The relationship between depressive symptoms and cigarette smoking in US adolescents.

AIMS: Data from the Teenage Attitudes and Practices Survey were analyzed to assess the relationship between depressive symptoms and cigarette smoking. DESIGNS, SETTING, PARTICIPANTS: Nationally representative sample of adolescents interviewed in 1989 and again in 1993. MEASUREMENTS: Prevalence rate and adjusted odds ratio for smoking at follow-up by depressive symptoms status at baseline. FINDINGS: Adolescents with depressive symptoms were more likely than other adolescents to start smoking. CONCLUSIONS: The associations between depressive symptoms and regular smoking appears to be established by adolescence.

Long-term trends in cigarette smoking among young U.S. adults.

Retrospective examination of a national probability sample revealed that young women, particularly those who dropped out of high school, have reached smoking rates as high or higher than subgroups of young men. These results suggest that surveillance, research, and public health programs are needed to address the rapid increase in smoking among young women.

Risk factors for sudden coronary death in the United States.

We assessed risk factors for sudden coronary death among persons without a history of coronary heart disease (unexpected sudden coronary death) and persons with a history of coronary heart disease (sudden coronary heart disease death). We analyzed national data to calculate death rates and odds ratios for both types of sudden coronary death. Among modifiable factors that we examined, only cigarette smoking increased risk for unexpected sudden coronary death [odds ratio (OR) = 1.8; 95% confidence interval (CI) = 1.2-2.7]. Diabetes mellitus (OR = 3.8; 95% CI = 2.5-5.8 for women), cigarette smoking (OR = 1.5; 95% CI = 1.0-2.1), and hypertension (OR = 1.4; 95% CI = 1.1-1.9) increased the risk for sudden coronary heart disease death. Etiologic factors for sudden death appear to differ depending on the presence or absence of coronary disease. With preexisting coronary disease, factors associated with chronic coronary disease may elevate sudden death risk; without coronary disease, factors that provoke ventricular arrhythmias may trigger sudden death.

Socioeconomic status, race, and death from coronary heart disease.

INTRODUCTION: Data to assess factors associated with differences in coronary heart disease mortality between Caucasians and African Americans are limited. We assessed risks for sudden, nonsudden, and other coronary death between Caucasians and African Americans in relation to known risk factors for coronary disease and socioeconomic status. METHODS: We analyzed data from the 1986 National Mortality Followback Survey, the 1985 National Health Interview Survey, and the U.S. Bureau of the Census. Logistic regression methods were used to create multivariate models to assess the relationship of socioeconomic status and other known modifiable risk factors to death from each of the three coronary diseases for Caucasians and African Americans separately. RESULTS: In an age- and gender-adjusted analysis of data on men 25-44 years old and women 25-54 years old, African Americans had about twice the risk for sudden, nonsudden, or other coronary death as did Caucasians. Adjusted risks for coronary death for Caucasians associated with modifiable risk factors (cigarette smoking, body weight, diabetes, and hypertension) either resembled or were slightly greater than those for African Americans. Half or more of all excess risks for African Americans in multivariate models could be explained by socioeconomic status. About 18% of excess sudden coronary death risk could be further explained by known modifiable coronary heart disease risk factors. CONCLUSIONS: Broad public health efforts are needed to address these causes of excess mortality.

Relationship between cigarette smoking and health risk and problem behaviors among US adolescents.

