aged 14 years or older was analysed. Weighted prevalence rates, adjusted odds ratio and conditional path models were performed. Results: Being a victim of IPV was reported by 6% of the sample. Thus being, 4.1% reported being IPV perpetrators; these rates were 16.6% and 7.3%, respectively, among those who reported WPV (13%). WPV was associated with being a victim of IPV in adult life, but not with becoming a perpetrator, regardless of being a victim of physical violence during childhood. There was a direct effect of WPV on IPV mediated by depressive symptoms. Alcohol and cocaine consumption and age of drinking initiation mediated only when combined with depressive symptoms. Discussion and Conclusions: Intergenerational transmission models of IPV through exposure during childhood can help to explain the high rates of domestic violence in Brazil. Our findings provide evidence to implement targeted prevention strategies where they are needed most: the victims of premature adverse experiences.

McKinney, Christy M., Caetano, Raul, 2016 Substance use and race and ethnicity 1483.

Miller, Ted, Cohen, Mark, Hendrie, Delia, 2017 Non-economic damages due to physical and sexual assault: Estimates from civil jury awards Forensic Science and Criminology, 2 (1), Article 1. doi: 10.15761/fsc.1000106 Impact Factor: N/A Abstract

This paper presents a detailed study of jury awards for compensatory damages to victims of crime. Such awards typically result when victims sue third parties who are responsible for some form of negligence such as inadequate security or alcohol over-service. We obtained nationwide data on jury awards to crime victims and examined the relationship between physical losses, medical costs, offender and victim characteristics, and the ultimate compensatory jury award. Despite the large variability in jury awards, we were able to explain 45%-50% of the variation in the natural log of jury awards for physical assault. The awards systematically vary with the severity of physical injuries sustained by the victim. Considerably more variation is found in the case of sexual assault. We use our regressions to construct estimates of noneconomic damages – the pain, suffering and reduced quality of life endured by the average victim of violent crime in the U.S.

Miller, Ted, Galvin, Deborah, 2016 Assessing and responding to substance misuse in law enforcement Southern Illinois University Law Journal, 40 (3), 475-500. Impact Factor: 2.829 Abstract

This article assesses the extent of substance misuse among law enforcement personnel. Part I introduces the topic and describes the risks of police work including occupational injury and stress. Part II explores substance misuse rates in law enforcement. Part III provides lessons about how to structure effective prevention. Part IV describes effective workplace programs for preventing or reducing misuse and concludes with a summary of Substance Abuse and Mental Health Services Administration (SAMHSA) workplace prevention resources relevant to law enforcement.

Miller, Ted R., Nygaard, Peter, Gaidus, Andrew, Grube, Joel W., Ponicki, William R., Lawrence, Bruce A., Gruenewald, Paul J., 2017 Heterogeneous costs of alcohol and drug problems across cities and counties in California Alcoholism: Clinical and Experimental Research, 41 (4), 758-768. doi: 10.1111/acer.13337 Impact Factor: 2.53 Abstract

Background: Estimates of economic and social costs related to alcohol and other drug (AOD) use and abuse are usually made at state and national levels. Ecological analyses demonstrate, however, that substantial variations exist in the incidence and prevalence of AOD use and problems including impaired driving, violence, and chronic disease between smaller geopolitical units like counties and cities. This study examines the ranges of these costs across counties and cities in California. Methods: We used estimates of the incidence and prevalence of AOD use, abuse, and related problems to calculate costs in 2010 dollars for all 58 counties and an ecological sample of 50 cities with populations between 50,000 and 500,000 persons in California. The estimates were built from archival and public-use survey data collected at state, county, and city levels over the years from 2009 to 2010. Results: Costs related to alcohol use and related problems exceeded those related to illegal drugs across all counties and most cities in the study. Substantial heterogeneities in costs were observed between cities within counties. Conclusions: AOD costs are heterogeneously distributed across counties and cities, reflecting the degree to which different populations are engaged in use and abuse across the state. These findings provide a strong argument for the distribution of treatment and prevention resources proportional to need.

