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1.  The epidemiological profile of alcohol and other drug use in metropolitan China 
Purpose
There is evidence that alcohol, tobacco, and other drug use may be rising in China, but epidemiological studies that examine several drugs simultaneously and the transition from initial try to current use are limited. The present study provides an epidemiological profile of drug use in contemporary metropolitan China.
Methods
A multistage probability sampling method was used to select household-dwelling adults in Beijing and Shanghai. Standard face-to-face interviews with 5,201 participants were completed during 2002–2003.
Results
An estimated 70–76% had used any type of drug: alcohol and tobacco were the most commonly used drugs (alcohol, 67%; tobacco, 39%). Regarding extra-medical use of internationally regulated drugs, sedatives and analgesics were most common and illegal drug use was rare. The majority of tobacco users used it recently (82.5%), especially young adults. Male–female differences were observed in lifetime tobacco use, but not for recent use. Concurrent use of alcohol and tobacco was very common.
Conclusion
Psychoactive drug use is common in metropolitan China. Public health policies and prevention initiatives may be needed to address associated problems that may increase following the country’s rapid socioeconomic change.
doi:10.1007/s00038-010-0127-6
PMCID: PMC3992952  PMID: 20157758
Substance use; Epidemiology; China; Alcohol; Tobacco
2.  Disability associated with mental disorders in metropolitan China: An application of the quantile regression approach 
Psychiatry research  2012;199(3):212-219.
Recently active mental disorders are associated with substantial disability, but there is little research on residual disability once symptoms have subsided. The aim of this study is to estimate the degree to which recent disability might be due to recent or past history of mental disorders using a quantile regressions model that makes it possible to study the full range of disability. Data were from cross-sectional surveys of Chinese living in Beijing and Shanghai, China (n=1,628). The World Health Organization Disability Assessment Schedule and the WHO Composite International Diagnostic Interview was used to assess recent disability and common mental disorders, respectively. Recently active mental disorders are found to be associated with elevated levels of disability, especially for current substance use disorder. Anxiety disorders stand out with high levels of disability. Individuals at the higher disability levels show large variations in their disability levels. These epidemiological estimates from China add to the evidence base on the global burden of neuropsychiatric disorders, quantifying the hypothesized influence of recently active and past disorders with the novel quantile regression approach. In future studies, we hope to complete more detailed studies of the causal role of mental disorders in the development of disability.
doi:10.1016/j.psychres.2012.03.019
PMCID: PMC3399993  PMID: 22494707
survey; epidemiology; methods; disability; substance use disorders; anxiety disorders
3.  An Updated Global Picture of Cigarette Smoking Persistence among Adults 
Background
Cross-national variance in smoking prevalence is relatively well documented. The aim of this study is to estimate levels of smoking persistence across 21 countries with a hypothesized inverse relationship between country income level and smoking persistence.
Methods
Data from the World Health Organization World Mental Health Survey Initiative were used to estimate cross-national differences in smoking persistence–the proportion of adults who started to smoke and persisted in smoking by the date of the survey.
Result
There is large variation in smoking persistence from 25% (Nigeria) to 85% (China), with a random-effects meta-analytic summary estimate of 55% with considerable cross-national variation. (Cochran's heterogeneity Q statistic=6,845; p<0.001). Meta-regressions indicated observed differences are not attributable to differences in country income level, age distribution of smokers, or how recent the onset of smoking began within each country.
Conclusion
While smoking should remain an important public health issue in any country where smokers are present, this report identifies several countries with higher levels of smoking persistence (namely, China and India).
doi:10.1016/j.jegh.2012.06.003
PMCID: PMC3635135  PMID: 23626929
4.  Are early-onset cannabis smokers at an increased risk of depression spells? 
Journal of Affective Disorders  2012;138(1-2):54-62.
Background
A recent research focus is a set of hypothesized adult-onset mental health disturbances possibly due to early-onset cannabis use (EOCU, onset <18 years). We seek to estimate the suspected EOCU-associated excess odds of experiencing an incident depression spell during adulthood, with comparisons to never cannabis smokers and those with delayed cannabis onset (i.e., not starting to smoke cannabis until adulthood).
Methods
The National Surveys on Drug Use and Health (NSDUH) assess non-institutionalized community-dwelling residents of the United States after probability sampling each year. In aggregate, the NSDUH analytical sample included 173,775 adult participants from survey years 2005–2009 (74–76% of designated respondents). Standardized computer-assisted interviews collected information on background determinants, age of first cannabis use, and depression spell onset. Logistic regression was used to estimate EOCU-depression spell associations in the form of odds ratios, with statistical adjustment for sex, age, race/ethnicity, years of cannabis involvement, tobacco cigarette onset, and alcohol onset.
