Positive Influences and Challenges for the Deaf Community Navigating Access to HIV Information, Testing, and Treatment in Kampala, Uganda: A Qualitative Study.

Although sub-Saharan Africa has the highest HIV burden globally, few studies have investigated disabilities and HIV in this region. We conducted a secondary analysis of text data from in-depth interviews (2014-2015) to describe HIV perceptions among a subsample of 73 deaf individuals participating in the Crane survey, Kampala, Uganda. Being deaf was defined as being profoundly or functionally deaf, having deafness onset 5 + years ago, and preferring sign language to communicate. Among participants ever tested for HIV (47%), most (88%) had a negative test. Thematic analysis revealed overcoming challenges/barriers followed by socioeconomic status, support systems, HIV, stigma, abuse, and health conditions as major themes. An unanticipated finding was the role of sex work to support basic living needs. The data showed related themes among participants, suggesting a complex context in which deaf participants experience HIV prevention and treatment. It is important to tailor HIV interventions for deaf and disabled persons.

Patterns of marijuana and tobacco use associated with suboptimal self-rated health among US adult ever users of marijuana.

The purpose of this study was to examine the patterns of marijuana and tobacco use and their associations with suboptimal self-rated health (SRH) among US adults who reported "ever, even once, using marijuana or hashish." Data came from the 2009-2012 National Health and Nutrition Examination Survey, restricting to respondents aged 20 years and older who reported using marijuana at least once in their lifetime (n = 3,210). We assessed the age-adjusted prevalence of mutually exclusive groups of regular (at least once a month for more than one year) and non-regular marijuana smoking by current (serum cotinine ≥ 3.08 ng/mL) and not current use of tobacco. Suboptimal SRH status was defined as "fair" or "poor" in response to the question "Would you say that in general your health is excellent, very good, good, fair, or poor?" We produced prevalence ratios with multivariable log-linear regression models. Among ever users of marijuana, the age-adjusted prevalence of regular marijuana smoking with current tobacco use, non-regular marijuana smoking with current tobacco use, and regular marijuana smoking without current tobacco use was 24.7%, 15.2%, and 21.1%, respectively. When compared to non-regular marijuana smokers without current tobacco use, the adjusted prevalence ratio for reporting suboptimal SRH was 1.98 (95% CI: 1.50-2.61), 1.82 (95% CI: 1.40-2.37), and 1.34 (95% CI: 1.05-1.69), respectively. In conclusion, among adult ever users of marijuana, current tobacco use is high and strongly associated with suboptimal SRH; regular marijuana smoking with or without current tobacco use is significantly associated with suboptimal SRH.

Modes of ever marijuana use among adult tobacco users and non-tobacco users-Styles 2014.

BACKGROUND: Tobacco and marijuana use are related behaviors; therefore, it is important to identify how users consume marijuana, and how it varies with tobacco use status. We estimated the modes of ever marijuana use among current, former, and never adult tobacco users. METHODS: Weighted data were analyzed for 4181 adults from 2014 Styles, an online consumer panel survey of US adults, to estimate proportions for modes of ever marijuana use. Differences in modes of ever marijuana use between categories of tobacco use status were assessed (p-value <0.05). RESULTS: More than half of current (56.6%) and former tobacco users (50.9%) had ever used marijuana, whereas only 13.0% of never tobacco users had ever used marijuana. Among ever marijuana users, joint use was the most common mode of use among current (86.4%), former (92.5%), and never (79.8%) tobacco users. Similarly, other modes of marijuana use were significantly higher in current and former tobacco users compared to never tobacco users. CONCLUSIONS: Prevalence of all modes of ever marijuana use was higher in current and former tobacco users. These findings underscore the importance of considering the relationship between marijuana and tobacco use when developing programs and policies aimed at preventing and reducing marijuana use.

National Surveys and Tobacco Use Among African Americans: A Review of Critical Factors.