Miller, Ted R., Steinbeigle, Ryan, Lawrence, Bruce A., Peterson, Cora, Florence, Curtis, Barr, Marilyn, Barr, Ronald G., 2017 Lifetime cost of abusive head trauma at ages 0–4, USA Prevention Science, doi: 10.1007/s11121-017-0815-z Impact Factor: 2.926 Abstract

This paper aims to estimate lifetime costs resulting from abusive head trauma (AHT) in the USA and the break-even effectiveness for prevention. A mathematical model incorporated data from Vital Statistics, the Healthcare Cost and Utilization Project Kids’ Inpatient Database, and previous studies. Unit costs were derived from published sources. From society’s perspective, discounted lifetime cost of an AHT averages $5.7 million (95% CI $3.2–9.2 million) for a death. It averages $2.6 million (95% CI $1.0–2.9 million) for a surviving AHT victim including $224,500 for medical care and related direct costs (2010 USD). The estimated 4824 incident AHT cases in 2010 had an estimated lifetime cost of $13.5 billion (95% CI $5.5–16.2 billion) including $257 million for medical care, $552 million for special education, $322 million for child protective services/criminal justice, $2.0 billion for lost work, and $10.3 billion for lost quality of life. Government sources paid an estimated $1.3 billion. Out-of-pocket benefits of existing prevention programming would exceed its costs if it prevents 2% of cases. When a child survives AHT, providers and caregivers can anticipate a lifetime of potentially costly and life-threatening care needs. Better effectiveness estimates are needed for both broad prevention messaging and intensive prevention targeting high-risk caregivers.

Mills, Britain A., Caetano, Raul, 2016 Alcohol use and related problems along the United States–Mexico border Alcohol Research: Current Reviews, 38 (1), 79-81. Impact Factor: 3.528 Abstract

This article discuses the alcohol use and related problems along the United States–Mexico border. The southern border the United States shares with Mexico has been of particular interest to alcohol researchers because of the presence of multiple risk factors conducive to alcohol related problems. The border also separates two distinct geopolitical areas with longstanding differences in alcohol policy. In Mexico, the legal drinking age is 18, compared with 21 in the United States, and alcohol is comparatively inexpensive. U.S. residents living near the country’s border with Mexico are at higher risk for alcohol use and related consequences. This risk is accentuated among young people and is tightly connected to this group’s higher frequency of bar attendance, whether on the U.S. or Mexico side of the border. Travelling to Mexico to drink— a major focus of early border research—contributes to this risk but falls short of fully explaining it. U.S. policymakers should be aware that high levels of alcohol-related risks on the border are not simply a south-of-the-border phenomenon. To a large extent, they reflect factors within U.S. borders that are under their direct control.

Reingle, J.M., Caetano, R., Mills, B.A., Vaeth, P.A.C., 2015 Drinking context and companions as predictors of alcohol use among border and non-border Mexican Americans Hispanic Journal of Behavioral Science, 31 (1), 1-13. doi: DOI: 10.1177/0739986314564569 Impact Factor: .603 Abstract

Alcohol dependence is prevalent among Mexican Americans, as 15% of men meet the threshold for dependency. Drinking in a bar increases the odds of binge drinking; however, research is not clear regarding whether drinking companions within the bar setting further increases risk. Therefore, we examine whether drinking place (bars) and companion (friends) have direct or synergistic effects on binge drinking. Data included two samples of Mexican American drinkers, one group who resides along the U.S.-Mexico border (N = 691) and a similar group living in large cities that are not proximal to the border (N = 660). Among border residents, drinking with friends was significantly associated with binge drinking on the maximum drinking occasion. Drinking at bars was associated with increased drinking among non-border residents only. These findings suggest that drinking context and choosing friends as drinking companions are related to one’s propensity to binge drink on a single heavy drinking occasion, and these risk factors differ across context.

Rennie, S, Groves, AK, Hallfors, DD, Iritani, BJ, Odongo, FS, Luseno, WK, 2017 The significance of benefit perceptions for the ethics of HIV research involving adolescents in Kenya Journal of Empirical Research on Human Research Ethics, doi: doi.org/10.1177/1556264617721556 Impact Factor: 1.352 Abstract

Assessment of benefits is traditionally regarded as crucial to the ethical evaluation of research involving human participants. We conducted focus group discussions (FGDs) with health and other professionals engaged with adolescents, caregivers/parents, and adolescents in Siaya County, Kenya, to solicit opinions about appropriate ways of conducting HIV research with adolescents. Our data revealed that many focus group participants have a profoundly positive conception of participation in health research, including studies conferring seemingly few benefits. In this article, we identify and analyze five different but interrelated types of benefits as perceived by Kenyan adolescent and adult stakeholders in HIV research, and discuss their ethical significance. Our findings suggest that future empirical and conceptual research should concentrate on factors that may trigger researcher obligations to improve benefit perceptions among research participants.

