Socioeconomic Disparities in Healthcare Access and Implications for All-Cause Mortality among US Adults: A 2000-2019 Record Linkage Study.

The United States (US) has witnessed a notable increase in socioeconomic disparities in all-cause mortality since 2000. While this period is marked by significant macroeconomic and health policy changes, the specific drivers of these mortality trends remain poorly understood. In this study, we assessed healthcare access variables and their association with socioeconomic status (SES)-related differences (exposure) in US all-cause mortality (outcome), since 2000. Our research drew upon cross-sectional data from the National Health Interview Survey (NHIS, 2000-2018), linked to death records from the National Death Index (NDI, 2000-2019) (n=486,257). The findings reveal that the odds of a lack of health insurance and unaffordability of needed medical care were over two-fold higher among individuals with lower education, compared to those with high education, following differential time trends. Moreover, elevated mortality risk was associated with lower education (up to 77%), uninsurance (17%), unaffordability (43%), and delayed care (12%). Uninsurance and unaffordability accounted for 4-6% of the disparities in time to mortality between low- and high-education groups. These findings were corroborated by income-based sensitivity analyses, emphasizing that inadequate healthcare access partially contributed to socioeconomic disparities in mortality. Effective policies promoting equitable healthcare access are imperative to mitigate socioeconomic disparities in mortality.

Navigating Threats of Wildfires and Individual Rights to Adopt 100% Tobacco-Free Policy in Rural California Community Colleges.

BACKGROUND: In California, all four-year public colleges have adopted 100% smoke-/tobacco-free policies (TFP) whereas community colleges (CCs), particularly rural CCs, are less likely to have tobacco-free environments. This raises concerns about health equity, particularly because smoking prevalence is higher in rural areas compared to urban. We examined policy adoption barriers and facilitators for rural California CCs with the aim of providing lessons learned to support TFP adoption by rural CCs and improve conditions for student health and well-being. METHODS: A multiple case study of four CCs in California with (n = 2) and without (n = 2) TFPs was conducted. Semi-structured interviews with 12 campus and community stakeholders, school administrative data, and policy-relevant documents were analyzed at the case level with comparison across cases to identify key barriers, facilitators and campus-specific experiences. RESULTS: All four CCs shared similar barriers to policy adoption including concerns about wildfires, individual rights, and fear of marginalizing people who smoke on campus. These CCs have experienced serious wildfires in the last ten years, have high community smoking prevalence, and fewer school resources for student health. For the two tobacco-free CCs, long-term wildfire mitigation efforts along with leadership support, campus/community partnerships and a collective approach involving diverse campus sectors were essential facilitators in successful TFP adoption. CONCLUSION: Study results underscore contextual pressures and campus dynamics that impact tobacco control efforts at colleges in rural communities. Strategies to advance college TFP adoption and implementation should recognize rural cultural and community priorities.

Simulation of Alcohol Control Policies for Health Equity (SIMAH) Project: Study Design and First Results.

Since about 2010, life expectancy at birth in the United States has stagnated and begun to decline, with concurrent increases in the socioeconomic divide in life expectancy. The Simulation of Alcohol Control Policies for Health Equity (SIMAH) Project uses a novel microsimulation approach to investigate the extent to which alcohol use, socioeconomic status (SES), and race/ethnicity contribute to unequal developments in US life expectancy and how alcohol control interventions could reduce such inequalities. Representative, secondary data from several sources will be integrated into one coherent, dynamic microsimulation to model life-course changes in SES and alcohol use and cause-specific mortality attributable to alcohol use by SES, race/ethnicity, age, and sex. Markov models will be used to inform transition intensities between levels of SES and drinking patterns. The model will be used to compare a baseline scenario with multiple counterfactual intervention scenarios. The preliminary results indicate that the crucial microsimulation component provides a good fit to observed demographic changes in the population, providing a robust baseline model for further simulation work. By demonstrating the feasibility of this novel approach, the SIMAH Project promises to offer superior integration of relevant empirical evidence to inform public health policy for a more equitable future.