Results
About 1 in 10 experienced a depression spell during adulthood, and both early-onset and adult-onset cannabis smokers had a modest excess odds of a depression spell compared to never cannabis smokers, even with covariate adjustment (OR = 1.7 & 1.8, respectively; both p<0.001). Estimates for early- and adult-onset cannabis smokers did not statistically differ from one another.
Limitations
Shared diathesis that might influence both EOCU and adult-onset depression spell is controlled no more than partially, as will be true until essentially all known early-life shared vulnerabilities are illuminated.
Conclusion
Cannabis smoking initiated at any age signals a modest increased risk of a spell of depression in adulthood, even when adjusted for suspected confounding variables studied here. Delaying cannabis onset until adulthood does not appear to diminish the cannabis-associated risk.
doi:10.1016/j.jad.2011.12.031
PMCID: PMC3351086  PMID: 22310034
cannabis; depression; early-onset; adult-onset; tobacco; alcohol
5.  Longitudinal Effects of Prenatal Cocaine Use on Mother-Child Interactions at Ages 3 and 5 
Objective
To assess the effect of maternal prenatal and past-year cocaine use on mother-child interactions across the preschool years.
Methods
The sample is drawn from the Miami Prenatal Cocaine Study (MPCS), a longitudinal follow-up of prenatal cocaine exposure (PCE) in a large cohort of African-American infants prospectively enrolled at birth. Analyses are based on the 366 children (168 PCE and 198 NCE) in the care of their biological mothers and with completed mother-child interaction measures at the 3- and/or 5-year assessments. Videotaped interactions were coded using a modified Egeland Teaching Task scheme. GLM/GEE models were used to evaluate the effect of PCE on the overall quality of maternal-child interaction, measured by the Egeland total score at both study visits, and on the individual Egeland subscales at the 5-year visit, while adjusting for other suspected influences on interactions.
Results
PCE dyads demonstrated less optimal overall mother-child interactions compared to NCE dyads. The estimated PCE-associated difference did not shift appreciably with statistical adjustment for child sex, child age at exam or other birth covariates. PCE dyads with past-year maternal cocaine use had significantly lower Egeland summary scores compared to children with neither exposure. In subscale analyses, PCE was most strongly associated with greater maternal intrusiveness and boundary dissolution at the 5-year visit.
Conclusions
Prenatal and past-year maternal cocaine use appear to be associated with poorer quality in mother-child interaction during early childhood. These dynamics should be considered when examining the association between prenatal cocaine exposure and child cognitive, behavioral, and academic outcomes.
doi:10.1097/DBP.0b013e31823968ab
PMCID: PMC3252426  PMID: 22157442
prenatal; cocaine; exposure; mother-child; interaction
6.  Childhood physical punishment and the onset of drinking problems: evidence from metropolitan China 
Drug and alcohol dependence  2011;118(1):31-39.
Background
Evidence in support of a suspected causal association linking childhood physical punishment (CPP) and later alcoholic beverage-related disturbances has been found in metropolitan China. Here, the focus shifts to the CPP association with the estimated risk of starting to drink, having the first drinking problem, and transitioning from first drink to the first drinking problem.
Methods
Data are from the World Mental Health Surveys-metropolitan China study, with representative samples of adult household residents living in two metropolitan cities, Beijing and Shanghai. Recalled information was available for early life experiences (including CPP, other childhood adversities, and parental alcohol and drug problems), as well as the onset age of drinking and drinking problems. Survival analyses were used to estimate the hazard ratio. A structural equation modeling approach was used to control for other inter-correlated childhood adversities.
Results
Cox proportional hazards modeling discloses statistically robust associations linking CPP with drinking and drinking problems, as well as more rapid transitions from first drink to first drinking problem, even after accounting for other childhood adversities and parental drinking problems. These associations cannot be attributed to a more general noxious family environment.
Conclusions
These results lay a foundation for future experimental studies on the possible causal relationship linking CPP with the onset of drinking problems and the transition from drinking to drinking problems.
doi:10.1016/j.drugalcdep.2011.02.013
PMCID: PMC3167011  PMID: 21474254
Alcohol use disorder; Childhood physical punishment; China; Epidemiology
7.  Novel Phenotype Issues Raised in Cross-National Epidemiological Research on Drug Dependence 
Stage-transition models based on the American Diagnostic and Statistical Manual (DSM) generally are applied in epidemiology and genetics research on drug dependence syndromes associated with cannabis, cocaine, and other internationally regulated drugs (IRD). Difficulties with DSM stage-transition models have surfaced during cross-national research intended to provide a truly global perspective, such as the work of the World Mental Health Surveys (WMHS) Consortium. Alternative simpler dependence-related phenotypes are possible, including population-level count process models for steps early and before coalescence of clinical features into a coherent syndrome (e.g., zero-inflated Poisson regression). Selected findings are reviewed, based on ZIP modeling of alcohol, tobacco, and IRD count processes, with an illustration that may stimulate new research on genetic susceptibility traits. The annual National Surveys on Drug Use and Health can be readily modified for this purpose, along the lines of a truly anonymous research approach that can help make NSDUH-type cross-national epidemiological surveys more useful in the context of subsequent genome wide association (GWAS) research and post-GWAS investigations with a truly global health perspective.
doi:10.1111/j.1749-6632.2009.05419.x
PMCID: PMC3012560  PMID: 20201862
alcohol; tobacco; dependence; epidemiology; phenotype
8.  Childhood predictors of first chance to use and use of cannabis by young adulthood 
Drug and alcohol dependence  2011;117(1):7-15.
