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1.  Youth Advocacy as a Tool for Environmental and Policy Changes That Support Physical Activity and Nutrition: An Evaluation Study in San Diego County 
As evidence grows about the benefits of policy and environmental changes to support active living and healthy eating, effective tools for implementing change must be developed. Youth advocacy, a successful strategy in the field of tobacco control, should be evaluated for its potential in the field of obesity prevention.
Community Context
San Diego State University collaborated with the San Diego County Childhood Obesity Initiative to evaluate Youth Engagement and Action for Health! (YEAH!), a youth advocacy project to engage youth and adult mentors in advocating for neighborhood improvements in physical activity and healthy eating opportunities. Study objectives included documenting group process and success of groups in engaging in community advocacy with decision makers.
In 2011 and 2012, YEAH! group leaders were recruited from the San Diego County Childhood Obesity Initiative’s half-day train-the-trainer seminars for adult leaders. Evaluators collected baseline and postproject survey data from youth participants and adult group leaders and interviewed decision makers.
Of the 21 groups formed, 20 completed the evaluation, conducted community assessments, and advocated with decision makers. Various types of decision makers were engaged, including school principals, food service personnel, city council members, and parks and recreation officials. Eleven groups reported change(s) implemented as a result of their advocacy, 4 groups reported changes pending, and 5 groups reported no change as a result of their efforts.
Even a brief training session, paired with a practical manual, technical assistance, and commitment of adult leaders and youth may successfully engage decision makers and, ultimately, bring about change.
PMCID: PMC3970770  PMID: 24674636
2.  Evaluation of California's Alcohol and Drug Screening and Brief Intervention Project for Emergency Department Patients 
Introduction: Visits to settings such as emergency departments (EDs) may present a “teachable moment” in that a patient may be more open to feedback and suggestions regarding their risky alcohol and illicit drug-use behaviors. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an 'opportunistic' public health approach that targets low-risk users, in addition to those already dependent on alcohol and/or drugs. SBIRT programs provide patients with comprehensive screening and assessments, and deliver interventions of appropriate intensity to reduce risks related to alcohol and drug use.
Methods: This study used a single group pre-post test design to assess the effect of the California SBIRT service program (i.e., CASBIRT) on 6 substance-use outcomes (past-month prevalence and number of days of binge drinking, illegal drug use, and marijuana use). Trained bilingual/bicultural Health Educators attempted to screen all adult patients in 12 EDs/trauma centers (regardless of the reason for the patient's visit) using a short instrument, and then delivered a brief motivational intervention matched to the patient's risk level. A total of 2,436 randomly selected patients who screened positive for alcohol and/or drug use consented to be in a 6-month telephone follow-up interview. Because of the high loss to follow-up rate, we used an intention-to-treat approach for the data analysis.
Results: Results of generalized linear mixed models showed modest reductions in all 6 drug-and alcohol-use outcomes. Men (versus women), those at relatively higher risk status (versus lower risk), and those with only one substance of misuse (versus both alcohol and illicit drug misuse) tended to show more positive change.
Conclusion: These results suggest that SBIRT services provided in acute care settings are associated with modest changes in self-reported recent alcohol and illicit drug use.
PMCID: PMC3656708  PMID: 23687546
3.  Ethnoracial Differences in Emergency Department Patients’ Tobacco Use 
Nicotine & Tobacco Research  2011;13(11):1037-1044.
This study examined ethnoracial differences in lifetime and recent tobacco use and related problems in a large convenience sample of Latino, Black, and Non-Latino White emergency department (ED) patients. In addition, ED patients’ use rates were compared with those of a statewide sample.
Trained bilingual/bicultural health educators screened almost 53,000 ED patients in 8 ED/trauma units throughout San Diego County over a 2-year period. Measures included sociodemographic characteristics and tobacco use measures from the Alcohol, Smoking, and Substance Involvement Screening Test brief screening instrument.
A consistent finding was the lower prevalence of tobacco use among Latino patients compared with Black and Non-Latino White patients. Compared with their general population counterparts, Non-Latino White, Latino, and Black patients were more likely to have used tobacco in their lifetime and on a daily basis.