OBJECTIVE: To examine whether sociodemographic factors and health risk and problem behaviors explain the prevalence of cigarette smoking among US adolescents. DESIGN: Probability survey. PARTICIPANTS: A nationally representative sample of US adolescents. MAIN OUTCOME MEASURES: Weighted prevalence, adjusted odds ratio (OR), and 95% confidence intervals (CIs) for current smoking status by health risk and problem behaviors. RESULTS: The prevalence of smoking was highest among adolescents who were white, older, and who had a high school education or lived in the Northeast. When we adjusted for sociodemographic factors and health risk and problem behaviors, smoking was associated with marijuana use (OR, 3.7; 95% CI, 2.7-5.1), binge drinking (OR, 2.1; 95% CI, 1.6-2.8), and fighting (OR, 1.4; 95% CI, 1.1-1.7) among white adolescent males. Similar associations between each of these 3 behaviors and cigarette smoking were found among white adolescent females and African American and Hispanic adolescent males and females. Cigarette smoking was also associated with using smokeless tobacco, having multiple sexual partners, and not using bicycle helmets among white adolescent males and females, having multiple sexual partners among Hispanic adolescent females, and carrying weapons among Hispanic adolescent males. CONCLUSIONS: Marijuana use, binge drinking, and fighting are correlates of cigarette smoking among US adolescents. These associations, which vary by sex and race or ethnicity, suggest clustering to form a risk behavior syndrome.

Comparison of sudden and nonsudden coronary deaths in the United States.

BACKGROUND: The present study was designed to compare risk factor prevalences in coronary heart disease deaths in persons dying within 1 hour of onset of cardiovascular symptoms (sudden coronary death), those dying without such sudden symptoms (nonsudden coronary death), and those with unknown duration of symptoms before death (other coronary death). METHODS AND RESULTS: Data from the 1986 National Mortality Followback Survey and the US Bureau of the Census were examined to assess death rates for sudden, nonsudden, and other coronary deaths. Multivariate logistic regression methods were used to calculate the odds ratio (OR), compared with nonsudden and other coronary deaths, for sudden coronary death associated with socioeconomic status variables, the person's location at death, and coronary heart disease risk factors. Mortality rates for all coronary deaths increased with age, were higher for men than women, and increased with decreasing years of schooling. The rate of sudden coronary death was highest for Hispanics. In 1986, an estimated 251,000 sudden coronary deaths (95% CI = 238,000 to 263,000) occurred in the United States. Sudden coronary deaths were less likely than nonsudden coronary deaths to occur at home (OR = 0.5, 95% CI = 0.4 to 0.6), but individuals who died of sudden coronary death were more likely to have been current cigarette smokers (OR = 1.3, 95% CI = 1.0 to 1.8). No other modifiable risk factors for coronary heart disease distinguished sudden coronary deaths from nonsudden coronary deaths. CONCLUSIONS: Contrary to the commonly held view, coronary deaths in the home are more likely to be nonsudden than sudden. Cigarette smoking more likely results in sudden than nonsudden coronary death, perhaps because of nicotine-induced ventricular arrhythmias.

Evaluation of smoking on the physical activity and depressive symptoms relationship.

Physical activity is inversely associated with depressive symptoms, and cigarette smoking is positively associated with depressive symptoms. Data from the first National Health and Nutrition Examination Survey (NHANES I) and the NHANES I Epidemiologic Follow-up study were analyzed to determine whether the relationship between physical activity and self-reported distress (depressive symptoms as measured by the Center for Epidemiologic Studies Depression Scale) was different for cigarette smokers and nonsmokers. Logistic regression was used to calculate odds ratios (adjusted for age, race, sex, education, alcohol use, and perceived health status) for depressive symptoms (> or = 16) associated with physical activity and smoking status among 2,054 respondents. At baseline, the odds ratio for depressive symptoms was about 2 times higher for moderately active smokers and nonsmokers, and 3 times higher for low active smokers and nonsmokers, compared with highly active nonsmokers. For 1,132 persons with a low number of depressive symptoms (< 16) at baseline, the incidence of depressive symptoms after 7-9 yr of follow-up was about 2 times higher for low/moderately active smokers and nonsmokers than for highly active nonsmokers. The association between physical activity and the prevalence and incidence of depressive symptoms is not significantly modified by smoking status.

Smoking prevalence in US birth cohorts: the influence of gender and education.