Aims
To prospectively examine the linkage between childhood antecedents and progression to early cannabis involvement as manifest in first chance to try it and then first onset of cannabis use.
Methods
Two consecutive cohorts of children entering first grade of a public school system of a large mid-Atlantic city in the mid 1980s (n=2311) were assessed (mean age 6.5 years) and then followed into young adulthood (15 years later, mean age 21) when first chance to try and first use were assessed for 75% (n=1698) of the original sample. Assessments obtained at school included standardized readiness scores (reading; math) and teacher ratings of behavioral problems. Regression and time to event models included covariates for sex, race, and family disadvantage.
Results
Early classroom misconduct, better reading readiness, and better math readiness predicted either occurrence or timing of first chance to try cannabis, first use, or both. Higher levels of childhood concentration problems and lower social connectedness were not predictive.
Conclusions
Childhood school readiness and behavioral problems may influence the risk for cannabis smoking indirectly via an increased likelihood of first chance to use. Prevention efforts that seek to shield youths from having a chance to try cannabis might benefit from attention to early predictive behavioral and school readiness characteristics. When a youth’s chance to try cannabis is discovered, there are new windows of opportunity for prevention and intervention.
doi:10.1016/j.drugalcdep.2010.12.023
PMCID: PMC3128694  PMID: 21288658
marijuana abuse/epidemiology; sex factors; child behavior; academic readiness
9.  Behavioral Problems and the Occurrence of Tobacco, Cannabis, and Coca Paste Smoking in Chile: Evidence based on Multivariate Response Models for School Survey Data 
Drug and alcohol dependence  2009;104(1-2):50-55.
Background
In this study we estimate suspected links between youthful behavioral problems and smoking of tobacco, cannabis, and coca paste.
Methods
In the Republic of Chile, school-attending youths were sampled from all 13 regions of the country, with sample size of 46,907 youths from 8th to 12th grades. A Generalized Estimating Equations (GEE) approach to multiple logistic regression was used to address three interdependent response variables, tobacco smoking, cannabis smoking, and coca paste smoking, and to estimate associations.
Results
Drug-specific adjusted slope estimates indicate that youths at the highest levels of behavioral problems are an estimated 1.1 times more likely to have started smoking tobacco, an estimated 1.6 times more likely to have started cannabis smoking, and an estimated 2.0 times more likely to have started coca paste smoking, as compared to youths at the lowest level of behavioral problems (p< 0.01).
Conclusion
In Chile, there is an association linking behavioral problems with onsets of smoking tobacco and cannabis, as well as coca paste; strength of association is modestly greater for coca paste smoking.
doi:10.1016/j.drugalcdep.2009.03.010
PMCID: PMC2735105  PMID: 19446410
Adolescent behavior; tobacco smoking; marijuana smoking; coca paste smoking; Chilean students
10.  Genome-Environmental Risk Assessment of Cocaine Dependence 
Cocaine-associated biomedical and psychosocial problems are substantial twenty-first century global burdens of disease. This burden is largely driven by a cocaine dependence process that becomes engaged with increasing occasions of cocaine product use. For this reason, the development of a risk-prediction model for cocaine dependence may be of special value. Ultimately, success in building such a risk-prediction model may help promote personalized cocaine dependence prediction, prevention, and treatment approaches not presently available. As an initial step toward this goal, we conducted a genome-environmental risk-prediction study for cocaine dependence, simultaneously considering 948,658 single nucleotide polymorphisms (SNPs), six potentially cocaine-related facets of environment, and three personal characteristics. In this study, a novel statistical approach was applied to 1045 case-control samples from the Family Study of Cocaine Dependence. The results identify 330 low- to medium-effect size SNPs (i.e., those with a single-locus p-value of less than 10−4) that made a substantial contribution to cocaine dependence risk prediction (AUC = 0.718). Inclusion of six facets of environment and three personal characteristics yielded greater accuracy (AUC = 0.809). Of special importance was the joint effect of childhood abuse (CA) among trauma experiences and the GBE1 gene in cocaine dependence risk prediction. Genome-environmental risk-prediction models may become more promising in future risk-prediction research, once a more substantial array of environmental facets are taken into account, sometimes with model improvement when gene-by-environment product terms are included as part of these risk predication models.
