Adolescent Advertising Exposure to Cannabis Products in Rural Oklahoma via Medical Dispensaries.

OBJECTIVE: We assess cannabis advertising exposure among adolescents in rural Oklahoma from medical dispensaries. METHOD: Our mixed-methods study identified medical dispensaries within a 15-minute drive time of rural Oklahoma high schools. Study staff completed observational data collection forms and took photographs of each dispensary. Quantitative data from the forms and qualitative coding of photographs were used to describe dispensary characteristics and likely advertising exposure for adolescents. RESULTS: Ninety-two dispensaries were identified across 20 rural communities. The majority presented as retail spaces (n = 71). Product (n = 22) and price promotions (n = 27) were common. Coding of dispensary photographs found that product promotions advertised cannabis use modalities, with cannabis flower being the most common (n = 15), followed by edibles (n = 9) and concentrates (n = 9). Among dispensaries with price promotions, discounts (n = 19) and prices under $10 (n = 14) were common. CONCLUSIONS: Sampled rural medical dispensaries present as retail spaces and are a likely source of adolescent cannabis advertising exposure.

Theory, Measurement, and Psychometric Properties of Risk and Protective Factors for Drug Misuse Among Adolescents Living on or near the Cherokee Nation Reservation.

A team of tribe-based behavioral health specialists and university-based researchers partnered to implement a cluster randomized trial for the prevention of drug misuse among adolescents attending public high schools on or near the Cherokee Nation Reservation in northeastern Oklahoma. The conceptual framework, which guided intervention and measurement design for the trial, incorporates indigenous knowledge and worldviews with empirically-based frameworks and evidence-based practices. Our goal is to serve multicultural youth, families, and schools and to provide a model of effective strategies for wide dissemination. This paper presents the conceptual model, survey design, and psychometric properties of scales to measure risk and protective factors for substance misuse. The survey includes common measures drawn from the PhenX Toolkit on substance use patterns-adolescent module, measured with standard items from the Monitoring the Future (MTF) study and items harmonized across ten NIH-funded research projects with diverse samples of youth. In our trial, brief (20-minute) self-report questionnaires were administered to 10th grade students in fall 2021 (n = 919, 87% response rate) and spring 2022 (n = 929, 89% response rate) in 20 participating high schools on or near the Cherokee Nation Reservation. The sample primarily fell into the following three categories of race/ethnicity identification: only American Indian (AI-only, 29%), AI and another race/ethnicity (AI+, 27%), and only White (35%). Results indicate that risk and protective factor scales were reliably and validly measured with 10 scales and 10 subscales. There were minimal differences between youth who identified as AI only, AI+, and White only, especially for the main scales, which provide confidence in the interpretation of trial outcomes across demographic groups. Study results may not be generalizable to AI/AN youth who live and attend school in more homogenous reservation lands, or alternatively, live in large diverse metropolitan areas.

Study protocol for a cluster randomized trial of a school, family, and community intervention for preventing drug misuse among older adolescents in the Cherokee Nation.

BACKGROUND: The national opioid crisis has disproportionately burdened rural White populations and American Indian/Alaska Native (AI/AN) populations. Therefore, Cherokee Nation and Emory University public health scientists have designed an opioid prevention trial to be conducted in rural communities in the Cherokee Nation (northeast Oklahoma) with AI and other (mostly White) adolescents and young adults. Our goal is to implement and evaluate a theory-based, integrated multi-level community intervention designed to prevent the onset and escalation of opioid and other drug misuse. Two distinct intervention approaches-community organizing, as implemented in our established Communities Mobilizing for Change and Action (CMCA) intervention protocol, and universal school-based brief intervention and referral, as implemented in our established Connect intervention protocol-will be integrated with skill-based training for adults to strengthen social support for youth and also with strategic media. Furthermore, we will test systems for sustained implementation within existing organizational structures of the Cherokee Nation and local schools and communities. This study protocol describes the cluster randomized trial, designed to measure implementation and evaluate the effectiveness on primary and secondary outcomes. METHODS: Using a cluster randomized controlled design and constrained randomization, this trial will allocate 20 high schools and surrounding communities to either an intervention or delayed-intervention comparison condition. With a proposed sample of 20 high schools, all enrolled 10th grade students in fall 2021 (ages 15 to 17) will be eligible for participation. During the trial, we will (1) implement interventions through the Cherokee Nation and measure implementation processes and fidelity, (2) measure opioid and other drug use and secondary outcomes every 6 months among a cohort of high school students followed over 3 years through their transition out of high school, (3) test via a cluster randomized trial the effect of the integrated CMCA-Connect intervention, and (4) analyze implementation costs. Primary outcomes include the number of days during the past 30 days of (1) any alcohol use, (2) heavy alcohol use (defined as having at least four, among young women, or five, among young men, standard alcoholic drinks within a couple of hours), (3) any marijuana use, and (4) prescription opioid misuse (defined as "without a doctor's prescription or differently than how a doctor or medical provider told you to use it"). DISCUSSION: This trial will expand upon previous research advancing the scientific evidence regarding prevention of opioid and other drug misuse during the critical developmental period of late adolescent transition to young adulthood among a sample of American Indian and other youth living within the Cherokee Nation reservation. TRIAL REGISTRATION: ClinicalTrials.gov NCT04839978 . Registered on April 9, 2021. Version 4, January 26, 2022.