INTRODUCTION: Beginning in the 1970s, US national surveys showed African American youth having a lower prevalence of cigarette smoking than white youth. Yet, during adulthood, African Americans have a smoking prevalence comparable to white adults. Data sources chosen can contribute in different ways to understanding tobacco use behaviors among African American youth and adults; this article is a review of national and/or state-based health surveys to examine their methodology, racial and ethnic classifications, and tobacco-use related measures. METHODS: Eleven national and/or state based surveys were selected for review. Eight surveys were multitopic and included questions on tobacco use and three surveys were tobacco specific. Survey methods included telephone (4), household (3), and school (4). Three major characteristics examined for each survey were: (1) survey design and methods, (2) racial and ethnic background classification, and (3) selected tobacco smoking questions. Within these three characteristics, 15 factors considered to be important for examining tobacco use behaviors by African Americans were identified a priori using previously published reviews and studies. RESULTS: Within survey design and methods, the majority of surveys (≥7) oversampled African Americans and did not use proxy respondents for tobacco questions. All surveys used Office of Management and Budget standard classification for race/ethnicity classification. The majority of surveys (≥7) captured five of the seven tobacco-related smoking questions. CONCLUSIONS: Programmatic objectives and/or research questions should guide the selection of data sources for tobacco control programs and researchers examining African American tobacco use behaviors. IMPLICATIONS: This review of 11 national and state tobacco-related surveys shows that these surveys provide much needed estimates of tobacco use behaviors. However, as tobacco programs and researchers seek to examine tobacco use behaviors among African Americans, it is important to consider multiple surveys as each can contribute to informing the tobacco experience in African Americans. Most importantly, programmatic objectives and/or research questions should guide the selection of data sources for tobacco control programs and researchers examining African American tobacco use behaviors.

Not Just Cigarettes: A More Comprehensive Look at Marijuana and Tobacco Use Among African American and White Youth and Young Adults.

INTRODUCTION: Cigarettes, cigars, and marijuana have generally been studied in isolation yet their use does not occur in isolation. Focus on cigarette smoking may overstate the observation that African American youth and young adults are less likely to smoke any combustible product compared with their white counterparts. Assessing cigarette, cigar, and marijuana use trends may help identify the extent of this difference. METHODS: Data from the 2002-2012 National Survey on Drug Use and Health (N = 25 541 to N = 28 232) were used to investigate past 30-day cigarette, cigar, and marijuana use trends among African American and white youth (12-17) and young adults (18-25). Logistic regressions assessed trends in combustible tobacco (cigarettes and cigars) and marijuana use, alone and in combination. RESULTS: From 2002-2012, the absolute difference in cigarette smoking prevalence between African American and white youth (9.6%-4.2%) and young adults (19.0%-10.5%) narrowed. Any combustible tobacco/marijuana use was significantly lower among African Americans than whites but, relative to cigarettes, the absolute difference was much smaller among youth (7.2%-2.2%) and young adults (15.8%-5.6%). Among any combustible tobacco/marijuana users, using two or more substances ranged from 31.4% to 40.3% among youth and 29.1% to 39.8% among young adults. CONCLUSION: Any combustible tobacco/marijuana use trends suggest the smoking prevalence difference between African American and white youth and young adults is real, but less pronounced than when assessing cigarette smoking alone. Policies and programs addressing smoking behaviors may benefit from broadening focus to monitor and address cigar and marijuana use as well. IMPLICATIONS: Trends in any use of cigarettes, cigars, and/or marijuana suggest the difference in smoking prevalence between African American and white youth and young adults is real, but less pronounced than when cigarette smoking is assessed alone. In 2012, more than 10% of African American and white youth, more than a third of African American young adults, and nearly half of white young adults reported past 30-day use of cigarette, cigars, and/or marijuana. Public health programs aimed at reducing these behaviors among youth and young adults could be informed by considering detailed, race-specific information regarding tobacco and marijuana use patterns.

Exposure and response to current text-only smokeless tobacco health warnings among smokeless tobacco users aged ≥18years, United States, 2012-2013.