doi:10.3389/fgene.2012.00083
PMCID: PMC3355331  PMID: 22629285
cocaine dependence; genome-environmental risk prediction; childhood abuse; GBE1 gene; tree-assembling ROC
11.  Sociodemographic Correlates of Transitions from Alcohol Use to Disorders and Remission in the São Paulo Megacity Mental Health Survey, Brazil 
Aims: To evaluate sociodemographic correlates associated with transitions from alcohol use to disorders and remission in a Brazilian population. Methods: Data are from a probabilistic, multi-stage clustered sample of adult household residents in the São Paulo Metropolitan Area. Alcohol use, regular use (at least 12 drinks/year), DSM-IV abuse and dependence and remission from alcohol use disorders (AUDs) were assessed with the World Mental Health version of the Composite International Diagnostic Interview. Age of onset (AOO) distributions of the cumulative lifetime probability of each alcohol use stage were prepared with data obtained from 5037 subjects. Correlates of transitions were obtained from a subsample of 2942 respondents, whose time-dependent sociodemographic data were available. Results: Lifetime prevalences were 85.8% for alcohol use, 56.2% for regular use, 10.6% for abuse and 3.6% for dependence; 73.4 and 58.8% of respondents with lifetime abuse and dependence, respectively, had remitted. The number of sociodemographic correlates decreased from alcohol use to disorders. All transitions across alcohol use stages up to abuse were consistently associated with male gender, younger cohorts and lower education. Importantly, low education was a correlate for developing AUD and not remitting from dependence. Early AOO of first alcohol use was associated with the transition of regular use to abuse. Conclusion: The present study demonstrates that specific correlates differently contribute throughout alcohol use trajectory in a Brazilian population. It also reinforces the need of preventive programs focused on early initiation of alcohol use and high-risk individuals, in order to minimize the progression to dependence and improve remission from AUD.
doi:10.1093/alcalc/agr007
PMCID: PMC3080240  PMID: 21414952
12.  Estimated Effect of Prenatal Cocaine Exposure on Examiner-Rated Behavior at Age 7 Years 
Neurotoxicology and teratology  2011;33(3):370-378.
Prenatal cocaine exposure has been linked to increased child behavior difficulties in some studies but not others.
Objective
The primary aim was to estimate the relationship between in utero cocaine exposure and child behavioral functioning at age 7 years with ratings made by blinded examiners during a structured testing session. A second aim was to examine whether caregiver drug use and psychological problems might mediate suspected relationships between prenatal cocaine exposure and aspects of examiner-rated behavior.
Methods
407 children (212 cocaine-exposed, 195 non-exposed) participating in the longitudinal Miami Prenatal Cocaine Study (MPCS) were rated with regard to their behavior during a neuropsychological assessment conducted at age 7 years. Raters were trained research psychometricians blinded to drug exposure. Individual behavioral items were summarized and the cocaine-behavior relationship was estimated within the context of latent variable modeling, using Mplus software.
Results
Two latent variables, Behavioral Regulation and Sociability, were derived via exploratory latent structure analysis with promax rotation. Prenatal cocaine exposure, statistically controlling for child sex, test age, and prenatal exposure to alcohol, tobacco, and marijuana, was associated with Behavioral Regulation (estimated slope ß = -0.25; 95% CI = -0.48, -0.02; p = 0.04) but not Sociability (estimated slope ß = -0.03; 95% CI = -0.26, 0.20; p = 0.79). Neither postnatal drug use by caregivers nor the severity of their psychological problems at age 5 follow-up predicted levels of child Behavioral Regulation or Sociability at age 7 years (p>0.10).
Conclusions
Examiner ratings of child behavior at age 7 revealed less optimal behavioral regulation for prenatally cocaine-exposed compared to non-exposed children, in contrast with what had been previously found from parent-report data. This evidence highlights the potential value of trained observers in assessing behavioral outcomes of children exposed in utero to drugs and other toxicants.
doi:10.1016/j.ntt.2011.02.014
PMCID: PMC3138213  PMID: 21640292
prenatal cocaine exposure; behavior; examiner ratings; caregiver drug use; caregiver psychological functioning; behavioral regulation
13.  Children taking risks: The association with cocaine and other drug use by young adulthood 
Addictive behaviors  2008;33(9):1154-1161.
