Housing type and secondhand tobacco smoke exposure among non-smoking New York City adults, 2004 and 2013-14.

Secondhand tobacco smoke (SHS) exposure has declined due to smoking reductions, expanding workplace and public smoke-free air laws, and smoke-free housing policy promotion. Population-based studies examining objective SHS exposure biomarkers have documented reductions over time, however non-smoking urban adults are more likely to have elevated cotinine (a metabolite of nicotine) compared with national averages. Evidence suggests residential housing type may impact urban SHS exposure risk. Direct associations between multiunit housing (MUH) and elevated cotinine have been identified among children but not yet examined among adults. We used data from the cross-sectional 2004 and 2013/14 New York City Health and Nutrition Examination Surveys to investigate associations between MUH (single-family versus 2; 3-99; and 100 + units) and likelihood of elevated serum cotinine among nonsmoking adults (2004: n = 1324; 2013/14: n = 946), adjusting for socio-demographics (sex, age, race/ethnicity, education, income) and self-reported SHS exposure variables. Combined and single-year adjusted multivariable regressions were conducted. Elevated cotinine was defined as a serum level of ≥ 0.05 ng/ml. Combined year adjusted multivariable regression analyses found no difference in elevated cotinine by housing type among non-smoking adults. By survey year, elevated cotinine did not vary by housing type in 2004, while non-smoking adults in 3-99 unit buildings were twice as likely to have elevated cotinine compared with single family residents in 2013/14 (adjusted Odds Ratio = 2.55 (1.13, 5.79)). While SHS exposure has declined, relative burden may be increasing among MUH residents. In urban settings with extensive MUH, attention to housing-based policies and programmatic interventions is critical to reducing SHS exposure.

E-cigarette Use Among Middle and High School Students in New York City Before and After Passage of Tobacco 21.

INTRODUCTION: Despite declines in cigarette smoking in the US, electronic cigarette (e-cigarette) use has increased among middle and high school students. In 2014, New York City (NYC) implemented Tobacco 21 (T21) to prohibit sales to anyone under age 21. Our study goal was to measure the effectiveness of T21 on e-cigarette use. METHODS: We used the New York State (NYS) Youth Tobacco Survey-a biennial, school-based, self-administered survey. We explored middle (N = 5249) and high (N = 7296) school NYC students' (male and female) current (past 30 days') e-cigarette use from 2014 (pre-T21) to 2018 (post-T21). Results were compared with students in the rest of NYS (ROS). Bivariate and multivariable logistic regression analyses assessed correlates of e-cigarette use, beliefs about harmfulness, addictiveness, and susceptibility. RESULTS: NYC high school students' current e-cigarette use increased from 2014 to 2018 (8.1% vs 23.5%, P < .001). Middle school students' use increased between 2014 (4.8%) and 2016 (9.0%) yet reversed by 2018 (5.7%) (2014 vs 2018, P = .576). ROS middle school (2.2% vs 7.4%, P < .001) and high school (12.0% vs 29.3%, (P < .001) use increased from 2014 to 2018. Willingness to try e-cigarettes among those who had never tried an e-cigarette was twice as high (AOR = 2.19, 95% CI = 1.15-3.17) among NYC high school students in 2018 compared with 2014. CONCLUSIONS: E-cigarette use increased among NYC high school students despite T21. T21 may have reduced use among middle school students over time. Programs that denormalize e-cigarettes and policies that further restrict access are needed to decrease youth e-cigarette use.

Implementing Smoke-Free Housing Policies Among Multiunit Housing Owners in New York City Between 2012 and 2015.