INTRODUCTION: We assessed US adult smokeless tobacco (SLT) users' exposure and response to SLT health warnings, which are currently in text-only format, covering 30% of the two primary surfaces of SLT containers and 20% of advertisements. METHODS: Data were from the 2012-2013 National Adult Tobacco Survey. Past 30-day exposure to SLT health warnings among past 30-day SLT users (n=1626) was a self-report of seeing warnings on SLT packages: "Very often," "Often," or "Sometimes" (versus "Rarely" or "Never"). We measured the association between SLT health warning exposure and perceptions of SLT harmfulness and addictiveness using logistic regression. RESULTS: Of past 30-day SLT users, 77.5% reported exposure to SLT health warnings, with lower prevalence reported among females and users of novel SLT products (snus/dissolvable tobacco). Furthermore, exposure reduced linearly with reducing education and annual household income (p<0.01). Among exposed past 30-day SLT users, 73.9% reported thinking about the health risks of SLT, while 17.1% reported stopping SLT use on ≥1 occasion within the past 30days. Exposure to SLT warnings was associated with perceived SLT harmfulness (AOR=2.16; 95% CI=1.15-4.04), but not with perceived SLT addictiveness. CONCLUSION: Socioeconomic disparities found in exposure and response to SLT health warnings can be addressed through implementation of large pictorial warnings.

Vital Signs: Exposure to Electronic Cigarette Advertising Among Middle School and High School Students - United States, 2014.

INTRODUCTION: Electronic cigarette (e-cigarette) use has increased considerably among U.S. youths since 2011. Tobacco use among youths in any form, including e-cigarettes, is unsafe. Tobacco product advertising can persuade youths to start using tobacco. CDC analyzed data from the 2014 National Youth Tobacco Survey to estimate the prevalence of e-cigarette advertisement exposure among U.S. middle school and high school students. METHODS: The 2014 National Youth Tobacco Survey, a school-based survey of middle school and high school students in grades 6-12, included 22,007 participants. Exposure to e-cigarette advertisements (categorized as "sometimes," "most of the time," or "always") was assessed for four sources: retail stores, Internet, TV and movies, and newspapers and magazines. Weighted exposure estimates were assessed overall and by school type, sex, race/ethnicity, and grade. RESULTS: In 2014, 68.9% of middle and high school students (18.3 million) were exposed to e-cigarette advertisements from at least one source. Among middle school students, exposure was highest for retail stores (52.8%), followed by Internet (35.8%), TV and movies (34.1%), and newspapers and magazines (25.0%). Among high school students, exposure was highest for retail stores (56.3%), followed by Internet (42.9%), TV and movies (38.4%), and newspapers and magazines (34.6%). Among middle school students, 23.4% reported exposure to e-cigarette advertising from one source, 17.4% from two sources, 13.7% from three sources, and 11.9% from four sources. Among high school students, 21.1% reported exposure to e-cigarette advertising from one source, 17.0% from two sources, 14.5% from three sources, and 18.2% from four sources. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Approximately seven in 10 U.S. middle and high school students were exposed to e-cigarette advertisements in 2014. Exposure to e-cigarette advertisements might contribute to increased use of e-cigarettes among youths. Multiple approaches are warranted to reduce youth e-cigarette use and exposure to e-cigarette advertisements, including efforts to reduce youth access to settings where tobacco products, such as e-cigarettes, are sold, and regulation of youth-oriented e-cigarette marketing.

Tobacco and Marijuana Initiation Among African American and White Young Adults.

INTRODUCTION: African American youth use marijuana at similar rates and tobacco at lower rates compared with white youth; however, in adulthood, tobacco use is similar. Tobacco and marijuana use are closely associated; differing initiation patterns may contribute to observed racial differences in tobacco prevalence by age. Therefore, it is important to assess tobacco and marijuana initiation patterns by race. METHODS: Data were obtained from 56,555 adults aged 18-25 who completed the 2005-2012 National Survey on Drug Use and Health. The analysis was restricted to those who reported ever use of marijuana and combustible tobacco (cigarettes and/or cigars). Three mutually exclusive categories of initiation patterns were evaluated: use of marijuana before tobacco; marijuana and tobacco at the same age; and tobacco before marijuana. Multivariable regression models were used to assess changes over time and compare these outcomes by race while controlling for sociodemographics, risk perceptions, and current substance use. RESULTS: In 2005, 26.6% of African American and 14.3% of white young adults used marijuana before tobacco, compared with 41.5% of African American and 24.0% of white young adults in 2012 (P < .001). Overall, African American young adults had greater odds of using marijuana before tobacco (AOR = 1.79; 95% CI: 1.67, 1.91) compared with whites. CONCLUSION: African American young adults were more likely than whites to use marijuana before tobacco and both groups were increasingly likely to use marijuana before tobacco over time. A greater understanding of how marijuana initiation interacts with tobacco initiation could inform more effective tobacco and marijuana use prevention efforts. IMPLICATIONS: Among ever users of combustible tobacco and marijuana, greater proportions of African American young adults used marijuana before tobacco or at the same age than their white counterparts. Moreover, both African Americans and whites were more likely to use marijuana before tobacco in 2012 compared with 2005. Tobacco control policy may benefit from a broader understanding of the patterns of initiation to tobacco and marijuana use. Some public health interventions aimed at preventing and reducing combustible tobacco use among African American young adults may be strengthened by considering marijuana use.