In this report from a longitudinal study, the main aim was to evaluate the long-term predictive strength of a novel cartoon-based risk-taking trait assessment, which might prove to have utility in future research on mechanisms leading toward illegal drug involvement. The study population originated as 2,311 first-graders entering 19 elementary schools during two successive school years. The assessments started when the children were midway through primary school in the same school system. The key response variable was participants’ use of cocaine by the time of a young adult assessment. We found that for each standard deviation increase in the risk-taking scale there was a two fold increase in the risk of becoming a cocaine user by young adulthood (estimated relative risk, RR = 1.9; 95% confidence interval, CI = 1.3, 2.7). Independently, onset of cannabis use by young adulthood also was predicted by risk-taking scale values, but use of legal drugs (alcohol and tobacco) was not. These long-span associations provide support for new research on very early risk-taking mechanisms that lead toward illegal drug involvement.
doi:10.1016/j.addbeh.2008.04.016
PMCID: PMC2533157  PMID: 18550295
risk-taking; cocaine; cannabis; children; longitudinal; drug initiation
14.  Willingness to treat drug dependence and depression: comparisons of future health professionals 
Purpose
Stigma-related feelings, including degree of enthusiasm and willingness to work with alcohol, drug, and mental disorder (ADM) patients, as well as anticipated success in such work, will be required for the United States to be successful in its new initiatives for ADM screening, brief intervention, and effective referral to treatment and rehabilitation services (SBIRT). This study investigates students of medicine and social work with respect to their stigma-related feelings and degree of enthusiasm or willingness to treat patients affected by alcohol dependence, nicotine dependence, or major depression. Inference is strengthened by an anonymous online survey approach, with use of randomized reinforcers to gain at least partial experimental control of nonparticipation biases that otherwise are present in student survey data.
Material and methods
All students on required course rosters were asked to participate in a two-part in-class and online assessment; 222 participated, with a gradient of participation induced via randomly drawn reinforcers for online survey participation. Between-group comparisons were made with a multivariate generalized linear model and generalized estimating equations approach that adjusts for covariates.
Results
Medical and social work students did not differ from each other with respect to their willingness to treat patients affected by major depression, alcohol dependence, or nicotine dependence, but together were less willing to treat nicotine and alcohol dependence-affected patients as compared to depression-affected patients. Personal history was not associated with the students' willingness to treat, but men were less willing to treat. Drawing strength from the randomized reinforcer experimental design nested within this survey approach, the study evidence suggests potential nonparticipation bias in standard surveys on this topic.
Conclusion
These results indicate that future health professionals may prefer to treat depression as opposed to drug dependence conditions. For SBIRT success, curriculum change with educational interventions may be needed to increase willingness to treat patients with neuropsychiatric conditions such as drug dependence. Future research requires attention to a possible problem of nonparticipation bias in surveys of this type.
doi:10.2147/SAR.S14747
PMCID: PMC3124145  PMID: 21731413
alcohol dependence; nicotine dependence; depression; health professionals; stigma
15.  Mental Disorders in Megacities: Findings from the São Paulo Megacity Mental Health Survey, Brazil 
PLoS ONE  2012;7(2):e31879.
Background
World population growth is projected to be concentrated in megacities, with increases in social inequality and urbanization-associated stress. São Paulo Metropolitan Area (SPMA) provides a forewarning of the burden of mental disorders in urban settings in developing world. The aim of this study is to estimate prevalence, severity, and treatment of recently active DSM-IV mental disorders. We examined socio-demographic correlates, aspects of urban living such as internal migration, exposure to violence, and neighborhood-level social deprivation with 12-month mental disorders.
Methods and Results
A representative cross-sectional household sample of 5,037 adults was interviewed face-to-face using the WHO Composite International Diagnostic Interview (CIDI), to generate diagnoses of DSM-IV mental disorders within 12 months of interview, disorder severity, and treatment. Administrative data on neighborhood social deprivation were gathered. Multiple logistic regression was used to evaluate individual and contextual correlates of disorders, severity, and treatment. Around thirty percent of respondents reported a 12-month disorder, with an even distribution across severity levels. Anxiety disorders were the most common disorders (affecting 19.9%), followed by mood (11%), impulse-control (4.3%), and substance use (3.6%) disorders. Exposure to crime was associated with all four types of disorder. Migrants had low prevalence of all four types compared to stable residents. High urbanicity was associated with impulse-control disorders and high social deprivation with substance use disorders. Vulnerable subgroups were observed: women and migrant men living in most deprived areas. Only one-third of serious cases had received treatment in the previous year.
Discussion
Adults living in São Paulo megacity had prevalence of mental disorders at greater levels than similar surveys conducted in other areas of the world. Integration of mental health promotion and care into the rapidly expanding Brazilian primary health system should be strengthened. This strategy might become a model for poorly resourced and highly populated developing countries.
doi:10.1371/journal.pone.0031879
PMCID: PMC3279422  PMID: 22348135
16.  Stigmatizing Clients with Mental Health Conditions: An Assessment of Social Work Student Attitudes 
Social work in mental health  2011;9(4):253-271.