Roberts, Sarah, Thomas, Sue, Treffers, Ryan, Drabble, Laurie, 2017 Forty years of state alcohol and pregnancy policies in the USA: Best practices for public health or efforts to restrict women’s reproductive rights? Alcohol and Alcoholism, 1-7. doi: 10.1093/alcalc/agx047 Impact Factor: 2.54 Abstract

Short Summary: The number of states with alcohol and pregnancy policies has increased since 1970 (1 in 1974 and 43 in 2013). Alcohol and pregnancy policies are becoming increasingly punitive. These punitive policies are associated with efforts to restrict women’s reproductive rights rather than policies that effectively curb alcohol-related public health harms. Aims: Alcohol consumption during pregnancy remains a public health problem despite >40 years of attention. Little is known about how state policies have evolved and whether policies represent public health goals or efforts to restrict women’s reproductive rights. Methods: Our data set includes US state policies from 1970 through 2013 obtained through original legal research and from the National Institute for Alcohol Abuse and Alcoholism’s (NIAAA)’s Alcohol Policy Information System. Policies were classified as punitive to women or supportive of them. The association between numbers of punitive policies and supportive policies in 2013 with a measure of state restrictions on reproductive rights and Alcohol Policy Effectiveness Scores (APS) was estimated using a Pearson’s correlation. Results: The number of states with alcohol and pregnancy policies has increased from 1 in 1974 to 43 in 2013. Through the 1980s, state policy environments were either punitive or supportive. In the 1990s, mixed punitive and supportive policy environments began to be the norm, with punitive policies added to supportive ones. No association was found between the number of supportive policies in 2013 and a measure of reproductive rights policies or the APS, nor was there an association between the number of punitive policies and the APS. The number of punitive policies was positively associated, however, with restrictions on reproductive rights. Conclusion: Punitive alcohol and pregnancy policies are associated with efforts to restrict women’s reproductive rights rather than effective efforts to curb public health harms due to alcohol use in the general population. Future research should explore the effects of alcohol and pregnancy policies.

Romano, E., de la Rosa, M., Sanchez, M., Babino, R., 2017 Riding with impaired drivers among recent Latino immigrants in southern Florida Journal of Immigrant and Minority Health, doi: 10.1007/s10903-016-0511-2 Impact Factor: 1.314 Abstract

In a previous effort we showed that compared with immigrants who are permanent residents, undocumented immigrants are more likely to binge drink, but less likely to drink while impaired (DWI) partly due to their limited amount of driving. This report examines a related risk: riding with an impaired driver (RWI). Data came from an ongoing longitudinal sample of Latino immigrants to Miami-Dade County, FL. Descriptive analyses and regression techniques were applied. While DWI rates among Latino immigrants is heavily limited by their access to a car, RWI rates were not restricted by driving limitations, nor related to participants' legal immigration status (LIS). RWI rates were linked only to heavy drinking. Because it is not affected by driving limitations, RWI for these Latino immigrants is perhaps a more immediate risk than DWI. Addressing RWI among Latino immigrants should be a priority for traffic safety to Miami/Dade country.

Romano, Eduardo, Voas, Robert B, Camp, Bayliss, 2017 Cannabis and crash responsibility while driving below the alcohol per se legal limit Accident Analysis & Prevention, 10837-43. doi: 10.1016/j.aap.2017.08.003 Impact Factor: 2.07 Abstract

There is a growing interest in how extensively the use of marijuana by drivers relates to crash involvement. While cognitive, lab-based studies are consistent in showing that the use of cannabis impairs driving tasks, epidemiological, field-based studies have been inconclusive regarding whether cannabis use causes an increased risk of accidents. There is ample evidence that the presence of cannabis among drivers with a BAC=0.08g/dL highly increases the likelihood of a motor vehicle crash. Less clear, however, is the contribution of cannabis to crash risk when drivers have consumed very little or no alcohol. This effort addresses this gap in knowledge. We took advantage of a unique database that merged fatal crashes in the California Statewide Integrated Traffic Records System (SWITRS) and the Fatality Analysis Reporting System (FARS), which allows for a precise identification of crash responsibility. To account for recent increase in lab testing, we restricted our sample to cover only the years 1993-2009. A total of 4294 drivers were included in the analyses. Descriptive analyses and logistic regressions were run to model the contribution of alcohol and drugs to the likelihood of being responsible in a fatal crash. We found evidence that compared with drivers negative for alcohol and cannabis, the presence of cannabis elevates crash responsibility in fatal crashes among drivers at zero BACs (OR=1.89) and with 0<BAC<0.05g/dL (OR=3.42), suggesting that emphasis on curbing impaired driving should not be solely focused on heavy-drinking drivers. Data limitations however caution about the generalizability of study findings. Special efforts to understand the effect of cannabis on fatal crashes, in particular in the absence of alcohol, are needed.