Inequitable access to general and behavioral healthcare in the US during the COVID-19 pandemic: A role for telehealth?

Wide-ranging effects of the COVID-19 pandemic have led to increased psychological distress and alcohol consumption, and disproportionate hardship for disadvantaged groups. Early in the pandemic, telehealth services were expanded to maintain healthcare access amidst lockdowns, medical office closures, and fear of infection. This study examines general and behavioral healthcare access and disparities during the first year of the pandemic. Data are from the 2019-2020 US National Alcohol Survey (collected February 2019 to April 2020) and its COVID follow-up survey conducted January 30 to March 28, 2021 (N = 1819). General and behavioral healthcare-related outcomes were assessed at follow-up, and included perceived need for and receipt of care, delayed care, and use of telehealth since April 1, 2020. Results indicate that the majority of respondents with perceived need for healthcare received some behavioral healthcare (reported by 63%) and particularly general healthcare (88%), but nearly half (48%) delayed needed care. Delays were mostly due to COVID-related reasons, but cost barriers also were common and significantly impeded care-seeking by uninsured persons, young adults, rural residents, and persons whose employment was reduced by the pandemic. Disparities in the receipt of healthcare were pronounced for Hispanic/Latinx (vs. White) and lower-income (vs. higher-income) groups (AORs <0.37, p's < 0.05). Notably, telehealth was commonly used by Hispanic/Latinx and lower-income groups for general and particularly behavioral healthcare. Results suggest that telehealth has provided an important bridge to healthcare for certain medically underserved groups during the pandemic, and may be vital to future efforts to increase equity in healthcare access.

Can lifestyle factors explain racial and ethnic inequalities in all-cause mortality among US adults?

BACKGROUND: Racial and ethnic inequalities in all-cause mortality exist, and individual-level lifestyle factors have been proposed to contribute to these inequalities. In this study, we evaluate the extent to which the association between race and ethnicity and all-cause mortality can be explained by differences in the exposure and vulnerability to harmful effects of different lifestyle factors. METHODS: The 1997-2014 cross-sectional, annual US National Health Interview Survey (NHIS) linked to the 2015 National Death Index was used. NHIS reported on race and ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic/Latinx), lifestyle factors (alcohol use, smoking, body mass index, physical activity), and covariates (sex, age, education, marital status, survey year). Causal mediation using an additive hazard and marginal structural approach was used. RESULTS: 465,073 adults (18-85 years) were followed 8.9 years (SD: 5.3); 49,804 deaths were observed. Relative to White adults, Black adults experienced 21.7 (men; 95%CI: 19.9, 23.5) and 11.5 (women; 95%CI: 10.1, 12.9) additional deaths per 10,000 person-years whereas Hispanic/Latinx women experienced 9.3 (95%CI: 8.1, 10.5) fewer deaths per 10,000 person-years; no statistically significant differences were identified between White and Hispanic/Latinx men. Notably, these differences in mortality were partially explained by both differential exposure and differential vulnerability to the lifestyle factors among Black women, while different effects of individual lifestyle factors canceled each other out among Black men and Hispanic/Latinx women. CONCLUSIONS: Lifestyle factors provide some explanation for racial and ethnic inequalities in all-cause mortality. Greater attention to structural, life course, healthcare, and other factors is needed to understand determinants of inequalities in mortality and to advance health equity.

Trends in mortality from alcohol, opioid, and combined alcohol and opioid poisonings by sex, educational attainment, and race and ethnicity for the United States 2000-2019.