Research suggests that stigma plays a major role in discouraging clients from participating in mental health treatment. Because social workers provide a significant amount of such services, this study investigates social work student stigma as a function of their willingness to treat clients with alcohol dependence, nicotine dependence, depression, and Alzheimer’s disease. Students’ held higher levels of stigma toward nicotine dependent clients and less toward those with depression. Personal histories of depression and student age – but not smoking or alcohol use – were predictive of higher stigma levels towards nicotine dependent clients. Implications for social work are discussed.
doi:10.1080/15332985.2010.540516
PMCID: PMC3138623  PMID: 21779152
Stigma; Willingness to Treat; Drug Dependence; Depression; Alzheimer’s disease; Social Work Students
17.  Harsh physical punishment as a specific childhood adversity linked to adult drinking consequences: Evidence from China 
Addiction (Abingdon, England)  2010;105(12):2097-2105.
Aims
The aim of the current study is to estimate the association between childhood physical punishment (CPP) and level of alcohol use disorder (AUD), using two different approaches to take other childhood adversities into account.
Design and Setting
Population survey using face-to-face interviews to a representative sample of non-institutionalized adult residents of Beijing and Shanghai, China.
Participants
A total of 5201 participants aged 18 to 70 years old.
Measurements
A version of the World Mental Health Composite International Diagnostic Interview was used. Standardized assessments covered early life experiences of childhood physical punishment, other childhood adversities, parental drinking problems, childhood conduct problems, and clinical features of AUD.
Findings
A robust association linking CPP and level of AUD was found, holding other childhood adversities constant (probit coefficient=0.70, 95% CI=1.40, 1.00) via covariate terms in Structural Equations Modeling. Furthermore, there was evidence that CPP might exert an additional influence on level of AUD over and above a generally noxious family environment (probit coefficient=0.20, 95% CI=0.02, 0.38).
Conclusion
There appears to be a robust association between reports of harsh punishment in childhood and alcohol dependence in adulthood adjusting for a range of possible confounding factors. Whether the association is causal or whether both are related to a common underlying factor or recall bias needs to be investigated further.
doi:10.1111/j.1360-0443.2010.03079.x
PMCID: PMC2975861  PMID: 20854335
18.  Propensity score techniques and the assessment of measured covariate balance to test causal associations in psychological research 
Psychological methods  2010;15(3):234-249.
There is considerable interest in using propensity score (PS) statistical techniques to address questions of causal inference in psychological research. Many PS techniques exist, yet few guidelines are available to aid applied researchers in their understanding, use and evaluation. This study gives an overview of available techniques for PS estimation and PS application. It also provides a way to help compare PS techniques, using the resulting measured covariate balance as the criterion for selecting between techniques. The empirical example for this study involves the potential causal relationship linking early-onset cannabis problems and subsequent negative mental health outcomes, using data from a prospective cohort study. PS techniques are described and evaluated based on their ability to balance the distributions of measured potentially confounding covariates for individuals with and without early-onset cannabis problems. This paper identifies the PS techniques that yield good statistical balance of the chosen measured covariates within the context of this particular research question and cohort.
doi:10.1037/a0019623
PMCID: PMC2936698  PMID: 20822250
observational studies; causal inference; standardized bias; cannabis
19.  Early Cannabis Use and Estimated Risk of Later Onset of Depression Spells: Epidemiologic Evidence From the Population-based World Health Organization World Mental Health Survey Initiative 
American Journal of Epidemiology  2010;172(2):149-159.
Early-onset cannabis use is widespread in many countries and might cause later onset of depression. Sound epidemiologic data across countries are missing. The authors estimated the suspected causal association that links early-onset (age <17 years) cannabis use with later-onset (age ≥17 years) risk of a depression spell, using data on 85,088 subjects from 17 countries participating in the population-based World Health Organization World Mental Health Survey Initiative (2001–2005). In all surveys, multistage household probability samples were evaluated with a fully structured diagnostic interview for assessment of psychiatric conditions. The association between early-onset cannabis use and later risk of a depression spell was studied using conditional logistic regression with local area matching of cases and controls, controlling for sex, age, tobacco use, and other mental health problems. The overall association was modest (controlled for sex and age, risk ratio = 1.5, 95% confidence interval: 1.4, 1.7), was statistically robust in 5 countries, and showed no sex difference. The association did not change appreciably with statistical adjustment for mental health problems, except for childhood conduct problems, which reduced the association to nonsignificance. This study did not allow differentiation of levels of cannabis use; this issue deserves consideration in future research.
doi:10.1093/aje/kwq096
PMCID: PMC2915487  PMID: 20534820
cannabis; depression; mental health; world health
20.  Epidemiological evidence on count processes in the formation of tobacco dependence 
Nicotine & Tobacco Research  2010;12(7):734-741.