Russell, Cristel Antonia, Russell, Dale Wesley, Grube, Joel W., McQuarrie, Edward, 2017 Alcohol Storylines in Television Episodes: The Preventive Effect of Countering Epilogues Journal of Health Communication, 22 (8), 657-665. Impact Factor: 1.614 Abstract

This experimental study assessed whether alcohol television storylines impact youth drinking attitudes and intentions and whether corrective epilogues can potentially moderate this impact. Television episodes were professionally produced to depict heavy drinking leading to either positive or negative consequences. The pro- and anti-alcohol episodes were shown alone or with an epilogue where a main character discussed the deleterious effects of excessive drinking. Attitudes toward drinkers and drinking intentions were measured subsequently, along with reactions to the episode and demographic data, among participants aged 14–17 using an online study. Exposure to the pro-alcohol episode was related to more positive attitudes toward drinkers. Including an epilogue after a pro-alcohol episode was related to more negative viewers’ attitudes toward drinkers and lower drinking intentions compared to a pro-alcohol episode with no epilogue. By contrast, including an epilogue after an anti-alcohol episode was unrelated to attitudes toward drinkers or drinking intentions. Viewing a single television episode with a pro-alcohol message may lead to more positive attitudes toward drinkers. The finding that a brief epilogue may reduce the impact of the pro-alcohol storyline suggests easily implemented preventive strategies to counter the adverse impact of substance use portrayals in entertainment programming.

Scherer, M., Canham, S., Voas, R.B., Furr-Holden, C.D., 2017 Intercorrelation of alcohol and other drug use disorders among a national sample of drivers Journal of Psychoactive Drugs, doi: 10.1080/02791072.2017.1366605 Impact Factor: 1.175 Abstract

This study examined the relationship between alcohol, marijuana, cocaine, and painkiller use disorders in a sample of drivers. We studied nighttime drivers aged 16 to 87 (n = 4,277) from the 2007 National Roadside Survey who reported substance use behaviors and provided breath tests for alcohol. Logistic regression analyses assessed the relationships between (1) substance (i.e., alcohol/marijuana/cocaine/pain killer) use disorders; (2) demographic characteristics; and (3) BAC levels. Overall, 13.2% of participants met criteria for marijuana use disorder, 7% met criteria for cocaine use disorder, and 15.4% met criteria for extra-medicinal painkiller use disorder. When self-report data were analyzed, three reciprocal associations emerged: (1) marijuana use disorders and alcohol use disorders were correlated; (2) marijuana use disorders and cocaine use disorders were correlated; and (3) cocaine use disorders and painkiller use disorders were correlated. BAC data revealed that marijuana and cocaine use disorders were both associated with positive BAC levels, but only cocaine use disorders were associated with BAC levels over the legal limit. Results suggest significant poly-substance use disorders in a sample of nighttime drivers, with variations by demographic characteristics. The individual and public health consequences of multiple substance use disorders among drivers are significant.

Scherer, Michael, Romano, Eduardo, Caldwell, Susan, Taylor, Eileen, 2017 The impact of retail beverage service training and social host laws on adolescents’ DUI rates in San Diego County, California Traffic Injury Prevention, doi: 10.1080/15389588.2017.1350268 Impact Factor: 1.14 Abstract