Anti-poverty policy and health: Attributes and diffusion of state earned income tax credits across U.S. states from 1980 to 2020.

PURPOSE: The U.S. federal Earned Income Tax Credit (EITC) is often considered the most effective antipoverty program for families in the U.S., leading to a variety of improved outcomes such as educational attainment, work incentives, economic activity, income, and health benefits for mothers, infants and children. State EITC supplements to the federal credit can significantly enhance the magnitude of this intervention. In this paper we advance EITC and health research by: 1) describing the diffusion of state EITC policies over 40 years, 2) presenting patterns in important EITC policy dimensions across space and time, and 3) disseminating a robust data set to advance future research by policy analysts and scientists. METHODS: We used current public health law research methods to systematically collect, conduct textual legal analysis, and numerically code all EITC legislative changes from 1980 through 2020 in the 50 states and Washington, D.C. RESULTS: First, the pattern of diffusion across states and time shows initial introductions during the 1990s in the Midwest, then spreading to the Northeast, with more recent expansions in the West and South. Second, differences by state and time of important policy dimensions are evident, including size of credit and refundability. Third, state EITC benefits vary considerably by household structure. CONCLUSION: Continued research on health outcomes is warranted to capture the full range of potential beneficial effects of EITCs on family and child wellbeing. Lawyers and policy analysts can collaborate with epidemiologists and economists on other high-quality empirical studies to assess the many dimensions of policy and law that potentially affect the social determinants of health.

Effects of State-Level Earned Income Tax Credit Laws on Birth Outcomes by Race and Ethnicity.

Purpose: Health disparities persist in birth outcomes by mother's income, education, and race in the United States. Disadvantaged mothers may experience benefit from supplements to family income, such as the earned income tax credit (EITC). We examined the effects of state-level EITCs on birth outcomes among women with a high school education or less, stratified by race and ethnicity. Methods: A quasi-experimental multistate and multiyear difference-in-differences design is used to assess effects of the presence and generosity of 23 state-level EITC laws on birth outcomes from 1994 to 2013. The methods utilized the U.S. National Vital Statistics System birth data for the outcomes: birth weight, probability of low birth weight (LBW; <2500 g), and gestation weeks. Results: Across all subgroups, any level of state EITC is associated with better birth outcomes with the largest effects seen among states with more generous EITCs. Black mothers experience larger percentage point reductions in the probability of LBW and increases in gestation duration. Among mothers with a high school education or less, results translate into 3760 fewer LBW babies with black mothers and 8364 fewer LBW babies with white mothers per year at the most generous state EITC level (i.e., 10% or more of federal and refundable). Hispanic and non-Hispanic mothers display relatively similar effects. Conclusions: The EITC at the federal and state level is an effective policy tool to reduce poverty and improve birth outcomes across racial and ethnic subgroups. Given the historically higher risk among black mothers, state-level EITC expansions offer one policy option to address this persistent health disparity.

Effects of changes in earned income tax credit: Time-series analyses of Washington DC.

Poverty has numerous deleterious effects on health, and the Earned Income Tax Credit (EITC) is the major policy tool used to alleviate poverty in the U.S. We evaluate effects of four distinct changes in earned income tax credit law in Washington, DC on maternal behaviors and infant outcomes. An interrupted time-series design was used with 312 monthly measures from 1990 through 2015 analyzed in 2018 (total n = 225,933 births). States with no EITC were included as the comparison group; analyses involved ARIMA modeling. Outcomes were derived from birth certificates, and included percent of live births below 2500 g, mean birth weight, mean gestation weeks, first trimester prenatal care, and maternal smoking during pregnancy. We found a pattern of significant improvements across all three infant outcome measures, with the size of the effect estimate monotonically matching the magnitude of the tax credit-ranging from a 1.9 (-2.9, -0.9) reduction in rate per 100 births of low birth weight for the smaller 10% credit, to a 4.7 (-5.4, -4.0) reduction with the 40% credit. Results for maternal smoking and prenatal care were mixed. Results suggest that earned income tax credit policies improve birth outcomes; mechanisms for this effect deserve further study.

Alcohol retail sales licenses and sexually transmitted infections in Texas counties, 2008-2015.