Openness to Using Non-cigarette Tobacco Products Among U.S. Young Adults.

INTRODUCTION: National data indicate that the prevalence of non-cigarette tobacco product use is highest among young adults; however, little is known about their openness to use these products in the future and associated risk factors. This study sought to characterize openness to using non-cigarette tobacco products and associated factors among U.S. young adults. METHODS: In 2014, National Adult Tobacco Survey data (2012-2013) were analyzed to characterize openness to using the following tobacco products among all young adults aged 18-29 years (N=5,985): cigars; electronic cigarettes ("e-cigarettes"); hookah; pipe tobacco; chew, snuff, or dip; snus; and dissolvables. Among those who were not current users of each product, multivariable logistic regression was used to examine associations between demographics, cigarette smoking status, lifetime use of other non-cigarette products, perceived harm and addictiveness of smoking, and receipt of tobacco industry promotions and openness to using each product. RESULTS: Among all young adults, openness to using non-cigarette tobacco products was greatest for hookah (28.2%); e-cigarettes (25.5%); and cigars (19.1%). In multivariable analyses, which included non-current users of each product, non-current ever, current, and former smokers were more likely than never smokers to be open to using most examined products, as were men and adults aged 18-24 years. Receipt of tobacco industry promotions was associated with openness to using e-cigarettes; chew, snuff, or dip; and snus. CONCLUSIONS: There is substantial openness to trying non-cigarette tobacco products among U.S. young adults. Young adults are an important population to consider for interventions targeting non-cigarette tobacco product use.

Cigarette, Cigar, and Marijuana Use Among High School Students - United States, 1997-2013.

What is already known on this topic? Since 2010, the proportion of U.S. 12th grade students who reported using marijuana during the preceding 30 days (21.4%) has surpassed the proportion reporting use of cigarettes during the preceding 30 days (19.2%).What is added by this report? During 1997­2013, the proportion of white, black, and Hispanic high school students overall who were exclusive cigarette or cigar users decreased 64%, from 20.5% to 7.4%. The proportion of white, black, and Hispanic students who were exclusive marijuana users more than doubled from 4.2% to 10.2%, and among cigarette or cigar users, marijuana use increased, with considerable increases identified among black and Hispanic students toward the end of the study period.What are the implications for public health practice? Despite significant declines since 1997, approximately 30% of white, black, and Hispanic U.S. high school students were current users of cigarettes, cigars, or marijuana in 2013. Policy and programmatic efforts might benefit from integrated approaches that focus on reducing the use of tobacco and marijuana among youths.

Associations of Self-Reported Cigarette Smoking with Chronic Obstructive Pulmonary Disease and Co-Morbid Chronic Conditions in the United States.

