Impact and Equity of New York City's Tobacco Retail Reduction Initiative.

INTRODUCTION: High levels of tobacco retailer density in communities is associated with a range of tobacco use behaviors and is a key structural driver of tobacco-related disparities. This study evaluates the impacts of New York City's (NYC) novel policy intervention to cap tobacco retail licenses on tobacco retailer density levels and neighborhood inequities in tobacco access. METHODS: Using geocoded tobacco retail licensing data from 2010 to 2022, Bayesian conditional autoregressive Poisson panel models estimated the association between policy implementation in 2018 and retailer density per 1,000 population, controlling for neighborhood-level sociodemographic factors. Data were analyzed in 2023. RESULTS: The number of tobacco retail licenses decreased from 9,304 in 2010 to 5,107 in 2022, with the rate of decline significantly accelerating post-policy (-14·2% versus -34·2%). Policy effects were stronger in districts with lower income and greater proportions of non-Hispanic Black residents. CONCLUSIONS: NYC's policy substantially reduced tobacco retailer density and appeared to close longstanding patterns of inequity in tobacco access, serving as a rare example of a tobacco control policy that may effectively reduce tobacco-related disparities. This emergent approach to restructure tobacco retail in communities may reach populations that have not benefitted from traditional tobacco control policies and should be considered by other localities.

Firearm Death Rates in Rural vs Urban US Counties.

This cross-sectional study examines the variability in firearm mortality risk by county type across the full rural-urban continuum in the US.

Collateral consequences of the school-to-prison pipeline: Adolescent substance use and developmental risk.

OBJECTIVE: The adolescent health consequences of the school-to-prison pipeline remain underexplored. We test whether initiating components of the school-to-prison pipeline-suspensions, expulsions, and school policing-are associated with higher school-average levels of student substance use, depressed feelings, and developmental risk in the following year. METHOD: We linked 2003-2014 data from the California Healthy Kids Survey and the Civil Rights Data Collection from over 4,800 schools and 4,950,000 students. With lagged multi-level models, we estimated relationships between the school prevalence of total discipline, out-of-school discipline, and police-involved discipline, and standardized school-average levels of 6 substance use measures and 8 measures of developmental risk, respectively. RESULTS: The prevalence of school discipline predicted subsequent school-mean substance use and developmental risk. A one-unit higher prevalence of total discipline predicted higher school levels (in standard deviations) of binge drinking alcohol (0.14, 95% CI: 0.11, 0.17), drinking alcohol (0.15, 95% CI: 0.12, 0.18), smoking tobacco (0.09, 95% CI: 0.06, 0.12), using cannabis (0.16, 95% CI: 0.14, 0.19), using other drugs (0.17, 95% CI: 0.14, 0.21), and violence/harassment (0.16, 95% CI: 0.12, 0.2). Total discipline predicted lower levels of reported community support (-0.07, 95% CI: -0.1, -0.05), feeling safe in school (-0.12, 95% CI: -0.16, -0.09), and school support (-0.16, 95% CI: -0.19, -0.12). Associations were greater in magnitude for more severe out-of-school discipline. Findings were inconsistent for police-involved discipline. CONCLUSION: Exclusionary school discipline and school policing-core elements of the school-to-prison pipeline-are previously unidentified population predictors of adolescent substance use and developmental risk.

School Health Predictors of the School-to-Prison Pipeline: Substance Use and Developmental Risk and Resilience Factors.