Results indicate the high tobacco risk status of ED patients, regardless of ethnicity. More work is needed to develop effective approaches for ED-initiated tobacco interventions for patients in various racial/ethnic groups. Offering tobacco cessation support in opportune venues such as the ED holds great potential to improve accessibility to public health interventions for many underserved communities who may not have regular interaction with a primary care provider.
PMCID: PMC3203134  PMID: 21742651
4.  Adolescents’ Use of Indoor Tanning: A Large-Scale Evaluation of Psychosocial, Environmental, and Policy-Level Correlates 
American journal of public health  2011;101(5):930-938.
We evaluated psychosocial, built-environmental, and policy-related correlates of adolescents’ indoor tanning use.
We developed 5 discrete data sets in the 100 most populous US cities, based on interviews of 6125 adolescents (aged 14–17 years) and their parents, analysis of state indoor tanning laws, interviews with enforcement experts, computed density of tanning facilities, and evaluations of these 3399 facilities’ practices regarding access by youths. After univariate analyses, we constructed multilevel models with generalized linear mixed models (GLMMs).
In the past year, 17.1% of girls and 3.2% of boys had used indoor tanning. The GLMMs indicated that several psychosocial or demographic variables significantly predicted use, including being female, older, and White; having a larger allowance and a parent who used indoor tanning and allowed their adolescent to use it; and holding certain beliefs about indoor tanning’s consequences. Living within 2 miles of a tanning facility also was a significant predictor. Residing in a state with youth-access legislation was not significantly associated with use.
Current laws appear ineffective in reducing indoor tanning; bans likely are needed. Parents have an important role in prevention efforts.
PMCID: PMC3076411  PMID: 21421947
5.  Women's smoking history prior to entering the US Navy: a prospective predictor of performance 
Tobacco Control  2007;16(2):79-84.
To examine whether women's tobacco use prior to entering the US Navy is predictive of subsequent career performance. A priori predictions were that smoking at entry into the Navy would be related to early attrition, poorer job performance, more disciplinary problems and lower likelihood of re‐enlistment.
A prospective cohort analysis of 5487 women entering the US Navy between March 1996 and March 1997 was conducted. Navy attrition/retention and career performance measures, such as time in service, early attrition, type of discharge, misconduct, number of promotions, demotions and unauthorised absences, highest paygrade achieved, and re‐enlistment were examined.
Compared with never smokers, daily smokers at entry into the US Navy had subsequent career outcomes consistently indicating poorer job performance (eg, early attrition prior to serving a full‐term enlistment, more likely to have a less‐than‐honourable discharge, more demotions and desertions, lower achieved paygrade and less likely to re‐enlist). Other types of smokers consistently fell between never and daily smokers on career outcome measures.
For women entering the US Navy, being a daily smoker is a prospective predictor of poorer performance in the Navy. Future research should evaluate the effectiveness of cessation intervention with smoker‐enlistees prior to their entering the Navy, to assess the impact on subsequent career outcomes.
PMCID: PMC2598487  PMID: 17400943
6.  Measuring the stringency of states’ indoor tanning regulations 
We sought to describe the development of an instrument to quantify the stringency of state indoor tanning legislation in the United States, and the instrument’s psychometric properties. The instrument was then used to rate the stringency of state laws.
A 35-item instrument was developed. An overall stringency measure and 9 stringency subscales were developed, including one measuring minors’ access to indoor tanning. Stringency measures showed good internal consistency and interrater reliability.
In all, 55% of the 50 states and the District of Columbia had any indoor tanning law, and 41% had any law addressing minors’ access. Oregon, Illinois, South Carolina, Florida, Indiana, Iowa, and Rhode Island had high overall stringency scores, and Texas and New Hampshire were the most restrictive with regard to minors’ access.
Measurement of actual enforcement of the laws was not included in this study.
The instrument appears to be an easy-to-use, reliable, and valid methodology. Application of the instrument to actual laws showed that, in general, state laws are relatively weak, although there was considerable variability by state.
PMCID: PMC2659685  PMID: 17276543
7.  Enforcement of State Indoor Tanning Laws in the United States 
Preventing Chronic Disease  2008;5(4):A125.
Twenty-eight US states have passed legislation for indoor tanning facilities. To our knowledge, whether these state laws are actually enforced has not been evaluated previously in all 28 states. Therefore, we interviewed key informants in these states to assess enforcement practices.