OBJECTIVES: To assess long-term trends in cigarette smoking according to the combined influence of sex and education, this study examined smoking prevalence in successive US birth cohorts. METHODS: Data from nationally representative surveys were examined to assess smoking prevalence for six successive 10-year birth cohorts stratified by race or ethnicity, sex, and educational attainment. RESULTS: Substantial declines in smoking prevalence were found among men who had a high school education or more, regardless of race or ethnicity, and slight declines among women of the same educational background were revealed. However, little change was found in smoking prevalence among men of all race/ethnic groups with less than a high school education, and large increases were found among women with the same years of schooling, especially if they were White or African American. CONCLUSIONS: These data suggest that persons of low educational attainment have yet to benefit from policies and education about the health consequences of cigarette smoking.

Depression and smoking initiation among US Latinos.

We assessed the relationship between depression and smoking initiation among people of Mexican, Puerto Rican and Cuban ancestry residing in specific geographic areas of the United States. Survey data were examined to calculate incidence of smoking initiation and prevalences and odds ratios for ever smoking by presence of depressed mood, a history of major depression or both conditions. Depressed mood, a history of major depression or both conditions were associated with smoking initiation risks during childhood, adolescence and young adulthood. These findings suggest that the relationship between depressive states and smoking initiation is established early in life. More definitive studies are needed to confirm these findings.

Patterns of alcohol use and the risk of drinking and driving among US high school students.

Approximately one third of deaths among persons aged 15 to 24 years are the result of motor vehicle-related crashes. Data from a national sample of US high school students were used to assess patterns of alcohol use among adolescents in relation to the risk of drinking and driving. Prevalence and odds ratios were calculated for drinking and driving associated with patterns of alcohol use. Drinking and driving increased with increasing frequency of alcohol use and binge drinking and when alcohol was used in addition to other drugs. Efforts to reduce drinking and driving among adolescents should address underage drinking that is frequent or heavy.

Anabolic-steroid use, strength training, and multiple drug use among adolescents in the United States.

OBJECTIVE: This study examined the relationships between anabolic-steroid use and the use of other drugs, sports participation, strength training, and school performance among a nationally representative sample of US high school students. DESIGN: Randomized survey data from the 1991 Centers for Disease Control and Prevention Youth Risk Behavior Survey. SETTING: Public and private schools in the 50 United States and District of Columbia. PATIENTS: A total of 12,272 9th through 12th grade students. MAIN OUTCOME MEASURED: Prevalence of anabolic-steroid use. RESULTS: The frequency of anabolic-steroid use was significantly associated with the frequency of use of cocaine, the use of other drugs such as amphetamines and heroin, tobacco smoking, and alcohol use. The weighted prevalences of anabolic-steroid use were higher among male (4.08%) than female students (1.2%). Students living in the South (3.46%) reported higher prevalences than students in the Midwest (3.0%), West (2.02%), or Northeast (1.71%). Students with self-perceived below-average academic performances (5.10%) and students reporting injected drug use also reported higher anabolic-steroid use (51.57%). Based on a multiple logistic regression, the following variables were found to be significant predictors of anabolic-steroid use: injectable drug use (odds ratio [OR], 17.86), use of other drugs (OR, 4.19), male gender (OR, 2.79), alcohol use (OR, 1.38), and strength training (OR, 1.73). The variables that were significantly associated with anabolic-steroid use varied by gender and by region of the country. CONCLUSION: These data suggest that adolescent anabolic-steroid users in this country are more likely to engage in strength training, injected drug use, and the use of multiple drugs, even after controlling for sports participation and poorer academic performance. These data confirm previous findings of an association between multiple drug use and anabolic-steroid use. Also, engaging in strength-training exercises continued to be associated with anabolic-steroid use after controlling for drug use and other predictors.

Race and sex differences in rates of invasive cardiac procedures in US hospitals. Data from the National Hospital Discharge Survey.