PURPOSE: The purpose of the study is to establish prospective relationships among school mean levels of substance use, developmental risk and resilience factors, and school discipline. METHODS: We linked 2003-2014 data from the California Healthy Kids Survey and the Civil Rights Data Collection, from more than 4,800 schools and 4,950,000 students. With lagged multilevel linear models, we estimated relationships among standardized school average levels of six substance use measures; eight developmental risk and resilience factors; and the prevalence of total discipline, out-of-school discipline, and police-involved discipline. RESULTS: School mean substance use and risk/resilience factors predicted subsequent prevalence of discipline. For example, a one-standard deviation higher school mean level of smoking, binge drinking, and cannabis use was associated, respectively, with 16% (95% confidence interval [CI]: 14%, 18%), 18% (95% CI: 16%, 20%), and 21% (95% CI: 19%, 23%) higher subsequent prevalence of total discipline. A one-standard deviation higher mean level of community support and feeling safe in school was associated, respectively, with 21% (95% CI: 18%, 23%) and 9% (95% CI: 7%, 11%) lower total discipline. Higher violence/harassment was associated with 5% (95% CI: 4%, 7%) higher total discipline. Peer and home support, student resilience, and neighborhood safety were not associated with total discipline. Nearly all associations remained, attenuated, when we restricted to out-of-school and police-involved discipline. CONCLUSIONS: Schools with students who, on average, have higher substance use, less school and community support, and feel less safe in schools have a higher prevalence of school discipline and police contact. The public health implications of mass criminalization extend beyond criminal legal system settings and into schools.

Beyond survival: the broader consequences of prehospital transport by police for penetrating trauma.

BACKGROUND: Time to definitive hemorrhage control is a primary driver of survival after penetrating injury. For these injuries, mortality outcomes after prehospital transport by police and emergency medical service (EMS) providers are comparable. In this study we identify patient and geographic predictors of police transport relative to EMS transport and describe perceptions of police transport elicited from key stakeholders. METHODS: This mixed methods study was conducted in Philadelphia, Pennsylvania, which has the highest rate of police transport nationally. Patient data were drawn from Pennsylvania's trauma registry and geographic data from the US Census and American Community Survey. For all 7500 adults who presented to Philadelphia trauma centers with penetrating injuries, 2006-2015, we compared how individual and geospatial characteristics predicted the odds of police versus EMS transport. Concurrently, we conducted qualitative interviews with patients, police officers and trauma clinicians to describe their perceptions of police transport in practice. RESULTS: Patients who were Black (OR 1.50; 1.20-1.88) and Hispanic (OR 1.38; 1.05-1.82), injured by a firearm (OR 1.58; 1.19-2.10) and at night (OR 1.48; 1.30-1.69) and who presented with decreased levels of consciousness (OR 1.18; 1.02-1.37) had higher odds of police transport. Neighborhood characteristics predicting police transport included: percent of Black population (OR 1.18; 1.05-1.32), vacant housing (OR 1.40; 1.20-1.64) and fire stations (OR 1.32; 1.20-1.44). All stakeholders perceived speed as police transport's primary advantage. For patients, disadvantages included pain and insecurity while in transport. Police identified occupational health risks. Clinicians identified occupational safety risks and the potential for police transport to complicate the workflow. CONCLUSIONS: Police transport may improve prompt access to trauma care but should be implemented with consideration of the equity of access and broad stakeholder perspectives in efforts to improve outcomes, safety, and efficiency. LEVEL OF EVIDENCE: Epidemiological study, level III.

Urban Green Space and Its Impact on Human Health.

Background: Over half of the world's population now lives in urban areas, and this proportion is expected to increase. While there have been numerous reviews of empirical studies on the link between nature and human health, very few have focused on the urban context, and most have examined almost exclusively cross-sectional research. This review is a first step toward assessing the possibility of causal relationships between nature and health in urban settings. Methods: Through systematic review of published literature, we explored the association between urban green space and human health. Results: We found consistent negative association between urban green space exposure and mortality, heart rate, and violence, and positive association with attention, mood, and physical activity. Results were mixed, or no association was found, in studies of urban green space exposure and general health, weight status, depression, and stress (via cortisol concentration). The number of studies was too low to generalize about birth outcomes, blood pressure, heart rate variability, cancer, diabetes, or respiratory symptoms. Conclusions: More studies using rigorous study design are needed to make generalizations, and meta-analyses, of these and other health outcomes possible. These findings may assist urban managers, organizations, and communities in their efforts to increase new or preserve existing green space.

Racial Differences in Geographic Access to Medical Care as Measured by Patient Report and Geographic Information Systems.