BACKGROUND: The ongoing opioid epidemic and increases in alcohol-related mortality are key public health concerns in the USA, with well-documented inequalities in the degree to which groups with low and high education are affected. This study aimed to quantify disparities over time between educational and racial and ethnic groups in sex-specific mortality rates for opioid, alcohol, and combined alcohol and opioid poisonings in the USA. METHODS: The 2000-2019 Multiple Cause of Death Files from the National Vital Statistics System (NVSS) were used alongside population counts from the Current Population Survey 2000-2019. Alcohol, opioid, and combined alcohol and opioid poisonings were assigned using ICD-10 codes. Sex-stratified generalized least square regression models quantified differences between educational and racial and ethnic groups and changes in educational inequalities over time. RESULTS: Between 2000 and 2019, there was a 6.4-fold increase in opioid poisoning deaths, a 4.6-fold increase in combined alcohol and opioid poisoning deaths, and a 2.1-fold increase in alcohol poisoning deaths. Educational inequalities were observed for all poisoning outcomes, increasing over time for opioid-only and combined alcohol and opioid mortality. For non-Hispanic White Americans, the largest educational inequalities were observed for opioid poisonings and rates were 7.5 (men) and 7.2 (women) times higher in low compared to high education groups. Combined alcohol and opioid poisonings had larger educational inequalities for non-Hispanic Black men and women (relative to non-Hispanic White), with rates 8.9 (men) and 10.9 (women) times higher in low compared to high education groups. CONCLUSIONS: For all types of poisoning, our analysis indicates wide and increasing gaps between those with low and high education with the largest inequalities observed for opioid-involved poisonings for non-Hispanic Black and White men and women. This study highlights population sub-groups such as individuals with low education who may be at the highest risk of increasing mortality from combined alcohol and opioid poisonings. Thereby the findings are crucial for the development of targeted public health interventions to reduce poisoning mortality and the socioeconomic inequalities related to it.

Longitudinal assessment of drinking changes during the pandemic: The 2021 COVID-19 follow-up study to the 2019 to 2020 National Alcohol Survey.

BACKGROUND: Surveys of changes in drinking during the COVID-19 pandemic have primarily relied on retrospective self-report. Further, most such surveys have not included detailed measures of alcohol use patterns, such as beverage-specific consumption, nor measures of alcohol use disorder (AUD) symptoms that would allow a comprehensive understanding of changes in alcohol use. METHODS: Data from 1819 completed interviews from the N14C follow-up survey to the 2019 to 2020 National Alcohol Survey (N14) were conducted between January 30 and March 28, 2021. Questions on alcohol use from the Graduated Frequency series, beverage-specific quantity and frequency, and DSM-5 AUD items were asked in both surveys and used to estimate changes from pre-pandemic drinking to drinking during the pandemic. Analyses focus on changes in these measures over time and comparisons between key subgroups defined by gender, race/ethnicity, and age. RESULTS: Key findings include particularly large increases in drinking and AUD for African Americans and women, reduced drinking and heavy drinking prevalence among men and White respondents, and a concentration of increased drinking and AUD among respondents aged 35 to 49. Increases in alcohol use were found to be driven particularly by increases in drinking frequency and the consumption of spirits. CONCLUSIONS: Results confirm prior findings of overall increases and subgroup-specific changes, and importantly, provide detailed information on the patterns of change across major socio-demographic subgroups. Substantial increases in the prevalence of DSM-5 moderate to severe AUDs are a novel finding that is of particular concern.

Associations of clustered health risk behaviors with diabetes and hypertension in White, Black, Hispanic, and Asian American adults.

BACKGROUND: The clustering of Big Four contributors to morbidity and mortality-alcohol misuse, smoking, poor diet, and physical inactivity-may further elevate chronic health risk, but there is limited information about their specific combinations and associated health risks for racial/ethnic minority groups. We aimed to examine patterns of clustering in risk behaviors for White, Black, Hispanic, and Asian American adults and their associations with diabetes and hypertension. As these behaviors may be socioeconomically-patterned, we also examined associations between clustering and socioeconomic status (SES). METHODS: Latent class analyses and multinomial and logistic regressions were conducted using a nationally-representative sample of United States (US) adults ages 40-70 (N = 35,322) from Waves 2 (2004-2005) and 3 (2012-2013) of the National Epidemiologic Survey on Alcohol and Related Conditions. Obesity was used as a proxy for unhealthy diet. The outcomes were diabetes and hypertension. RESULTS: A relatively-healthy-lifestyle class was found only among White adults. Common patterns of unhealthy clustering were found across groups with some variations: the obese-inactive class among White, Black, and Hispanic adults (and the inactive class among Asian adults); the obese-inactive-smoking class among White, Black, and Hispanic adults; the smoking-risky-drinking class among White and Hispanic adults; and the smoking-risky-drinking-inactive class among Black and Asian adults. Positive associations of unhealthier clustering (having a greater number of risk behaviors) with lower SES (i.e., family income and education) and with health conditions were more consistent for Whites than for other groups. For racial minority groups, lower education than income was more consistently associated with unhealthy clusters. The associations between unhealthier clustering and diabetes and hypertension were less clear for Blacks and Asians than for Whites, with no significant association observed for Hispanics. CONCLUSION: Concerted efforts to address clustered risk behaviors in most US adults, particularly in racial/ethnic minority groups given the high prevalence of unhealthy clustering, are warranted.