Smoke-free regulations are the norm in workplaces and public outdoor areas across New York City (NYC), and smoke-free apartment building regulations are less widespread. In 2017, more than one-third (37.6%) of NYC multiunit housing (MUH) residents reported breathing secondhand smoke (SHS) from neighboring units. In 2015, the NYC Health Department conducted a cross-sectional phone survey among a random sample of NYC low-income and market-rate MUH property owners/managers as a follow-up to a 2012 study. The study compared owners' experiences and attitudes regarding smoke-free policies. Bivariate and multivariable logistic regression analyses were used. Overall, the proportion of owners who have a policy prohibiting smoking in individual units (33% vs 37%) increased between 2012 and 2015. In both waves, owners without low-income units (wave 1: 36%, wave 2: 40%) were more likely to have smoke-free housing policies than those with low-income units (wave 1: 26%, wave 2: 30%). The models adjusted for factors such as current smoking, size and nature of housing units, and several beliefs. Owners in 2015 were more likely to have a smoke-free policy (adjusted odds ratio [AOR]: 1.25, 95% confidence interval (CI): 1.003, 1.564) and, among those without a current smoke-free policy, to have future interest in smoke-free unit policies (AOR: 1.68, 95% CI: 1.17, 2.39) than in 2012. An increasing proportion of NYC MUH owners are reducing tenant exposure to SHS and providing them with a healthier environment. We expect to see further expansion of smoke-free housing in NYC as positive norms grow.

Smoking Social Norms Among Young Adults in New York City.

More than half of young adult (YA) (ages 18-26) smokers are non-daily smokers. While standard cessation methods are generally successful with adults and daily smokers, there is evidence that they are not as successful among non-daily smokers or young adults. Additionally, YA smokers are also in a transition period to regular smoking, making research on understanding how interpersonal and environmental factors affect this group of smokers critical. Randomized time location sampling was used to create a sample of New York City YA bar patrons between June and November 2013, who completed a self-administered survey (1,916 surveys). Questions were asked about perceived smoking social norms, stigma, behaviors, and demographics. Overall, almost half of the YA reported being current smokers (44.1%); one-third were non-daily smokers (36.7%) and less than ten percent were daily smokers (7.4%). Non-daily smokers compared with daily smokers had greater odds of believing New Yorkers disapproved of smoking [adjusted odds ratio (ORadj 1.76, 95 % CI 1.10-2.79)], keeping tobacco a secret from certain people (ORadj 1.84, 1.14-2.96) and feeling guilty when smoking (ORadj: 2.54; 1.45-4.45). Non-daily smokers had 41% lower odds of reporting how people who are important to you disapproved of smoking than daily smokers (ORadj: 0.59; 0.38-0.94). Further studies of interpersonal/environmental factors among YA smokers may support modifications to cessation programs that result in more successful YA quit attempts.

Translating research into action: An evaluation of the World Trade Center Health Registry's Treatment Referral Program.

This manuscript describes the design, implementation and evaluation of the World Trade Center (WTC) Health Registry's Treatment Referral Program (TRP), created to respond to enrollees' self-reported 9/11-related physical and mental health needs and promote the use of WTC-specific health care. In 2009-2011, the TRP conducted personalized outreach, including an individualized educational mailing and telephone follow-up to 7,518 selected enrollees who resided in New York City, did not participate in rescue/recovery work, and reported symptoms of 9/11-related physical conditions or posttraumatic stress disorder (PTSD) on their most recently completed Registry survey. TRP staff spoke with enrollees to address barriers to care and schedule appointments at the WTC Environmental Health Center for those eligible. We assessed three nested outcomes: TRP participation (e.g., contact with TRP staff), scheduling appointments, and keeping scheduled appointments. A total of 1,232 (16.4%) eligible enrollees participated in the TRP; 32% of them scheduled a first-time appointment. We reached 84% of participants who scheduled appointments; 79.4% reported having kept the appointment. Scheduling an appointment, but not keeping it, was associated with self-reported unmet health care need, PTSD, and poor functioning (≥14 days of poor physical or mental health in the past 30 days) (P < 0.05). Neither scheduling nor keeping an appointment was associated with demographic characteristics. Successful outreach to disaster-exposed populations may require a sustained effort that employs a variety of methods in order to encourage and facilitate use of post-disaster services. Findings from this evaluation can inform outreach to the population exposed to 9/11 being conducted by other organizations.