BACKGROUND: The question of how smoking, COPD, and other chronic diseases are related remains unresolved. Therefore, we examined relationships between smoking, COPD, and 10 other chronic diseases and assessed the prevalence of co-morbid chronic conditions among people with COPD. METHODS: We analyzed cross-sectional data from 405,856 US adults aged 18 years or older in the 2011 Behavioral Risk Factor Surveillance System. We used log-linear regression to estimate prevalence ratios (PRs) and their corresponding 95% confidence intervals (CIs) for these relationships adjusting for age, gender, race/ethnicity, marital status, educational attainment, annual household income, and health insurance coverage. RESULTS: Overall, 17.5% reported being current cigarette smokers, 6.9% reported having COPD, and 71.2% reported another chronic condition. After age-adjustment, prevalence of COPD was 14.1% (adjusted PR = 3.9; 95% CI: 3.7, 4.1) among current smokers and 7.1% (adjusted PR = 2.5; 95% CI: 2.4, 2.7) among former smokers compared to 2.9% among never smokers. The most common chronic conditions among current smokers after age-adjustment were high cholesterol (36.7%), high blood pressure (34.6%), arthritis (29.4%), depression (27.4%), and asthma (16.9%). In separate multivariable models, smoking and COPD were associated with each of the 10 other chronic conditions (p < 0.05), which also included cancer, coronary heart disease, diabetes, kidney disease, and stroke; COPD modified associations between smoking and co-morbidities, while smoking did not modify associations between COPD and co-morbidities. CONCLUSIONS: Our findings confirm previous evidence and highlight the continuing importance of comprehensive care coordination for people with COPD and co-morbid chronic conditions and also tobacco prevention and control strategies.

Clinical interventions to reduce secondhand smoke exposure among pregnant women: a systematic review.

OBJECTIVE: To conduct a systematic review of clinical interventions to reduce secondhand smoke (SHS) exposure among non-smoking pregnant women. DATA SOURCES: We searched 16 databases for publications from 1990 to January 2013, with no language restrictions. STUDY SELECTION: Papers were included if they met the following criteria: (1) the study population included non-smoking pregnant women exposed to SHS, (2) the clinical interventions were intended to reduce SHS exposure at home, (3) the study included a control group and (4) outcomes included either reduced SHS exposure of non-smoking pregnant women at home or quit rates among smoking partners during the pregnancy of the woman. DATA EXTRACTION: Two coders independently reviewed each abstract or full text to identify eligible papers. Two abstractors independently coded papers based on US Preventive Services Task Force criteria for study quality (good, fair, poor), and studies without biochemically-verified outcome measures were considered poor quality. DATA SYNTHESIS: From 4670 papers, we identified five studies that met our inclusion criteria: four focused on reducing SHS exposure among non-smoking pregnant women, and one focused on providing cessation support for smoking partners of pregnant women. All were randomised controlled trials, and all reported positive findings. Three studies were judged poor quality because outcome measures were not biochemically-verified, and two were considered fair quality. CONCLUSIONS: Clinical interventions delivered in prenatal care settings appear to reduce SHS exposure, but study weaknesses limit our ability to draw firm conclusions. More rigorous studies, using biochemical validation, are needed to identify strategies for reducing SHS exposure in pregnant women.

Sex-specific relationships between adverse childhood experiences and chronic obstructive pulmonary disease in five states.

PURPOSE: Adverse childhood experiences (ACEs) before age 18 have been repeatedly associated with several chronic diseases in adulthood such as depression, heart disease, cancer, diabetes, and stroke. We examined sex-specific relationships between individual ACEs and the number of ACEs with chronic obstructive pulmonary disease (COPD) in the general population. MATERIALS AND METHODS: Data from 26,546 women and 19,015 men aged ≥18 years in five states of the 2011 Behavioral Risk Factor Surveillance System were analyzed. We used log-linear regression to estimate prevalence ratios (PRs) and their corresponding 95% confidence intervals (CIs) for the relationship of eight ACEs with COPD after adjustment for age group, race/ethnicity, marital status, educational attainment, employment, asthma history, health insurance coverage, and smoking status. RESULTS: Some 63.8% of women and 62.2% of men reported ≥1 ACE. COPD was reported by 4.9% of women and 4.0% of men. In women, but not in men, there was a higher likelihood of COPD associated with verbal abuse (PR =1.30, 95% CI: 1.05, 1.61), sexual abuse (PR =1.69, 95% CI: 1.36, 2.10), living with a substance abusing household member (PR =1.49, 95% CI: 1.23, 1.81), witnessing domestic violence (PR =1.40, 95% CI: 1.14, 1.72), and parental separation/divorce (PR =1.47, 95% CI: 1.21, 1.80) during childhood compared to those with no individual ACEs. Reporting ≥5 ACEs (PR =2.08, 95% CI: 1.55, 2.80) compared to none was associated with a higher likelihood of COPD among women only. CONCLUSION: ACEs are related to COPD, especially among women. These findings underscore the need for further research that examines sex-specific differences and the possible mechanisms linking ACEs and COPD. This work adds to a growing body of research suggesting that ACEs may contribute to health problems later in life and suggesting a need for program and policy solutions.