Black-White differences in barriers to specialty alcohol and drug treatment: findings from a qualitative study.

The objective of this study was to explore, in-depth, differences in barriers to specialty alcohol and drug treatment services between Black and White participants with recent substance use disorders (SUD). We recruited 34 participants with a recent SUD of White and Black racial/ethnic descent for qualitative interviews. Interviews were coded to identify barriers to specialty treatment. We found that barriers related to stigma and lack of social support were more pervasive in the narratives of Blacks as compared to Whites. Results suggest that stigma and lack of perceived social support may impact Blacks more than Whites in seeking SUD treatment.

Alcohol Consumption, Cardiovascular-Related Conditions, and ALDH2*2 Ethnic Group Prevalence in Asian Americans.

BACKGROUND: Little is known about the relationships between alcohol consumption and cardiovascular disease (CVD) and related chronic conditions in Asian Americans and how such risk relationships vary among their subgroups. We examine these relationships in Asian Americans and their moderation by ethnic prevalence of a variant the aldehyde dehydrogenase gene: ALDH2*2. METHODS: Multiple logistic regression modeling was performed using a nationally representative sample of Asian-American adults aged 30 to 70 (n = 1,720) from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 2 (2004 to 2005) and 3 (2012 to 2013). Outcomes considered were diabetes, hypertension, high cholesterol, CVD, any of the 3 conditions (i.e., diabetes, high cholesterol, and CVD) documented to have a J-shaped relationship with drinking (CVDRC3), and any of the CVD-related conditions (ANYCVD). Demographic and socioeconomic characteristics, health insurance coverage, and other lifestyle risk factors (smoking and obesity/overweight) were adjusted. Analyses were stratified by gender. RESULTS: Alcohol consumption level was positively associated only with hypertension in Asian males, with consuming 7 to 14 drinks per week associated with more than double the risk of lifetime abstinence. For females, alcohol consumption had a dose-response relationship with high cholesterol and CVDRC3. Membership in the higher ALDH2*2 ethnic group overall was associated with lower risk of CVD-related conditions. However, compared to abstainers in lower ALDH2*2 group, females in the higher ALDH2*2 group who consumed more than 7 drinks per week had a higher risk of diabetes, hypertension, CVDRC3, and ANYCVD. CONCLUSIONS: Asian Americans may have increased risk of CVD-related conditions at relatively low alcohol consumption levels. Among Asian-American females, in particular, any amount of drinking may increase risk for high cholesterol or any of the CVD-related conditions previously documented to have a curvilinear relationship with drinking. These risks may be particularly elevated for those in ethnic groups with a high prevalence of ALDH2*2.

Alcohol policy effects on 100% chronic alcohol-attributable mortality across racial/ethnic subgroups.