Introduction: Driving under the influence (DUI) citations are still a serious concern among drivers aged 16-20 years and have been shown to be related to increased risk of fatal and non-fatal crashes. A battery of laws and policies has been enacted to address this concern. While numerous studies have evaluated these policies, there is still a need for comprehensive policy evaluations that take into account a variety of contextual factors. Previous effort by this research team examined the impact of 20 minimum legal drinking age (MLDA)-21 laws in the state of California, as they impacted alcohol-related crash rates among drivers under 21 years of age while at the same time accounting for alcohol and gas taxes, unemployment rates, sex distribution among drivers, and sobriety checkpoints. The current research seeks to expand this evaluation to the county level (San Diego, County). More specifically, we evaluate the impact of measures subject to County control such as Retail Beverage Service (RBS) laws and Social Host (SH) laws, as well as media coverage, city employment, alcohol outlet density, number of sworn officers, alcohol consumption, and taxation policies to determine the most effective point of intervention for communities seeking to reduce underage DUI citations. Methods: Annual DUI citation data (2000 to 2013), RBS and SH policies, and city-wide demographic, economic, and environmental information were collected and applied to each of the 20 cities in San Diego County, California. A structural equation model was fit to estimate the relative contribution of the variables of interest to DUI citation rates. Results: Alcohol consumption and alcohol outlet density both demonstrated a significant increase in DUI rates, while RBS laws, SH laws, alcohol tax rates, media clusters, gas tax rates and unemployment rates demonstrated significant decreases in DUI rates. Conclusions: At the county level, although RBS, SH laws, and media efforts were found to contribute to a significant reduction in DUI rates, the largest significant contributors to reducing DUI rates were alcohol and gas taxation rates. Policy makers interested in reducing DUI rates among teenagers, should examine these variables within their specific communities and consider conducting community-specific research to determine the best way to do so. Future efforts should be made to develop models that represent specific communities who are interested in reducing DUI rates among drivers aged 16-20 years.

Smith, Michael, Miller, Ted R, Zaloshnja, Eduard, 2017 Enduring enrollments in West Virginia’s Medicaid programme due to severe injury Injury Prevention, doi: 10.1136/injuryprev-2017-042373 Impact Factor: 1.693 Abstract

Objective: To assess frequency, duration and costs of Medicaid conversions that occur when severe injury causes patients to enrol in Medicaid to pay their hospital bills. Once enrolled, Medicaid pays all their medical bills, not simply their injury bill. Data sources 2000–2005 West Virginia Medicaid claims data and 2000–2006 eligibility data for new enrollees under the age of 65. To model national costs, published Medicaid conversion rates across 14 states for 2003 and 2008 Healthcare Cost and Utilization Program Nationwide Inpatient Sample data. Methods: We identified enrollees who had hospital inpatient claims for injury within 30 days of enrolment, then tabulated eligibility duration and payments by year and in aggregate. For those with open-ended eligibility, we assumed future annual claims payments would equal average payments in eligibility years 5–6. We multiplied the mean payments data adjusted to national prices with the estimated conversions nationally. Results: Overall, 5.4% of hospitalised patients with injury in West Virginia converted to Medicaid, with 17% of conversions on Medicaid 7?years post injury. In 2010 dollars, Medicaid payments averaged $93?900 per conversion for non-injury medical care before the age of 65. Conversions added an estimated $87 in payments for non-injury care to governments’ medical payments per medically treated injury in the USA. They added 14% to governments’ gunshot and assault medical payments, 7.5% to its road crash medical payments and 6% to its total injury medical payments. Conclusions: These findings increase the rationale for governments to partner in injury prevention efforts.

Vaeth, Patrice A. C., Caetano, Raul, Mills, Britain A., 2016 Factors associated with depression among Mexican Americans living in U.S.–Mexico border and non-border areas Journal of Immigrant and Minority Health, 18 (4), 718-727. doi: 10.1007/s10903-015-0236-7 Impact Factor: 1.314 Abstract

Factors associated with CES-D depression among Mexican Americans living on and off the U.S.–Mexico border are examined. Data are from two studies of Mexican American adults. The Border Survey conducted face-to-face interviews in urban U.S.–Mexico border counties of California, Arizona, New Mexico, and Texas (N = 1307). The non-border HABLAS survey conducted face-to-face interviews in Houston, Los Angeles, New York, Philadelphia, and Miami (N = 1288). Both surveys used a multistage cluster sample design with response rates of 67 and 76 %, respectively. The multivariate analysis showed that border residence and higher perceived neighborhood collective efficacy were protective for depression among men. Among men, lower education, unemployment, increased weekly drinking, and poor health status were associated with depression. Among women, alcohol-related problems and poorer health status were also associated with depression. Further examinations of how neighborhood perceptions vary by gender and how these perceptions influence the likelihood of depression are warranted.