BACKGROUND: Research suggests that reduced retail alcohol outlet density may be associated with lower prevalence of HIV and other sexually transmitted infections (STIs). On-premise sale of alcohol for immediate consumption is theorized as increasing social interactions that can lead to sexual encounters. OBJECTIVE: We examined associations between on- and off-premise retail alcohol sales licenses and number of newly diagnosed HIV and STI cases in Texas counties. METHODS: Retail alcohol sales license data were obtained from the Texas Alcoholic Beverage Commission. HIV and bacterial STI data were obtained from the Texas Department of State Health Services. Associations between retail alcohol sales licenses and STIs were estimated using spatial linear models and Poisson mixed effects models for over-dispersed count data. RESULTS: Adjusting for county-specific confounders, there was no evidence of residual spatial correlation. In Poisson models, each additional on-premise (e.g., bar and restaurant) alcohol license per 10,000 population in a county was associated with a 1.5% increase (95% CI: 0.4%, 2.6%) in the rate of HIV and a 2.4% increase (95% CI: 1.9%, 3.0%) in the rate of bacterial STIs, adjusting for potential confounders. In contrast, number of off-premise licenses (e.g., take-out stores) was inversely associated with the incidence of STI and HIV, although the association with HIV was not statistically significant. CONCLUSIONS: This study adds to the limited literature on the association between retail alcohol availability and STIs. Additional research is needed on the role of alcohol availability (and policies affecting availability) in the spread of HIV and other STIs.

Effects of Alcohol Interventions on Other Drug Use in the Cherokee Nation.

OBJECTIVES: To evaluate effects of 2 alcohol prevention interventions-Communities Mobilizing for Change on Alcohol (CMCA), a community organizing intervention designed to reduce youth alcohol access, and CONNECT, an individual-level screening and brief intervention approach-on other drug use outcomes. METHODS: We conducted a community intervention trial with quarterly surveys over 3 years (2012-2015) of high school students living within the jurisdictional service area of the Cherokee Nation in Oklahoma. We used generalized estimating equations and linear probability models to examine intervention spillover effects on other drug use. RESULTS: We found significant reductions in drug use other than alcohol attributable to CMCA and CONNECT. CMCA was associated with a 35% reduction in chewing tobacco use, a 39% reduction in marijuana use, and a 48% reduction in prescription drug misuse. CONNECT was associated with a 26% reduction in marijuana use and a 31% reduction in prescription drug misuse. CONCLUSIONS: Nonalcohol drug use was consistently reduced as a result of 2 theoretically and operationally distinct alcohol prevention strategies. Evaluations of alcohol prevention efforts should continue to include other drug use to understand the broader effects of such interventions.

Communities mobilizing for change on alcohol (CMCA): secondary analyses of a randomized controlled trial showing effects of community organizing on alcohol acquisition by youth in the Cherokee nation.

AIMS: We evaluated the effects of a community organizing intervention, Communities Mobilizing for Change on Alcohol (CMCA), on the propensity of retail alcohol outlets to sell alcohol to young buyers without age identification and on alcohol acquisition behaviors of underage youth. DESIGN: Random assignment of community to treatment (n = 3) or control (n = 2). Student surveys were conducted four times per year for 3 years; the cohort was in 9th and 10th grades in the 2012-13 academic year. Alcohol purchase attempts were conducted every 4 weeks at alcohol retailers in each community (31 repeated waves). SETTING: The Cherokee Nation, located in northeastern Oklahoma, USA. PARTICIPANTS: A total of 1399 high school students (50% male; 45% American Indian) and 113 stores licensed to sell alcohol across five study communities. INTERVENTION: Local community organizers formed independent citizen action teams to advance policies, procedures and practices of local institutions in ways to reduce youth access to alcohol and foster community norms opposed to teen drinking. MEASUREMENTS: Perceptions regarding police enforcement and perceived difficulty of and self-reported actual acquisition of alcohol from parents, adults, peers and stores. FINDINGS: Alcohol purchases by young-appearing buyers declined significantly, an 18 [95% confidence interval (CI) = 3, 33] percentage-point reduction over the intervention period. Student survey results show statistically significant differences in the trajectory of perceived police enforcement, increasing 7 (4, 10) percentage points, alcohol acquisition from parents, decreasing 4 (0.1, 8) percentage points, acquisition from 21+ adults, decreasing 6 (0.04, 11) percentage points, from < 21 peers decreasing 8 (3, 13) percentage points and acquisition from stores decreasing 5 (1, 9) percentage points. CONCLUSIONS: A community organizing intervention, Communities Mobilizing for Change on Alcohol (CMCA), is effective in reducing the availability of alcohol to underage youth in the United states. Furthermore, results indicate that the previously reported significant effects of CMCA on teen drinking operate, at least in part, through effects on alcohol access.