A qualitative examination of health and health care utilization after the September 11th terror attacks among World Trade Center Health Registry enrollees.

BACKGROUND: Many individuals who have 9/11-related physical and mental health symptoms do not use or are unaware of 9/11-related health care services despite extensive education and outreach efforts by the World Trade Center (WTC) Health Registry (the Registry) and various other organizations. This study sought to evaluate Registry enrollees' perceptions of the relationship between physical and mental health outcomes and 9/11, as well as utilization of and barriers to 9/11-related health care services. METHODS: Six focus groups were conducted in January 2010 with diverse subgroups of enrollees, who were likely eligible for 9/11-related treatment services. The 48 participants were of differing race/ethnicities, ages, and boroughs of residence. Qualitative analysis of focus group transcripts was conducted using open coding and the identification of recurring themes. RESULTS: Participants described a variety of physical and mental symptoms and conditions, yet their knowledge and utilization of 9/11 health care services were low. Participants highlighted numerous barriers to accessing 9/11 services, including programmatic barriers (lack of program visibility and accessibility), personal barriers such as stigmatization and unfamiliarity with 9/11-related health problems and services, and a lack of referrals from their primary care providers. Moreover, many participants were reluctant to connect their symptoms to the events of 9/11 due to lack of knowledge, the amount of time that had elapsed since 9/11, and the attribution of current health symptoms to the aging process. CONCLUSIONS: Knowledge of the barriers to 9/11-related health care has led to improvements in the Registry's ability to refer eligible enrollees to appropriate treatment programs. These findings highlight areas for consideration in the implementation of the new federal WTC Health Program, now funded under the James Zadroga 9/11 Health and Compensation Act (PL 111-347), which includes provisions for outreach and education.

Comparison of health outcomes among affiliated and lay disaster volunteers enrolled in the World Trade Center Health Registry.

BACKGROUND: Volunteers (non-professional rescue/recovery workers) are universally present at man-made and natural disasters and share experiences and exposures with victims. Little is known of their disaster-related health outcomes. METHODS: We studied 4974 adult volunteers who completed the World Trade Center Health Registry 2006-07 survey to examine associations between volunteer type (affiliated vs. lay) and probable posttraumatic stress disorder (PTSD); new or worsening respiratory symptoms; post-9/11 first diagnosis of anxiety disorder, depression, and/or PTSD; and asthma or reactive airway dysfunction syndrome (RADS). Affiliated volunteers reported membership in a recognized organization. Lay volunteers reported no organizational affiliation and occupations unrelated to rescue/recovery work. Adjusted odds ratios (OR(adj)) were calculated using multinomial regression. RESULTS: Lay volunteers were more likely than affiliated volunteers to have been present in lower Manhattan, experience the dust cloud, horrific events and injury on 9/11 and subsequently to report unmet healthcare needs. They had greater odds of early post-9/11 mental health diagnosis (OR(adj) 1.6; 95% CI: 1.4-2.0) and asthma/RADS (1.8; 1.2-2.7), chronic PTSD (2.2; 1.7-2.8), late-onset PTSD (1.9; 1.5-2.5), and new or worsening lower respiratory symptoms (2.0; 1.8-2.4). CONCLUSIONS: Lay volunteers' poorer health outcomes reflect earlier, more intense exposure to and lack of protection from physical and psychological hazards. There is a need to limit volunteers' exposures during and after disasters, as well as to provide timely screening and health care post-disaster.

Mortality among survivors of the Sept 11, 2001, World Trade Center disaster: results from the World Trade Center Health Registry cohort.