In the United States, some racial/ethnic minorities suffer from higher rates of chronic alcohol problems, and alcohol-related morbidity and mortality than Whites. Furthermore, state-level alcohol policies may affect racial/ethnic subgroups differentially. We investigate effects of beverage-specific taxes and government control of spirits retail on alcohol-related mortality among non-Hispanic Whites, non-Hispanic Blacks, non-Hispanic American Indians/Alaska Natives (AI/AN) and Hispanics using death certificate and state-level alcohol policy data for 1999-2016. Outcomes were analyzed as mortality rates (per 10,000) from 100% alcohol-attributable chronic conditions ("100% chronic AAD"). Statistical models regressed racial/ethnic-specific logged mortality rates on state-level, one-year lagged and logged beer tax, one-year lagged and logged spirits tax, and one-year lagged government-controlled spirits sales, adjusted for mortality trends, fixed effects for state, and clustering of standard errors. Government control was significantly (P < 0.05) related to 3% reductions in Overall and non-Hispanic White mortality rates, and 4% reductions in Hispanic mortality rates from 100% chronic AAD. Tax associations were not robust. Results support that government control of spirits retail is associated with significantly lower 100% AAD from chronic causes Overall and among non-Hispanic Whites and Hispanics. Government control of spirits retail may reduce both population-level 100% chronic AAD as well as racial/ethnic disparities in 100% chronic AAD.

Support for Alcohol Policies in Marginalized Populations.

AIM: Kingdon [(2014) Agendas, Alternatives, and Public Policies. Essex. United Kingdom: Pearson Education Limited] argues that windows of opportunity to pass policies emerge when problems, solutions and policy support co-occur. This study aims to identify a set of alcohol policies with the potential to reduce alcohol-related disparities given high levels of support from marginalized groups, such as racial/ethnic minorities and lower-income groups. METHODS: This study used data from five US National Alcohol Surveys, which were based on household probability samples of adults in 1995 (n = 4243), 2000 (n = 5736), 2005 (n = 1445), 2010 (n = 4164) and 2015 (n = 4041). We used multiple logistic regression to determine the odds of policy support by racial/ethnic group and income level, considering price, place and marketing policies as well as individual-level interventions. RESULTS: Overall a majority of Americans supported banning alcohol sales in corner stores (59.4%), banning alcohol advertisements on television (55.5%), and establishing universal health coverage for alcohol treatment (80.0%). Support was particularly high among Blacks, Hispanics/Latinos and lower-income persons. Multivariate models showed that compared with White people, foreign-born Hispanics/Latinos had the most robust levels of support, including raising alcohol taxes (aOR = 2.40, 95% CI: 2.00, 2.88, P < 0.0001), banning alcohol sales in corner stores (aOR = 2.85, 95% CI: 2.22, 3.65, P < 0.0001) and reducing retail sales hours (aOR = 2.91, 95% CI: 2.38, 3.55, P < 0.0001). CONCLUSION: Of the policies examined, banning alcohol sales at corner stores is most likely to be in a "window of opportunity" for reducing alcohol-related disparities. By simultaneously reducing population-level consumption and harms from others' drinking, place-based policies have the potential to reduce harms experienced by marginalized groups.

Trends and disparities in American Indian/Alaska Native unintentional injury mortality from 1999 to 2016.

INTRODUCTION: Alcohol and drug use are significant problems in the US, and American Indian/Alaska Native (AI/AN) communities and individuals are known to be among the most affected. This study evaluates disparities in unintentional injury mortality causes since 1999. METHODS: Analyses in 2020 of unintentional injury mortality rate disparities between AI/ANs and white population over the 1999-2016 period with attention to motor vehicle crashes, alcohol poisoning, drug poisoning and all other cause types. Rates in each of the 10 states with the largest AI/AN populations were also investigated to account for geographical concentration. RESULTS: Motor vehicle mortality rates declined for both AI/AN and white groups, but a large racial disparity was maintained. Conversely, poisoning mortality rates rose substantially in both groups, with a jump in rates in 2007 due to a coding change, resulting in a large disparity that was maintained through 2016. Comparison of alcohol and drug poisonings showed that the AI/AN alcohol poisoning rate was about eight times the white rate, whereas drug poisoning rates were similar. For 'all other' unintentional injuries, the highest rates were seen for AI/AN men, with rates generally rising over the study period. State-specific analyses found substantial variation in AI/AN rates, with few or no disparities in New York and Texas. CONCLUSIONS: Results indicate substantial and persisting disparities in unintentional injury mortality, with especially large differences in alcohol poisoning. The absence of disparities in New York and Texas suggest the importance of situational factors.