BACKGROUND: Geographic access-the travel burden required to reach medical care-is an important aspect of care. Studies, which typically rely on geographic information system (GIS) calculated travel times, have found some evidence of racial disparities in spatial access to care. However, the validity of these studies depends on the accuracy of travel times by patient race. OBJECTIVES: To determine if there are racial differences when comparing patient-reported and GIS-calculated travel times. RESEARCH DESIGN: Data came from the Philadelphia Area Prostate Cancer Access Study (P Access), a cohort study of men diagnosed with localized prostate cancer. We conducted cross-sectional analysis of 2136 men using multivariable linear mixed-effects models to examine the effect of race on differences in patient-reported and GIS-calculated travel times to urology and radiation oncology cancer providers. RESULTS: Patient-reported travel times were, on an average, longer than GIS-calculated times. For urology practices, median patient-reported travel times were 12.7 minutes longer than GIS-calculated travel times for blacks versus 7.2 minutes longer for whites. After adjusting for potential confounders, including socioeconomic status and car access, the difference was significantly greater for black patients than white patients (2.0 min; 95% confidence interval, 0.58-3.44). CONCLUSIONS: GIS-calculated travel time may underestimate access to care, especially for black patients. Future studies that use GIS-calculated travel times to examine racial disparities in spatial access to care might consider including patient-reported travel times and controlling for factors that might affect the accuracy of GIS-calculated travel times.

A multidimensional view of racial differences in access to prostate cancer care.

BACKGROUND: Racial disparities in prostate cancer treatment and outcomes are widespread and poorly understood. In the current study, the authors sought to determine whether access to care, measured across multiple dimensions, contributed to racial differences in prostate cancer. METHODS: The Philadelphia Area Prostate Cancer Access Study (P2 Access) included 2374 men diagnosed with localized prostate cancer between 2012 and 2014. Men were surveyed to assess their experiences accessing care (response rate of 51.1%). The authors determined appointment availability at 151 urology practices using simulated patient telephone calls and calculated travel distances using geospatial techniques. Multivariable logistic regression models were used to determine the association between 5 different domains of access (availability, accessibility, accommodation, affordability, and acceptability) and receipt of treatment, perceived quality of care, and physician-patient communication. RESULTS: There were 1907 non-Hispanic white and 394 black men in the study cohort. Overall, approximately 85% of the men received definitive treatment with no differences noted by race. Black men were less likely to report a high quality of care (69% vs 81%; P<.001) and good physician-patient communication (60% vs 71%; P<.001) compared with white men. In adjusted models, none of the 5 domains of access were found to be associated with definitive treatment overall or with radical prostatectomy. All access domains were associated with perceived quality of care and communication, although these domains did not mediate racial disparities. CONCLUSIONS: To the authors' knowledge, the current study presents the first comprehensive assessment of prostate cancer care access, treatment, and patient experience, demonstrating that although access was related to overall perceived quality of care and better physician-patient communication, it did not appear to explain observed racial differences. Cancer 2017;123:4449-57. © 2017 American Cancer Society.

Telomere Length and Neighborhood Circumstances: Evaluating Biological Response to Unfavorable Exposures.

Background: Multilevel frameworks suggest neighborhood circumstances influence biology; however, this relationship is not well studied. Telomere length (TL) shortening has been associated with individual-level and neighborhood-level exposures and disease and may provide insights into underlying biologic mechanisms linking neighborhood with biology. To support neighborhood-biology investigations, we sought to determine the independent effect of neighborhood exposures on TL using standard multilevel linear regression models and quantile regression, a nonlinear, social science method applicable for testing the biologic hypothesis that extremes of the TL distribution are related to poor outcomes.Methods: In a multicenter, cross-sectional study, blood TL was measured in 1,488 individuals from 127 census tracts in three U.S. regions using terminal restriction fragment assays. Multilevel linear and quantile regression models were adjusted for individual-level race, education, perceived stress, and depression. Neighborhood exposures included population density, urban/residential crowding, residential stability/mobility, and socioeconomic status.Results: TL was not associated with any neighborhood variable using linear models, but quantile regression revealed inverse associations between population density and urban crowding at the lower tails of the TL distribution [5th (population density P = 0.03; urban crowding P = 0.002), 50th (both P < 0.001), 75th percentiles (both P < 0.001)]. TL was related to residential stability at the upper tail (95th percentile P = 0.006).Conclusions: Findings support the use of nonlinear statistical methods in TL research and suggest that neighborhood exposures can result in biological effects.Impact: TL may serve as an underlying example of a biologic mechanism that can link neighborhood with biology, thus supporting multilevel investigations in future studies. Cancer Epidemiol Biomarkers Prev; 26(4); 553-60. ©2017 AACRSee all the articles in this CEBP Focus section, "Geospatial Approaches to Cancer Control and Population Sciences."