Two trained interviewers used a structured survey instrument to interview 28 key informants who were knowledgeable about enforcement practices for laws regarding indoor tanning. Respondents provided information specific to the most populous city in their states.
Licensure for indoor tanning businesses was required in 22 of the 28 cities. Slightly less than half of the cities gave citations to tanning facilities that violated state law. Approximately 32% of the cities did not inspect indoor tanning facilities for compliance with state law, and another 32% conducted inspections less than annually. Of those cities that inspected at all, most conducted unannounced inspections.
The relatively low rates of annual inspections and citations are of concern. We recommend that future studies assess whether legislation, enforcement practices, or a combination of the 2 affects the practices of indoor tanning facilities or of consumers.
PMCID: PMC2578791  PMID: 18793513
8.  Randomized clinical trial of the effects of screening and brief intervention for illicit drug use: the life shift/shift gears study 
Although screening, brief intervention, and referral to treatment (SBIRT) has shown promise for alcohol use, relatively little is known about its effectiveness for adult illicit drug use. This randomized controlled trial assessed the effectiveness of the SBIRT approach for outcomes related to drug use among patients visiting trauma and emergency departments (EDs) at two large, urban hospitals.
A total of 700 ED patients who admitted using illegal drugs in the past 30 days were recruited, consented, provided baseline measures of substance use and related problems measured with the Addiction Severity Index-Lite (ASI-Lite), and then randomized to the Life Shift SBIRT intervention or to an attention-placebo control group focusing on driving and traffic safety (Shift Gears). Both groups received a level of motivational intervention matched to their condition and risk level by trained paraprofessional health educators. Separate measurement technicians conducted face-to-face follow-ups at 6 months post-intervention and collected hair samples to confirm reports of abstinence from drug use. The primary outcome measure of the study was past 30-day drug abstinence at 6 months post-intervention, as self-reported on the ASI-Lite.
Of 700 participants, 292 (42%) completed follow-up. There were no significant differences in self-reported abstinence (12.5% vs. 12.0% , p = 0.88) for Life Shift and Shift Gears groups, respectively. When results of hair analyses were applied, the abstinence rate was 7 percent for Life Shift and 2 percent for Shift Gears (p = .074). In an analysis in which results were imputed (n = 694), there was no significant difference in the ASI-Lite drug use composite scores (Life Shift +0.005 vs. Shift Gears +0.017, p = 0.12).
In this randomized controlled trial, there was no evidence of effectiveness of SBIRT on the primary drug use outcome.
Trial registration NCT01683227.
PMCID: PMC4046000  PMID: 24886786
Screening and brief intervention; Drug use; Emergency department patients
9.  Self-Reported Age of Onset and Telescoping for Cigarettes, Alcohol, and Marijuana Across Eight Years of the National Longitudinal Survey of Youth 
Smoking, drinking, and illicit drug use are leading causes of morbidity and mortality, both during adolescence as well as later in life. Although for some adolescents, substance use may last for only a brief period of experimentation, use of these substances in adolescence may have negative consequences. The determination of how well national and local policy and intervention efforts address teen substance use depends largely on the collection of valid and accurate data. Assessments of substance use rely heavily on retrospective self-report measures. The reliability and validity of self-reported substance use measures, however, may be limited by various sources of measurement error. This study utilizes four waves of data from the National Longitudinal Survey of Youth spanning eight years. Our wave-to-wave analyses examined the accuracy of self-reported age of onset for cigarette, alcohol and marijuana users. Findings indicate that approximately one-fourth of cigarette users, one-fifth of alcohol users and one-third of marijuana users reported their age of onset exactly the same across waves. Of those who reported the age of onset inaccurately, the error tended to be in the direction of reporting their age of onset as older at a latter wave relative to what was reported previously, known as forward telescoping. Results from multiple linear regression analyses showed that the single most consistent variable associated with telescoping was the number of years since the substance was first reported. Time since first report was the single consistent and strongly associated with telescoping in each wave-to-wave comparison for all three substances under study. Implications for policy and research are discussed.
PMCID: PMC3532889  PMID: 23284228
10.  Cancer resource center of the desert patient navigator program: removing financial barriers to access to cancer care for rural Latinos 
SpringerPlus  2013;2:15.