The Downward Spiral: Socioeconomic Causes and Consequences of Alcohol Dependence among Men in Late Young Adulthood, and Relations to Racial/Ethnic Disparities.

BACKGROUND: While young adults are generally at highest risk for alcohol problems, not all age out of problem drinking. Evidence suggests that Blacks and Latinos age out more slowly than Whites, particularly among men. Targeting men, we investigated whether differences in lifecourse SES might explain racial/ethnic disparities in alcohol dependence in late young adulthood, along with how experiencing alcohol dependence at that life stage relates to subsequent SES. METHODS: We used longitudinal, national data to (i) describe racial/ethnic disparities in late young adult alcohol dependence criteria (LYADC), (ii) examine whether income trajectory in early young adulthood contributes to these racial/ethnic disparities, and (iii) test whether LYADC reciprocally predicts income trajectory in early midlife. Data were from the 1979 National Longitudinal Survey of Youth (N = 3,993), which measured LYADC in 1994 (mean age = 33). Income trajectory classes were derived for early young adulthood (mean ages = 21 to 31) and, separately, early midlife (mean ages = 35 to 45). Analyses included negative binomial regressions and multinomial regressions. RESULTS: Both Black and US-born Latino men reported more LYADC than White men. Further, membership in the persistently low and slow increase (vs. stable middle) early young adult income trajectory classes was associated with more LYADC. Multivariate analyses suggested that Black-White disparities in LYADC were explained by early young adult income trajectories, whereas Latino-White disparities in the same were explained by both early young adult income trajectories and early education. In controlled models, more LYADC predicted a higher likelihood of membership in the persistently low (vs. stable middle) income trajectory class in early midlife. CONCLUSIONS: This study found that poorer SES in early adulthood contributes to alcohol dependence, which reciprocally contributes to poorer SES in early midlife. This cycle appears particularly likely to affect Black and US-born Latino men. Results underline the need to address socioeconomic factors in addressing racial/ethnic disparities in alcohol problems.

Improving the Validity of the Behavioral Risk Factor Surveillance System Alcohol Measures.

BACKGROUND: Valid measurement of alcohol use can be difficult in surveys, which are subject to biases like underreporting and differential nonresponse. Still, monitoring trends, policy impacts, disparities, and related issues all require valid individual- and state-level drinking data collected over time. Here, we propose a double-adjustment approach for improving the validity of the Behavioral Risk Factor Surveillance System (BRFSS) alcohol measures. METHODS: Validity analyses of the 1999 to 2016 BRFSS, a general population survey of U.S. adults. Measures are aggregated to state level for N = 918 observations, single-adjusted for BRFSS methodologic changes, and double-adjusted by per capita consumption. Fixed-effects models: (i) assess predictive validity using adjusted BRFSS drink volume to predict mortality outcomes and (ii) assess outcome validity using state-level alcohol taxes to predict adjusted BRFSS volume. RESULTS: Neither the raw nor the single-adjusted BRFSS drinking measures were related to mortality in the expected direction, while double-adjusted BRFSS volume and 5+ days were significantly positively related to mortality, as expected. Spirits and beer taxes were not related to single-adjusted BRFSS drinking in the expected direction. However, spirits and beer taxes were both significantly related to double-adjusted BRFSS volume in the expected directions. CONCLUSIONS: Future studies should consider using the double-adjusted BRFSS measures to ensure the validity of drinking survey data in analyses where variation over time is considered.

Subjective Social Status and Financial Hardship: Associations of Alternative Indicators of Socioeconomic Status with Problem Drinking in Asian Americans and Latinos.