Introduction:
Large-sample epidemiological studies of tobacco cigarette smoking routinely assess so-called “lifetime prevalence” of tobacco dependence. This work delves into the earliest stages of smoking involvement, focusing on newly incident tobacco cigarette smokers in the very recent past, and examines hypothesized subgroup variation in count processes that become engaged once smoking starts. Here, the term “count process” has two components: (a) whether smoking will be persistent and (b) the rate of smoking, conditional upon membership in a latent class of smokers who will persist, as estimated under the zero-inflated Poisson (ZIP) model for complex survey data.
Methods:
We estimate these ZIP parameters for nationally representative samples of newly incident smokers in the United States (all with smoking initiation within 24 months of assessment). Data are from the 2004–2007 National Surveys on Drug Use and Health.
Results:
Once cigarette smoking started, roughly 40%–45% persisted, and the estimated median rate was five smoking days/30 days, conditional on membership in the latent class of persistent smokers. Among non-Hispanic recent-onset cigarette smokers, Whites, Black/African Americans, Asians, and Native American/Alaskan Natives did not differ, but recent-onset smokers of Hispanic origin and those of Pacific Islander background had comparatively less cigarette involvement.
Discussion:
Tobacco prevention and control initiatives may require elaboration in the form of brief interventions, including interpersonal and social transactions that might constrain a mounting frequency of days of smoking before daily smoking starts, and until conventional smoking cessation medication aids become indicated. These very–early stage interventions (VESI) might be mounted within family or peer groups or in the primary care or school settings, but randomized trials to evaluate VESI interventions will be required.
doi:10.1093/ntr/ntq073
PMCID: PMC2902880  PMID: 20507897
21.  Evaluating the drug use “gateway” theory using cross-national data: Consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys* 
Drug and alcohol dependence  2010;108(1-2):84-97.
Background
It is unclear whether the normative sequence of drug use initiation, beginning with tobacco and alcohol, progressing to cannabis and then other illicit drugs, is due to causal effects of specific earlier drug use promoting progression, or to influences of other variables such as drug availability and attitudes. One way to investigate this is to see whether risk of later drug use in the sequence, conditional on use of drugs earlier in the sequence, changes according to time-space variation in use prevalence. We compared patterns and order of initiation of alcohol, tobacco, cannabis, and other illicit drug use across 17 countries with a wide range of drug use prevalence.
Method
Analyses used data from World Health Organization (WHO) World Mental Health (WMH) Surveys, a series of parallel community epidemiological surveys using the same instruments and field procedures carried out in 17 countries throughout the world.
Results
Initiation of “gateway” substances (i.e. alcohol, tobacco and cannabis) was differentially associated with subsequent onset of other illicit drug use based on background prevalence of gateway substance use. Cross-country differences in substance use prevalence also corresponded to differences in the likelihood of individuals reporting a non- normative sequence of substance initiation.
Conclusion
These results suggest the “gateway” pattern at least partially reflects unmeasured common causes rather than causal effects of specific drugs on subsequent use of others. This implies that successful efforts to prevent use of specific “gateway” drugs may not in themselves lead to major reductions in the use of later drugs.
doi:10.1016/j.drugalcdep.2009.12.001
PMCID: PMC2835832  PMID: 20060657
tobacco; alcohol; illicit drugs; gateway; WHO World Mental Health Surveys
22.  Willingness to treat drug dependence and depression: comparisons of future health professionals 
Purpose
Stigma-related feelings, including degree of enthusiasm and willingness to work with alcohol, drug, and mental disorder (ADM) patients, as well as anticipated success in such work, will be required for the United States to be successful in its new initiatives for ADM screening, brief intervention, and effective referral to treatment and rehabilitation services (SBIRT). This study investigates students of medicine and social work with respect to their stigma-related feelings and degree of enthusiasm or willingness to treat patients affected by alcohol dependence, nicotine dependence, or major depression. Inference is strengthened by an anonymous online survey approach, with use of randomized reinforcers to gain at least partial experimental control of nonparticipation biases that otherwise are present in student survey data.
Material and methods
All students on required course rosters were asked to participate in a two-part in-class and online assessment; 222 participated, with a gradient of participation induced via randomly drawn reinforcers for online survey participation. Between-group comparisons were made with a multivariate generalized linear model and generalized estimating equations approach that adjusts for covariates.
Results
Medical and social work students did not differ from each other with respect to their willingness to treat patients affected by major depression, alcohol dependence, or nicotine dependence, but together were less willing to treat nicotine and alcohol dependence-affected patients as compared to depression-affected patients. Personal history was not associated with the students’ willingness to treat, but men were less willing to treat. Drawing strength from the randomized reinforcer experimental design nested within this survey approach, the study evidence suggests potential nonparticipation bias in standard surveys on this topic.