Health disparities in cancer mortality for racial/ethnic minorities is a public health concern. Financial barriers are the major factors preventing cancer patients from accessing treatment in a timely manner. This article describes the characteristics of the Cancer Resource Center of the Desert (CRCD) Patient Navigator Program (PNP) in the rural underserved US-Mexico border region of the Imperial Valley. Financial navigation services and the insurance conversion process for cancer treatment are described.
CRCD data from 2010 to 2011 were analyzed to report the characteristics of cancer patients, focusing on insurance status changes. Eighty-one to 87% of the patients served were Latino/Hispanic. A case scenario is presented to depict the financial navigation process in converting the patients’ insurance status. Among the total samples, about 7% (n=32) in 2010 and 16% (n=68) in 2011 were in need of health insurance assistance upon their intake. Financial navigators successfully converted virtually all non- or inadequately-insured rural cancer patients to better insurance status.
Financial concerns are a significant thread that runs throughout the diagnostic, treatment, and post treatment journey of cancer patients. The complicated nature of patients’ circumstances and medical systems often hinders the patients going through the insurance conversion process. PNP plays a critical role in bridging the gap between patients and medical systems thus promoting cancer treatment access for this vulnerable population.
PMCID: PMC3589655  PMID: 23476895
11.  Randomized controlled trial to evaluate screening and brief intervention for drug-using multiethnic emergency and trauma department patients 
Screening and brief intervention (SBI) is a comprehensive, integrated public health approach to identify and deliver a spectrum of early detection and intervention services for substance use in general medical care settings. Although the SBI approach has shown promise for alcohol use, relatively little is known about its effectiveness for illicit drug use. We are evaluating the SBI approach for drug use using a rigorous randomized controlled trial. The purpose of the report is to describe the overall trial and its programmatic and methodological strengths with a focus on health educator (HE) selection and training. In addition, the baseline characteristics of the recently enrolled multiethnic cohort are described.
A randomized two-group repeated measures design is being used in which drug-related outcomes of an intervention group will be compared with those of an attention-placebo control group. Selection of bicultural paraprofessional HEs—their training in research concepts, comorbid mental health issues, special treatment of marijuana use, and nonscripted enhanced motivational interviewing as well as their ongoing monitoring and evaluation—are among the features described. The HEs enrolled, consented, and conducted an intervention among 700 illicit drug users in two large hospital emergency departments/trauma units. To be eligible, a participant needed to be an adult (age ≥18 years), an English or Spanish speaker, awake and able to give consent, and reachable by telephone to schedule a six-month follow-up interview.
A comprehensive HE training protocol combined with rigorous, ongoing process measurement resulted in skill mastery in many areas and a successful participant recruitment period. Strengths and limitations of the study protocol are discussed as well as the characteristics of those recruited. This trial will be among the first to provide information about the effectiveness of SBI for illicit drug use. Outcome analysis has not yet been completed, but demonstrated programming and design successes have implications for future research and service delivery.
Trial registration
PMCID: PMC3642029  PMID: 23566363
SBI; Emergency room patients; Drug use; Health educator; Curriculum; Training; Process measures
12.  Typologies of Recanting of Lifetime Cigarette, Alcohol and Marijuana Use During a Six Year Longitudinal Panel Study 
Drug and alcohol dependence  2011;118(2-3):134-140.
To identify if there are different typologies for adolescent self-reporters and recanters for alcohol, cigarette and marijuana use.
This study is a secondary data analysis and utilized four waves the National Longitudinal Survey of Youth child panel data. The study included adolescents aged ten and older who self-reported ever use of cigarettes (N=872), marijuana (N=854) or alcohol (N=837). Consistent responders were those who reported lifetime use of a specific substance and continued to report such use at each latter wave of data collection. Latent class analyses were utilized to investigate if there are different types of self-reporters for each substance class.
Three unique groups for each substance was identified. The first group of users, who had a late age of onset, tended to be consistent self-reporters across waves. Those who were early onset users of cigarettes and marijuana tended to recant their use while early onset alcohol users were consistent reporters. Those with moderate ages of onset had no consistent recanting patterns. The highest degree of recanting was found among the early onset marijuana users.
The results suggest that youth who begin their use at an earlier age may not be as reliable reporters as youth who initiate use at later ages. Our results suggest the veracity of prevalence estimates for licit and illicit substances could be different depending on the age of the respondent.