Background: Prior research shows inconsistent associations between socioeconomic status (SES) and alcohol outcomes, particularly for immigrant populations. Conventional markers of SES may not fully capture how social position affects health in these groups. Objective: We examine: (1) the associations of two alternative indicators, subjective social status (SSS) and financial hardship, with problem drinking outcomes, heavy episodic drinking (HED) and alcohol use disorder (AUD), for Asian Americans and Latinos; and (2) moderation of these relationships by educational level and nativity status. Methods: Multiple logistic regression modeling was performed using nationally-representative Asian American (n = 2,095) and Latino samples (n = 2,554) from the National Latino and Asian American Study. Age, gender, nativity, individual-level SES (income and education), unfair treatment, racial discrimination, and social support were adjusted. Results: Financial hardship was independently associated with AUD in both Asians and Latinos. Lower SSS was associated with increased AUD risk among individuals with college degrees or with US nativity in both populations. The association between financial hardship and HED was positive for US-born Latinos and foreign-born Asians, and negative for foreign-born Latinos. Conclusions: SSS and financial hardship are indicators of SES that may have particular relevance for immigrant health, independently of education and income, with SSS particularly meaningful for AUD in the more conventionally advantaged subgroups. There may be underlying processes affecting Asian and other Latino subgroups with similar socioeconomic and nativity profiles and exposing them to common risk/protective factors of AUD.

Gender Differences in Use of Alcohol Treatment Services and Reasons for Nonuse in a National Sample.

BACKGROUND: The majority of adults with alcohol use disorders do not obtain help, and women are less likely to utilize alcohol services than men. We sought to quantify gender differences in alcohol services utilization, overall and by type, using national longitudinal data and to explore potential gender differences in perceived need for help and reasons for not seeking help. METHODS: We analyzed data from the National Epidemiologic Survey on Alcohol and Related Conditions from White, African American, and Hispanic adults (n = 2,592) who met DSM-IV criteria for alcohol abuse or dependence at Wave 1 (2000 to 2001). We tested gender differences in Wave 2 (2004 to 2005) services utilization, perceived need for help, and treatment barriers using Rao-Scott chi-square tests and assessed predictors of outcomes in multivariable logistic regression, adjusting for problem severity, co-occurring disorders, and demographics. RESULTS: Women had much lower odds than men of utilizing any alcohol service (adjusted odds ratio [aOR] 0.53; 95% confidence interval [95% CI]: 0.33, 0.86), specialty services (aOR 0.41; 95% CI 0.19, 0.87), and 12-step groups (aOR 0.39; 95% CI 0.21, 0.71). Perceived need for help among those who had not used any services was very low (5%), with no gender difference. Further, men and women reported equivalent numbers of treatment barriers and the same rank order for the most frequently endorsed barriers. However, women were twice as likely as men to think a problem would get better by itself-the most frequent reason for not seeking help (47% vs. 24%, p < 0.001), and men were more likely than women to report unsuccessful past help-seeking and not thinking anyone could help (19% vs. 3%, p < 0.001 and 17% vs. 5%, p = 0.001, respectively). CONCLUSIONS: Consistent with previous studies, women were less likely to utilize alcohol services than men. Future interventions should address low problem recognition, and tailoring to gender-specific barriers may help close the disparity in services utilization.

Adverse childhood events and risk of diabetes onset in the 1979 National longitudinal survey of youth cohort.

BACKGROUND: Type 2 diabetes is a major public health problem with considerable personal and societal costs. Adverse childhood experiences (ACE) are associated with a number of serious and chronic health problems in adulthood, but these experiences have not been adequately studied in relation to diabetes in a US national sample. The association between ACE and poor health can be partially explained by greater risky health behaviors (RHB) such as smoking, heavy alcohol use, or obesity. Few studies have examined ACE in relation to adult onset Type 2 diabetes mellitus (T2DM) taking into account the role of RHB. Using longitudinal data from a representative US population sample followed over 30 years, this study examines the impact of ACE on the risk of diabetes onset. METHODS: Data from the 1982 to 2012 waves of the 1979 National Longitudinal Survey of Youth were analyzed, spanning ages 14 to 56. Bivariate and discrete-time survival models were used to assess the relationships between ACE and RHB including smoking, alcohol use, and obesity, and subsequent onset of diabetes. RESULTS: T2DM was reported by almost 10% of participants. Over 30% of women and 21% of men reported 2+ ACE events. Women reporting 2-3 or 4+ ACE events were more likely to develop diabetes with the mean number of ACE events being greater in those with diabetes compared to without (1.28 vs.1.05, p < .0001). For men there was no significant association between ACE and diabetes onset. For women, ACE was associated with heavy drinking, current smoking, and obesity. For men, ACE was associated with being underweight and daily smoking. In multivariate discrete-time survival models, each additional ACE increased risk of T2DM onset (ORadj = 1.14; 95% CI 1.02-1.26) for women but not for men. The relationship in women was attenuated when controlling for body mass index (BMI). CONCLUSION: ACE predicted diabetes onset among women, though this relationship was attenuated when controlling for BMI. Being overweight or obese was significantly more common among women with a history of ACE, which suggests BMI may be on the pathway from ACE to diabetes onset for women.