Conclusion
These results indicate that future health professionals may prefer to treat depression as opposed to drug dependence conditions. For SBIRT success, curriculum change with educational interventions may be needed to increase willingness to treat patients with neuropsychiatric conditions such as drug dependence. Future research requires attention to a possible problem of nonparticipation bias in surveys of this type.
doi:10.2147/SAR.S14747
PMCID: PMC3124145  PMID: 21731413
alcohol dependence; nicotine dependence; depression; health professionals; stigma
23.  Sex differences in TTC12/ANKK1 haplotype associations with daily tobacco smoking in Black and White Americans 
Nicotine & Tobacco Research  2010;12(3):251-262.
Introduction:
The 11q23.1 genomic region has been associated with nicotine dependence in Black and White Americans.
Methods:
By conducting linkage disequilibrium analyses of 7 informative single nucleotide polymorphisms (SNPs) within the tetratricopeptide repeat domain 12 (TTC12)/ankyrin repeat and kinase containing 1 (ANKK1)/dopamine (D2) receptor gene cluster, we identified haplotype block structures in 270 Black and 368 White (n = 638) participants, from the Baltimore Epidemiologic Catchment Area cohort study, spanning the TTC12 and ANKK1 genes consisting of three SNPs (rs2303380–rs4938015–rs11604671). Informative haplotypes were examined for sex-specific associations with daily tobacco smoking initiation and cessation using longitudinal data from 1993–1994 and 2004–2005 interviews.
Results:
There was a Haplotype × Sex interaction such that Black men possessing the GTG haplotype who were smokers in 1993–2004 were more likely to have stopped smoking by 2004–2005 (55.6% GTG vs. 22.0% other haplotypes), while Black women were less likely to have quit smoking if they possessed the GTG (20.8%) versus other haplotypes (24.0%; p = .028). In Whites, the GTG haplotype (vs. other haplotypes) was associated with lifetime history of daily smoking (smoking initiation; odds ratio = 1.6; 95% CI = 1.1–2.4; p = .013). Moreover, there was a Haplotype × Sex interaction such that there was higher prevalence of smoking initiation with GTG (77.6%) versus other haplotypes (57.0%; p = .043).
Discussion:
In 2 different ethnic American populations, we observed man–woman variation in the influence of the rs2303380–rs4938015–rs11604671 GTG haplotype on smoking initiation and cessation. These results should be replicated in larger cohorts to establish the relationship among the rs2303380–rs4938015–rs11604671 haplotype block, sex, and smoking behavior.
doi:10.1093/ntr/ntp201
PMCID: PMC2825103  PMID: 20133381
24.  Risk Management Post-Marketing Surveillance for the Abuse of Medications Acting on the Central Nervous System: Expert Panel Report 
Drug and alcohol dependence  2009;105(Suppl 1):S65-S71.
The abuse and diversion of medications is a significant public health problem. This paper is part of a supplemental issue of Drug and Alcohol Dependence focused on the development of risk management plans and post-marketing surveillance related to minimizing this problem. The issue is based on a conference that was held in October, 2008. An Expert Panel was formed to provide a summary of the conclusions and recommendations that emerged from the meeting involving drug abuse experts, regulators and other government agencies, pharmaceutical companies and professional and other non-governmental organizations. This paper provides a written report of this Expert Panel. Eleven conclusions and eleven recommendations emerged concerning the state of the art of this field of research, the regulatory and public health implications and recommendations for future directions. It is concluded that special surveillance tools are needed to detect the emergence of medication abuse in a timely manner and that risk management tools can be implemented to increase the benefit to risk ratio. The scientific basis for both the surveillance and risk management tools is in its infancy, yet progress needs to be made. It is also important that the unintended consequences of increased regulation and the imposition of risk management plans be minimized.
doi:10.1016/j.drugalcdep.2009.08.006
PMCID: PMC2844248  PMID: 19783383
Prescription drug abuse; regulation; epidemiology; policy; pharmacovigilance; abuse liability; risk management; surveillance
25.  Increased risk of suicidal ideation in smokers and former smokers compared to never smokers: Evidence from the Baltimore ECA follow-up study 
Objective
The incidence rate of suicidal ideation amongst current and former smokers versus never smokers is not known.
Main Findings
The age-adjusted incidence of suicidal ideation was highest among current smokers, followed by former, and never smokers. The adjusted hazard for suicide ideation was 2.22 (95%CI=1.48, 3.33) and 1.19 (95%CI=0.78, 1.82) for current and former smokers respectively, compared to never smokers.
Conclusion
Current smokers have increased risks of suicidal ideation above and beyond the risk for never and former smokers regardless of age, gender, history of depressive disorder and/or anxiety symptoms, and alcohol abuse/dependence. Smoking cessation might be beneficial for some suicide prevention efforts.
doi:10.1521/suli.2010.40.4.307
PMCID: PMC2936702  PMID: 20822357

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