PMCID: PMC3164929  PMID: 21524861
13.  Testing the Length of Time Theory of Recall Decay: Examining Substance Use Report Stability With 10 Years of National Longitudinal Survey of Youth Data 
Substance use & misuse  2011;46(9):1105-1112.
This article examines whether the proportion of recanters increases (or decreases) as a function of time o test length of time theory.
2,221 US respondents in the National Longitudinal Survey of Youth child data. Bivariate and logistic regression analyses were used.
Among recanters, 50% of cigarette and alcohol users recanted use by 4 years, and 50% of marijuana users recanted by 3 years. Predictors of recanting was being Black or Hispanic and younger age. The theory was not supported. Further research is needed to identify potential reasons why adolescents recant their use is such a short time span. The study’s limitations are noted.
PMCID: PMC3112355  PMID: 21406007
adolescent; self-report stability; alcohol; cigarette; marijuana; recanting; measurement; theory
15.  Youth Access to Artificial Ultraviolet Radiation Exposure: Practices of 3,647 U.S. Indoor Tanning Facilities 
Archives of dermatology  2009;145(9):997-1002.
To assess indoor tanning facility practices in a sample of facilities in 116 cities representing all 50 states.
Cross-sectional study
United States
Employees of 3,647 indoor tanning facilities were contacted by telephone. Data collectors (i.e., confederates) posed as prospective, fair-skinned, 15-year-old customers who had never tanned before.
Main Outcome Measures
Confederates asked respondents about their facility's practices related to parental consent, parental accompaniment, and allowable tanning session frequency.
Approximately 87% of the facilities required parental consent, 14% required parental accompaniment, 5% said they would not allow the confederate to tan due to her age, and 71% would allow tanning every day the first week of indoor tanning. In Wisconsin, which bans indoor tanning among those younger than 16 years, 70% of facilities would not allow the confederate to tan. Multivariate analyses indicated that facilities in states with a youth access law were significantly more likely to require parental consent and parental accompaniment than those in states without a youth access law. Law was not significantly related to allowable tanning frequency.
We recommend that additional states pass youth access legislation, preferably in the form of bans.
PMCID: PMC2769519  PMID: 19770438
16.  Density of Indoor Tanning Facilities in 116 Large U.S. Cities 
U.S. adolescents and young adults are using indoor tanning at high rates, even though it has been linked to both melanoma and squamous cell cancer. Because the availability of commercial indoor tanning facilities may influence use, data are needed on the number and density of such facilities.
In March 2006, commercial indoor tanning facilities in 116 large U.S. cities were identified, and the number and density (per 100,000 population) were computed for each city. Bivariate and multivariate analyses conducted in 2008 tested the association between tanning-facility density and selected geographic, climatologic, demographic, and legislative variables.
Mean facility number and density across cities were 41.8 (SD=30.8) and 11.8 (SD=6.0), respectively. In multivariate analysis, cities with higher percentages of whites and lower ultraviolet (UV)index scores had significantly higher facility densities than those with lower percentages of whites and higher UV index scores.
These data indicate that commercial indoor tanning is widely available in the urban U.S., and this availability may help explain the high usage of indoor tanning.
PMCID: PMC2656357  PMID: 19215849
17.  The Influence of Parents and Peers on Adolescent Indoor Tanning Behavior: Findings from a Multi-City Sample 
Indoor tanning is common among adolescents.
This study examined the influence of parents and peers on adolescent indoor tanning.
Telephone interviews were conducted with 5274 teen-parent pairs in the 100 largest US cities. Random coefficient regression analyses were conducted to examine the relationship between parental and peer factors and adolescent indoor tanning.
eens’ report of whether their parents allow them to tan indoors was the strongest predictor (aOR: 5.6), while parents’ modeling (aOR:1.2), attitudes (aOR: 1.1), and concern about teen tanning (aOR:1.9) were significantly but less strongly associated. Teens thinking most of their peers like to be tan (aOR: 1.7) and perceived percent of peers who tan indoors (aOR: 1.0) also were significantly associated. Limitations: The cross-sectional design was a limitation of this study.
Interventions targeting adolescent indoor tanning should address both family- and peer-related factors.
PMCID: PMC2330196  PMID: 17658194

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