Differential Consequences: Racial/Ethnic and Gender Differences in the Enduring Impact of Early Disadvantage on Heavy Drinking in Midlife.

We use a "chain of risks" model to identify risk factors for prolonged heavy drinking in a nationally representative US sample followed from adolescence to middle age, focusing on educational mediators and differential consequences of early exposure to family poverty and area-level disadvantage. Using data from the 1979 National Longitudinal Survey of Youth (civilian respondents ages 14-19 at baseline, N = 5781), longitudinal path models assessed racial/ethnic and gender differences in indirect effects of early disadvantage (duration of exposure to family poverty and area-level disadvantage during adolescence) on midlife heavy drinking. Educational mediators were high school academic performance (taking remedial coursework), high school completion, and attaining a college education. Subgroups were based on race/ethnicity (50.7% White, 30.5% Black, 18.8% Hispanic respondents) and gender (49.6% males). There was a significant indirect path from family poverty during adolescence to poor high school academic performance, lower educational attainment, and more heavy drinking in midlife. For Black respondents, there was an additional direct effect of early area-level disadvantage on greater midlife heavy drinking that was not seen for other groups. The effect of family poverty on reduced high school graduation was stronger for males than females. Enduring impacts of family poverty duration during adolescence on educational attainment have consequences for health risk behaviors in midlife. Due to differential exposure to early adversity, intersectoral interventions are needed to reduce disparities in alcohol outcomes and to promote health equity among high-risk populations.

Changing Racial/Ethnic Disparities in Heavy Drinking Trajectories Through Young Adulthood: A Comparative Cohort Study.

BACKGROUND: There is evidence of racial/ethnic differences in the age at which young adults age out of heavy drinking. Some studies have found Black and Hispanic drinkers engage in more frequent heavy drinking than White people beyond adulthood. Yet, the alcohol-related disparities literature has produced contradictory findings on whether an age-crossover effect is evident among racial/ethnic groups; that is, whether racial/ethnic minorities' drinking levels or trajectories are lower than White people at young ages but later exceed (or crossover) those of White people. This study extends this scant literature by assessing whether racial/ethnic differences in heavy drinking have changed over time (possibly accounting for mixed findings from prior research); and tests for an age-crossover effect in heavy drinking using longitudinal data from 2 cohorts born 20 years apart. METHODS: Data are from the 1979 (n = 10,963) and 1997 (n = 8,852) cohorts of the National Longitudinal Survey of Youth (NLSY). Generalized estimating equations were used to model trajectories of heavy drinking frequency from ages 17 to 31. Racial/ethnic differences were determined using sex-stratified models and 3-way interactions of race/ethnicity with age, age-squared, and cohort. RESULTS: Racial/ethnic differences in heavy drinking trajectories have changed over time in men and women. In the older NLSY cohort, Hispanic men and Black women surpassed White men's and women's heavy drinking frequency by age 31. This crossover was absent in the younger cohort, where trajectories of all racial-sex groups converged by age 31. Normative trajectories have changed in Hispanics and White people of both sexes, with a delay in age of peak frequency, and greater levels of heavy drinking in the younger cohort of women. CONCLUSIONS: Changes in heavy drinking trajectories over time suggest the need for targeted interventions during young adulthood. While disparities in young adult heavy drinking were no longer apparent in the more recent birth cohort, continued monitoring is important.