Frequent mental distress, chronic conditions, and adverse health behaviors in the Behavioral Risk Factor Surveillance Survey, Jordan, 2007.

INTRODUCTION: Recent evidence indicates that chronic diseases and mental illness are associated. In the Middle Eastern country of Jordan, chronic diseases and frequent mental distress (FMD) are increasing; however, the capacity for mental health care is limited. The objective of this study was to determine the association between FMD, chronic conditions, and adverse health behaviors in Jordan. METHODS: The third cycle of the Jordan Behavioral Risk Factor Surveillance Survey (2007) served as the data source for this study. The sample consisted of 3,612 noninstitutionalized Jordanian adults aged 18 years or older. Logistic regression was used to obtain odds ratios for the association between chronic conditions, health behaviors, and FMD adjusted for age, sex, marital status, education, income, and employment. RESULTS: In the adjusted models, people with hypertension (adjusted odds ratio [AOR], 2.0; 95% confidence interval [CI], 1.6-2.7), high cholesterol (AOR, 2.3; 95% CI, 1.6-3.2), diabetes (AOR, 1.6; 95% CI, 1.1-2.4), and asthma (AOR, 2.2; 95% CI, 1.5-3.1) and smokers (AOR, 1.5; 95% CI, 1.1-2.0) were more likely to have FMD than people without each of these conditions. Adults who reported vigorous physical activity were less likely to have FMD (AOR, 0.6; 95% CI, 0.4-0.9) than their less active counterparts. CONCLUSIONS: In Jordan, FMD was associated with several chronic conditions. As a result, we suggest additional research to examine the complex relationship between FMD and chronic conditions. More doctors in the primary health care system should be trained in mental health.

Fifty-five years of international epidemic-assistance investigations conducted by CDC's disease detectives.

For more than 60 years, the Centers for Disease Control and Prevention (CDC) has used its scientific expertise to help people throughout the world live healthier, safer, longer lives through science-based health action. In 1951, CDC officially established the Epidemic Intelligence Service to help build public health capacity. During 1950-2005, CDC's Epidemic Intelligence Service officers conducted 462 international epidemiologic field investigations in 131 foreign countries and 7 territories. Investigations have included responding to emerging infectious and noninfectious disease outbreaks, assisting in disaster response, and evaluating core components of public health programs worldwide. Approximately 81% of investigations were responses to infectious disease outbreaks, but the proportion of investigations related to chronic and other noninfectious conditions increased 7-fold (6%-45%). These investigations have contributed to detecting and characterizing new pathogens (e.g., severe acute respiratory syndrome-associated coronavirus) and conditions, provided insights regarding factors that cause or contribute to disease acquisition (e.g., Ebola hemorrhagic fever), led to development of new diagnostics and surveillance technologies, and provided information upon which global health policies and regulations can be based. CDC's disease detectives will undoubtedly continue to play a critical role in global health and in responding to emerging global disease threats.

Leadership in strategic information (LSI) building skilled public health capacity in Ethiopia.

BACKGROUND: In many developing countries, including Ethiopia, few have the skills to use data for effective decision making in public health. To address this need, the U.S. Centers for Disease Control and Prevention (CDC), in collaboration with two local Ethiopian organizations, developed a year long Leadership in Strategic Information (LSI) course to train government employees working in HIV to use data from strategic information sources. A process evaluation of the LSI course examined the impact of the training on trainees' skills and the strengths and weaknesses of the course. The evaluation consisted of surveys and focus groups. FINDINGS: Trainees' skill sets increased in descriptive and analytic epidemiology, surveillance, and monitoring and evaluation (M and E). Data from the evaluation indicated that the course structure and the M and E module required revision in order to improve outcomes. Additionally, the first cohort had a high attrition rate. Overall, trainees and key stakeholders viewed LSI as important in building skilled capacity in public health in Ethiopia. CONCLUSION: The evaluation provided constructive insight in modifying the course to improve retention and better address trainees' learning needs. Subsequent course attrition rates decreased as a result of changes made based on evaluation findings.