Vaeth, Patrice A. C., Wang-Schweig, Meme, Caetano, Raul, 2017 Drinking, Alcohol Use Disorder, and Treatment Access and Utilization Among U.S. Racial/Ethnic Groups Alcoholism, Clinical And Experimental Research, 41 (1), 6-19. doi: 10.1111/acer.13285 Impact Factor: 2.53 Abstract

Data from approximately 140 articles and reports published since 2000 on drinking, alcohol use disorder (AUD), correlates of drinking and AUD, and treatment needs, access, and utilization were critically examined and summarized. Epidemiological evidence demonstrates alcohol-related disparities across U.S. racial/ethnic groups. American Indians/Alaska Natives generally drink more and are disproportionately affected by alcohol problems, having some of the highest rates for AUD. In contrast, Asian Americans are less affected. Differences across Whites, Blacks, and Hispanics are more nuanced. The diversity in drinking and problem rates that is observed across groups also exists within groups, particularly among Hispanics, Asian Americans, and American Indians/Alaska Natives. Research findings also suggest that acculturation to the United States and nativity affect drinking. Recent studies on ethnic drinking cultures uncover the possible influence that native countries' cultural norms around consumption still have on immigrants' alcohol use. The reasons for racial/ethnic disparities in drinking and AUD are complex and are associated with historically rooted patterns of racial discrimination and persistent socioeconomic disadvantage. This disadvantage is present at both individual and environmental levels. Finally, these data indicate that admission to alcohol treatment is also complex and is dependent on the presence and severity of alcohol problems but also on a variety of other factors. These include individuals' sociodemographic characteristics, the availability of appropriate services, factors that may trigger coercion into treatment by family, friends, employers, and the legal system, and the overall organization of the treatment system. More research is needed to understand facilitators and barriers to treatment to improve access to services and support. Additional directions for future research are discussed.

Voas, Robert, Tippetts, A. S., Bergen, G., Grosz, M., Marques, P., 2016 Mandating treatment based on interlock performance: Evidence for effectiveness Alcoholism: Clinical and Experimental Research, 40 (9), 1953-1960. doi: 10.1111/acer.13149 Impact Factor: 2.53 Abstract

Background: Vehicle alcohol ignition interlocks reduce alcohol-impaired driving recidivism while installed, but recidivism reduction does not continue after removal. It has been suggested that integrating alcohol use disorder (AUD) treatment with interlock programs might extend the effectiveness of interlocks in reducing recidivism beyond their removal. This study evaluated the first implementation of a Florida policy mandating AUD treatment for driving under the influence (DUI) offenders on interlocks. Treatment was required when the offender accumulated 3 violations (defined as 2 "lockouts" within 4 hours; a lockout occurs when the device prevents a drinking driver from starting the vehicle). Methods: Cox regression was used to compare alcohol-impaired driving recidivism during the 48 months following the interlock removal between 2 groups: (i) 640 multiple DUI offenders who received AUD treatment while interlocks were installed; and (ii) 806 matched offenders not mandated to treatment while interlocks were installed. Results: The ignition interlock plus treatment group experienced 32% lower recidivism, 95% confidence interval [9, 49], following the removal of the interlock during the 12 to 48 months in which they were compared with the nontreatment group. We estimated that this decline in recidivism would have prevented 41 rearrests, 13 crashes, and almost 9 injuries in crashes involving the 640 treated offenders over the period following interlock removal. Conclusions: This study provides strong support for the inclusion of AUD treatment for offenders in interlock programs based on the number of times they are "locked out." The offenders required to attend treatment demonstrated a one-third lower DUI recidivism following their time on the interlock compared to similar untreated offenders.

Willging, CE, Trott, E, Fettes, D, Gunderson, L, Green, A, Hurlburt M, Aarons G, 2017 Research-Supported Intervention and Discretion among Frontline Workers Implementing Home Visitation Services Research on Social Work Practice, 27 (6), 11. doi: https://doi.org/10.1177/1049731515601897 Impact Factor: 1.586 Abstract

Objective: We examine how frontline workers and supervisors delivering a research-supported intervention (RSI) to reduce child neglect negotiated system-related challenges, the pragmatics of RSI implementation, and their professional identities and relationships with clients. Methods: We conducted semi-structured interviews, small group discussions, and focus groups with frontline workers and supervisors in one large county over two time periods. We used iterative coding to analyze qualitative data. Results: Frontline workers navigated several aspects of RSI implementation and sustainment: (1) contract requirements and information dissemination, (2) fidelity, (3) competing demands and crises, (4) structure versus creativity, and (5) relationships with clients. Conclusions: Workers dynamically negotiated multiple system- and provider-level (or outer- and inner-contextual) demands influencing RSI provision for clients with complex service needs. Results affirm the need to attend to the unintended consequences of implementing new contract, reimbursement, and other system or organizational processes and to address the “committed work” supporting RSI delivery.