BACKGROUND: Lower rates of invasive cardiac procedures have been reported for blacks and women than for white men. However, few studies have adjusted for differences in the type of hospital of admission, insurance status, and disease severity. SETTING, DESIGN, AND PARTICIPANTS: Data from the National Hospital Discharge Survey were used to investigate race and sex differences in rates of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery among 10,348 persons hospitalized for acute myocardial infarction. RESULTS: White men consistently had the highest procedure rates, followed by white women, black men, and black women. After matching for the hospital of admission and adjusting for age, in-hospital mortality, health insurance, and hospital transfer rates (with white men as the referent), the odds ratios for cardiac catheterization were 0.67 (95% confidence interval [CI], 0.51 to 0.87) for black men, 0.72 (95% CI, 0.63 to 0.83) for white women, and 0.50 (95% CI, 0.37 to 0.68) for black women. Similar race-sex differences were noted for percutaneous transluminal coronary angioplasty and coronary artery bypass surgery. CONCLUSIONS: Race and sex differentials in the rates of invasive cardiac procedures remained despite matching for the hospital of admission and controlling for other factors that influence procedure rates, suggesting that the race and sex of the patient influence the use of these procedures.

Epidemiology of tobacco use and dependence.

Knowledge of the epidemiology of tobacco use and dependence can be used to guide research initiatives, intervention programs, and policy decisions. Both the reduction in the prevalence of smoking among US adults and black adolescents and the decline in per capita consumption are encouraging. These changes have probably been influenced by factors operating at the individual (e.g., school-based prevention programs and cessation programs) and environmental (e.g., mass media educational strategies, the presence of smoke-free laws and policies, and the price of tobacco products) levels (for a discussion of these factors, see, e.g., refs. 2, 48, 52, 183, and 184). The lack of progress among adolescents, especially whites and males, and the high risk for experimenters of developing tobacco dependence present cause for great concern (48, 183-186). In addition to those discussed above, several areas of research can be recommended. 1. Better understanding of the clustering of tobacco use with the use of other drugs, other risk behaviors, and other psychiatric disorders could better illuminate the causal processes involved, as well as the special features of the interventions needed to prevent and treat tobacco dependence. 2. To better understand population needs, trend analyses of prevalence, initiation, and cessation should, whenever possible, incorporate standardized measures of these other risk factors. Future research should compare the effect of socioeconomic status variables on measures of smoking behavior among racial/ethnic groups in the United States. 3. For reasons that may be genetic, environmental, or both, some persons do not progress beyond initial experimentation with tobacco use (2, 48, 183, 187-192), but about one-third to one-half of those who experiment with cigarettes become regular users (48, 193, 194). Factors, both individual and environmental, that can influence the susceptibility of individuals to tobacco dependence need further attention. 4. To estimate their sensitivity and specificity, comparisons of the National Household Survey on Drug Abuse indicators of dependence with DSM-based criteria are needed. Public health action continues to be warranted to reduce the substantial morbidity and mortality caused by tobacco use (195). A paradigm for such action has been recommended and involves preventing the onset of use, treating tobacco dependence, protecting non-smokers from exposure to secondhand smoke, promoting nonsmoking messages while limiting the effect of tobacco advertising and promotion on young people, increasing the real (inflation-adjusted) price of tobacco products, and regulating tobacco products (186).

Trends in oral contraceptive use and cigarette smoking. Behavioral Risk Factor Surveillance System, 1982 and 1988.

OBJECTIVE: To investigate trends in oral contraceptive (OC) use and smoking among women of reproductive age and to determine factors related to smoking among OC users. DESIGN, SETTING, AND PARTICIPANTS: Telephone interviews of women aged 18 through 45 years in 16 states and the District of Columbia who participated in the Behavioral Risk Factor Surveillance System in 1982 (N = 3553) and in 1988 (N = 7384). RESULTS: Between 1982 and 1988, the prevalence of smoking decreased from 31% to 24% among OC users and from 32% to 28% among non-OC users. In both 1982 and 1988, more than half of the OC users who smoked were heavy smokers (smoked 15 or more cigarettes per day). Nearly one fourth of 35- to 45-year-old women who used OCs were smokers. After we standardized for age, race, and education, the decline in the prevalence of smoking among OC users did not differ substantially from the decline in smoking among non-OC users. CONCLUSIONS: Despite the possible synergistic effects of smoking and OC use on the risk of cardiovascular disease, we found no accelerated decline in the prevalence of smoking among OC users. As of 1988, nearly one fourth of all OC users were smokers. These data emphasize the need to reduce the prevalence of smoking among women who use OCs before they reach the age at which their risk for cardiovascular disease increases substantially.