A Neighborhood-Wide Association Study (NWAS): Example of prostate cancer aggressiveness.

PURPOSE: Cancer results from complex interactions of multiple variables at the biologic, individual, and social levels. Compared to other levels, social effects that occur geospatially in neighborhoods are not as well-studied, and empiric methods to assess these effects are limited. We propose a novel Neighborhood-Wide Association Study(NWAS), analogous to genome-wide association studies(GWAS), that utilizes high-dimensional computing approaches from biology to comprehensively and empirically identify neighborhood factors associated with disease. METHODS: Pennsylvania Cancer Registry data were linked to U.S. Census data. In a successively more stringent multiphase approach, we evaluated the association between neighborhood (n = 14,663 census variables) and prostate cancer aggressiveness(PCA) with n = 6,416 aggressive (Stage≥3/Gleason grade≥7 cases) vs. n = 70,670 non-aggressive (Stage<3/Gleason grade<7) cases in White men. Analyses accounted for age, year of diagnosis, spatial correlation, and multiple-testing. We used generalized estimating equations in Phase 1 and Bayesian mixed effects models in Phase 2 to calculate odds ratios(OR) and confidence/credible intervals(CI). In Phase 3, principal components analysis grouped correlated variables. RESULTS: We identified 17 new neighborhood variables associated with PCA. These variables represented income, housing, employment, immigration, access to care, and social support. The top hits or most significant variables related to transportation (OR = 1.05;CI = 1.001-1.09) and poverty (OR = 1.07;CI = 1.01-1.12). CONCLUSIONS: This study introduces the application of high-dimensional, computational methods to large-scale, publically-available geospatial data. Although NWAS requires further testing, it is hypothesis-generating and addresses gaps in geospatial analysis related to empiric assessment. Further, NWAS could have broad implications for many diseases and future precision medicine studies focused on multilevel risk factors of disease.

Using a Mystery-Caller Approach to Examine Access to Prostate Cancer Care in Philadelphia.

PURPOSE: Prior work suggests that access to health care may influence the diagnosis and treatment of prostate cancer. Mystery-caller methods have been used previously to measure access to care for health services such as primary care, where patients' self-initiate requests for care. We used a mystery-caller survey for specialized prostate cancer care to assess dimensions of access to prostate cancer care. MATERIALS AND METHODS: We created an inventory of urology and radiation oncology practices in southeastern Pennsylvania. Using a 'mystery caller' approach, a research assistant posing as a medical office scheduler in a primary care office, attempted to make a new patient appointment on behalf of a referred patient. Linear regression was used to determine the association between time to next available appointment with practice and census tract characteristics. RESULTS: We successfully obtained information on new patient appointments from 198 practices out of the 223 in the region (88.8%). Radiation oncology practices were more likely to accept Medicaid compared to urology practices (91.3% vs 36.4%) and had shorter mean wait times for new patient appointments (9.0 vs 12.8 days). We did not observe significant differences in wait times according to census tract characteristics including neighborhood socioeconomic status and the proportion of male African American residents. CONCLUSIONS: Mystery-caller methods that reflect real-world referral processes from primary care offices can be used to measure access to specialized cancer care. We observed significant differences in wait times and insurance acceptance between radiation oncology and urology practices.

Unintentional firearm death across the urban-rural landscape in the United States.