BACKGROUND: The Sept 11, 2001 (9/11) World Trade Center (WTC) disaster has been associated with several subacute and chronic health effects, but whether excess mortality after 9/11 has occurred is unknown. We tested whether excess mortality has occurred in people exposed to the WTC disaster. METHODS: In this observational cohort study, deaths occurring in 2003-09 in WTC Health Registry participants residing in New York City were identified through linkage to New York City vital records and the National Death Index. Eligible participants were rescue and recovery workers and volunteers; lower Manhattan area residents, workers, school staff and students; and commuters and passers-by on 9/11. Study participants were categorised as rescue and recovery workers (including volunteers), or non-rescue and non-recovery participants. Standardised mortality ratios (SMR) were calculated with New York City rates from 2000-09 as the reference. Within the cohort, proportional hazards were used to examine the relation between a three-tiered WTC-related exposure level (high, intermediate, or low) and total mortality. FINDINGS: We identified 156 deaths in 13,337 rescue and recovery workers and 634 deaths in 28,593 non-rescue and non-recovery participants. All-cause SMRs were significantly lower than that expected for rescue and recovery participants (SMR 0·45, 95% CI 0·38-0·53) and non-rescue and non-recovery participants (0·61, 0·56-0·66). No significantly increased SMRs for diseases of the respiratory system or heart, or for haematological malignancies were found. In non-rescue and non-recovery participants, both intermediate and high levels of WTC-related exposure were significantly associated with mortality when compared with low exposure (adjusted hazard ratio 1·22, 95% CI 1·01-1·48, for intermediate exposure and 1·56, 1·15-2·12, for high exposure). High levels of exposure in non-rescue and non-recovery individuals, when compared with low exposed non-rescue and non-recovery individuals, were associated with heart-disease-related mortality (adjusted hazard ratio 2·06, 1·10-3·86). In rescue and recovery participants, level of WTC-related exposure was not significantly associated with all-cause mortality (adjusted hazard ratio 1·25, 95% CI 0·56-2·78, for high exposure and 1·03, 0·52-2·06, for intermediate exposure when compared with low exposure). INTERPRETATION: This exploratory study of mortality in a well defined cohort of 9/11 survivors provides a baseline for continued surveillance. Additional follow-up is needed to establish whether these associations persist and whether a similar association over time will occur in rescue and recovery participants. FUNDING: US Centers for Disease Control and Prevention (National Institute for Occupational Safety and Health, Agency for Toxic Substances and Disease Registry, and National Center for Environmental Health); New York City Department of Health and Mental Hygiene.

Ischemic nitric oxide and poly (ADP-ribose) polymerase-1 in cerebral ischemia: male toxicity, female protection.

It is well established that tissue damage and functional outcome after experimental or clinical stroke are shaped by biologic sex. We investigated the novel hypothesis that ischemic cell death from neuronally derived nitric oxide (NO) or poly-ADP ribose polymerase (PARP-1) activation is sexually dimorphic and that interruption of these molecular death pathways benefits only the male brain. Female neuronal nitric oxide synthase (nNOS) knockout (nNOS-/-) mice exhibited exacerbated histological injury after middle cerebral artery occlusion (MCAO) relative to wild-type (WT) females, unlike the protection observed in male nNOS-/- littermates. Similarly, treatment with the nNOS inhibitor (7-nitroindozole, 25 mg/kg) increased infarction in female C57Bl6 WT mice, but protected male mice. The mechanism for this sexually specific response is not mediated through changes in protein expression of endothelial NOS or inducible NOS, or differences in intraischemic cerebral blood flow. Unlike male PARP-1 knockouts (PARP1-/-), female PARP1-/- littermates sustained grossly increased ischemic damage relative to sex-matched WT mice. Treatment with a PARP inhibitor (PJ-34, 10 mg/kg) resulted in identical results. Loss of PARP-1 resulted in reversal of the neuroprotective activity by the female sex steroid, 17beta estradiol. These data suggest that the previously described cell death pathways involving NO and PARP ischemic neurotoxicity may be operant solely in male brain and that the integrity of nNO/PARP-1 signaling is paradoxically protective in the female.