Effects of state-level Earned Income Tax Credit laws in the U.S. on maternal health behaviors and infant health outcomes.

The purpose of this paper is to investigate the effects of state-level Earned Income Tax Credit (EITC) laws in the U.S. on maternal health behaviors and infant health outcomes. Using multi-state, multi-year difference-in-differences analyses, we estimated effects of state EITC generosity on maternal health behaviors, birth weight and gestation weeks. We find little difference in maternal health behaviors associated with state-level EITC. In contrast, results for key infant health outcomes of birth weight and gestation weeks show small improvements in states with EITCs, with larger effects seen among states with more generous EITCs. Our results provide evidence for important health benefits of state-level EITC policies.

Recreational Cannabis Legalization and Opioid-Related Deaths in Colorado, 2000-2015.

OBJECTIVES: To examine the association between Colorado's legalization of recreational cannabis use and opioid-related deaths. METHODS: We used an interrupted time-series design (2000-2015) to compare changes in level and slope of monthly opioid-related deaths before and after Colorado stores began selling recreational cannabis. We also describe the percent change in opioid-related deaths by comparing the unadjusted model-smoothed number of deaths at the end of follow-up with the number of deaths just prior to legalization. RESULTS: Colorado's legalization of recreational cannabis sales and use resulted in a 0.7 deaths per month (b = -0.68; 95% confidence interval = -1.34, -0.03) reduction in opioid-related deaths. This reduction represents a reversal of the upward trend in opioid-related deaths in Colorado. CONCLUSIONS: Legalization of cannabis in Colorado was associated with short-term reductions in opioid-related deaths. As additional data become available, research should replicate these analyses in other states with legal recreational cannabis.

Multilevel Prevention Trial of Alcohol Use Among American Indian and White High School Students in the Cherokee Nation.

OBJECTIVES: To evaluate the effectiveness of a multilevel intervention designed to prevent underage alcohol use among youths living in the Cherokee Nation. METHODS: We randomly assigned 6 communities to a control, Communities Mobilizing for Change on Alcohol (CMCA; a community-organizing intervention targeting alcohol access) only, CONNECT (a school-based universal screening and brief intervention) only, or a combined condition. We collected quarterly surveys 2012-2015 from students starting in 9th and 10th grades and ending in 11th and 12th grades. Response rates ranged from 83% to 90%; 46% of students were American Indian (of which 80% were Cherokee) and 46% were White only. RESULTS: Students exposed to CMCA, CONNECT, and both showed a significant reduction in the probability over time of 30-day alcohol use (25%, 22%, and 12% reduction, respectively) and heavy episodic drinking (24%, 19%, and 13% reduction) compared with students in the control condition, with variation in magnitude of effects over the 2.5-year intervention period. CONCLUSIONS: CMCA and CONNECT are effective interventions for reducing alcohol use among American Indian and other youths living in rural communities. Challenges remain for sustaining intervention effects.

The Effect of an Increased Minimum Wage on Infant Mortality and Birth Weight.

OBJECTIVES: To investigate the effects of state minimum wage laws on low birth weight and infant mortality in the United States. METHODS: We estimated the effects of state-level minimum wage laws using a difference-in-differences approach on rates of low birth weight (< 2500 g) and postneonatal mortality (28-364 days) by state and month from 1980 through 2011. All models included state and year fixed effects as well as state-specific covariates. RESULTS: Across all models, a dollar increase in the minimum wage above the federal level was associated with a 1% to 2% decrease in low birth weight births and a 4% decrease in postneonatal mortality. CONCLUSIONS: If all states in 2014 had increased their minimum wages by 1 dollar, there would likely have been 2790 fewer low birth weight births and 518 fewer postneonatal deaths for the year.

Research design issues for evaluating complex multicomponent interventions in neighborhoods and communities.

Major advances in population health will not occur unless we translate existing knowledge into effective multicomponent interventions, implement and maintain these in communities, and develop rigorous translational research and evaluation methods to ensure continual improvement and sustainability. We discuss challenges and offer approaches to evaluation that are key for translational research stages 3 to 5 to advance optimized adoption, implementation, and maintenance of effective and replicable multicomponent strategies. The major challenges we discuss concern (a) multiple contexts of evaluation/research, (b) complexity of packages of interventions, and (c) phases of evaluation/research questions. We suggest multiple alternative research designs that maintain rigor but accommodate these challenges and highlight the need for measurement systems. Longitudinal data collection and a standardized continuous measurement system are fundamental to the evaluation and refinement of complex multicomponent interventions. To be useful to T3-T5 translational research efforts in neighborhoods and communities, such a system would include assessments of the reach, implementation, effects on immediate outcomes, and effects of the comprehensive intervention package on more distal health outcomes.