BACKGROUND: Unintentional injuries are one of the leading causes of death in the United States. Many of these injuries are preventable, and unintentional firearm injuries, in particular, may be responsive to prevention efforts. We investigated the relationship between unintentional firearm death and urbanicity among adults. METHODS: This study was a retrospective analysis of national death certificate data. Unintentional adult firearm deaths in the United States from 1999 to 2006 were identified using the Multiple Cause of Death Data files from the National Center for Health Statistics. Decedents were assigned to a county of death and classified along an urban-rural continuum defined by population density and proximity to metropolitan areas. Total unintentional firearm death rates by county were analyzed in adjusted analyses using negative binomial regression. RESULTS: A total of 4,595 unintentional firearm injury deaths of adults occurred in the United States during the study period (a mean of 574.4 per year). Adjusted rates of unintentional firearm death showed increases from urban to rural counties. Americans in the most rural counties were significantly more likely to die of unintentional firearm deaths than those in the most urban counties (relative rate, 2.16; 95% confidence interval, 1.44-3.21, p = 0.002). CONCLUSION: Rates of unintentional firearm death are significantly higher in rural counties than in urban counties. Prevention strategies should be tailored to account for both geographic location and manner of firearm injury. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Weekend and night outcomes in a statewide trauma system.

OBJECTIVE: To evaluate whether mortality and clinical outcomes vary for injured patients in a mature trauma system on weeknights and weekends compared with weekdays. DESIGN: Retrospective cohort study. SETTING: Pennsylvania trauma system. PATIENTS: A total of 90,461 patients over 5 years. INTERVENTION: Treatment at a level I, II, or III trauma center. MAIN OUTCOME MEASURES: In-hospital mortality, time to procedures, and length of stay. RESULTS: In adjusted analyses, patients presenting on weeknights were no more likely to die than patients presenting during weekdays, and patients presenting on weekends were less likely to die than patients presenting on weekdays (odds ratio = 0.89; 95% confidence interval, 0.81-0.97). Presenting on weeknights was associated with longer intensive care unit stay (incidence rate ratio = 1.06; 95% confidence interval, 1.02-1.10) and longer hospital stay (incidence rate ratio = 1.02; 95% confidence interval, 1.00-1.04). Presenting on weekends was associated with longer intensive care unit stay (incidence rate ratio = 1.04; 95% confidence interval, 1.02-1.10) but not longer hospital stay. Delays to laparotomy or craniotomy were not seen in either group. CONCLUSIONS: We demonstrate comparable mortality among injured patients presenting on weeknights vs weekdays and lower mortality among injured patients on weekends vs weekdays. Systems-based solutions of the trauma model are protective against the weekend effect and inform care for other emergency care-sensitive conditions.

Survival among elderly patients after fractures of the distal radius.

Studies have documented increased mortality rates in patients sustaining hip and vertebral fractures. Distal radius fractures are common injuries among the elderly and are a significant source of disability. This study analyzed survival rates in an elderly patient cohort after distal radius fractures and determined mortality risk factors. In addition, the mortality rates in our patient cohort were compared with those of the general population of the United States matched for age and gender. The records of 325 elderly patients (250 women, 65 men) treated for distal radius fractures between 1992 and 1999 were reviewed and submitted to the national death registry maintained by the National Death Index and the Center for Disease Control and Prevention. The mortality experience of the patient cohort was analyzed by using bivariate statistical tests and multivariate regression. Average age at diagnosis was 77.4 years (range, 65-106 y). A total of 21% of patients (29% of men, 19% of women) died during the study period. After accounting for variations in age, total number of comorbidities, and Charlson comorbidity index, men were 2.65 times more likely to die than women (95% CI, range, 1.31-5.36) and their hazard of death was 1.83 times that of women (95% CI, range, 1.07-3.14). After accounting for variations in age and gender, patients with comorbidities were 5.23 times more likely to die (95% CI, range, 1.80-15.23) and did not survive as long as those without comorbidities. At 7 years after radius fracture, the cumulative estimated survival in the cohort under study was 57% compared with an expected value of 71% for the US population. Survival rates after distal radius fractures were notably lower than those expected for individuals of the same age and gender in standard populations. Men were twice as likely to die as women and did so almost twice as quickly.