Sports participation, age at smoking initiation, and the risk of smoking among US high school students.

OBJECTIVE: To examine smoking patterns, smoking initiation, and the relationship of sports participation and age at smoking initiation to regular and heavy smoking among adolescents. DESIGN: Survey. PARTICIPANTS: A nationally representative sample of US high school students. OUTCOME MEASURES: Prevalences of smoking patterns, prevalence and incidence of smoking initiation, and prevalences and odds of regular and heavy smoking in relation to sports participation and age at smoking initiation. RESULTS: Seventy-two percent of students reported experimenting with, formerly, or ever smoking cigarettes, and 32% reported smoking in the past 30 days. Students who had participated in interscholastic sports were less likely to be regular and heavy smokers than were others who had not participated. Smoking initiation rates increased rapidly after age 10 years and peaked at age 13 to 14 years. Students who began smoking at age 12 years or younger were more likely to be regular and heavy smokers than were students who began smoking at older ages. CONCLUSIONS: These data suggest that smoking initiation at a young age can increase the risk of nicotine addiction during adolescence and that sports participation may influence smoking behavior. Interventions to prevent smoking should be available before age 12 years to help combat the smoking epidemic among youth.

The influence of safety belt laws on self-reported safety belt use in the United States.

We assessed rates and trends in safety belt use by presence and type of safety belt law using data from states participating in the 1984-1989 Behavioral Risk Factor Surveillance System. State(s) with a safety belt law allowing law enforcement officers to stop vehicles for occupants' failure to use safety belts (primary enforcement law) had greater and more rapid increases in safety belt use rates than did states with laws requiring that vehicles must first be stopped for some other violation before a citation or fine for occupants' failure to use safety belts could be imposed (secondary enforcement law). Larger and sustained increases in safety belt use occurred when safety belt laws became effective or when fines were imposed for violations than when laws were first enacted. These data suggest that primary enforcement laws result in greater and more rapid increases in safety belt use than do secondary enforcement laws, and that initial increases in safety belt use following implementation of laws are sustained.

Self-perceived stress and the risk of peptic ulcer disease. A longitudinal study of US adults.

BACKGROUND: Although many physicians and laypersons believe that stress plays a role in the occurrence of peptic ulcer disease, the importance of stress in the pathogenesis of peptic ulcers remains controversial. METHODS: To investigate the relationship between perceived stress and peptic ulcer disease we used data from the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study--a nationally representative cohort study of US adults. This analysis included 4511 persons who had not previously been diagnosed with peptic ulcer disease. RESULTS: At baseline, 68% of the cohort perceived themselves as stressed. During 13 years of follow-up, 208 persons developed ulcers; the cumulative incidence of ulcers was 7.2% for persons who were stressed and 4.0% for persons who were not. After we adjusted for age, sex, education, smoking status, and regular aspirin use, persons who perceived themselves as stressed were 1.8 times more likely to develop ulcers than those who did not (95% confidence interval, 1.3 to 2.5). We also found a graded relationship between the perceived amount of stress and the incidence of peptic ulcers; relative to nonstressed persons, the relative risk of developing an ulcer was 1.4, 1.9, 2.3, 2.4, and 2.9 at five increasing levels of stress. CONCLUSIONS: These findings suggest that persons who perceive their lives as stressful may be at increased risk for the development of peptic ulcer disease.