Racial/Ethnic Inequities in Adverse Childhood Experiences and Selected Health-Related Behaviors and Problems Among Maryland Adolescents.

We examined racial/ethnic inequities in the prevalence of adverse childhood experiences (ACEs) and examined the association between ACEs and selected health-related behaviors and problems. Data for this cross-sectional study come from the 2018 Maryland Youth Risk Behavior Survey/Youth Tobacco Survey, a statewide survey of high school students (n = 40,188). ACEs included caregiver verbal abuse and household food insecurity, substance use or gambling, mental illness, and involvement with the criminal justice system. We estimated the prevalence of ACEs overall and by race/ethnicity, and then used multiple logistic regression to determine associations between ACEs and emotional/behavioral problems, adjusting for race/ethnicity. Outcome variables included emotional distress, poor school performance, suicidal ideation, fighting, alcohol use, and marijuana use. More than one fifth of students reported each individual ACE. Differences in the prevalence of ACEs by race/ethnicity were statistically significant (p < .001). More than one fourth (25.8%) reported one of the five ACEs, 15.1% reported two, and 15.4% reported three or more. For each ACE, reporting having experienced it (vs. not) was associated with a >30% higher prevalence for each of the outcome variables. Among students who reported three or more ACEs (relative to none), the odds of emotional distress and suicidal ideation were more than 8 times greater. Among Maryland adolescents, ACEs are common, are inequitably distributed by race/ethnicity, and are strongly linked to behavioral health. Findings suggest the need to monitor ACEs as a routine component of adolescent health surveillance and to refocus assessment and intervention toward "upstream" factors that shape adolescent health.

Polytobacco use among a nationally-representative sample of black high school students.

BACKGROUND: Studies of the patterns of polytobacco use have increased. However, understanding the patterns of using multiple tobacco products among Black adolescents is minimal. This study identified the patterns of polytobacco use among U.S. Black adolescents. METHODS: Latent class analysis (LCA) was used to identify patterns of adolescent polytobacco use among a representative sample of Black youth from the 2017 Youth Risk Behavior Survey (n = 2782). Ever and recent (past 30 day) use of cigarettes, electronic cigarettes, cigars, and dip or chewing tobacco were used as latent class indicators. Multinomial regression was conducted to identify the association if smoking adjusting for sex, age, grade, and marijuana use. RESULTS: Most students were in the 9th grade (29%), e-cigarette users (21%) and were current marijuana users (25%). Three profiles of tobacco use were identified: Class 1: Non-smokers (81%), Class 2: E-cigarette Users (14%), and Class 3: Polytobacco Users (5%). Black adolescent Polytobacco users were the smallest class, but had the highest conditional probabilities of recent cigarette use, e-cigarette use, ever smoking cigars or chewing tobacco. Ever and current use of marijuana were associated with increased odds of being in the e-cigarette user versus non-smoker group, and current marijuana use was associated with increased odds of polytobacco use (aOR = 24.61, CI = 6.95-87.11). CONCLUSIONS: Findings suggests the need for targeted interventions for reducing tobacco use and examining the unique effects of polytobacco use on Black adolescents. Findings confirm a significant association of marijuana use with tobacco use.

Understanding Community-based HIV/AIDS Service Organizations: An Invaluable Source of HPV-related Cancer Information for At-risk Populations.

To describe non-clinical HIV service providers (NCHSPs) as surrogate seekers and health information mavens for people living with HIV (PLWH), men who have sex with men (MSM), and other vulnerable populations.In May/June 2016, we recruited 30 NCHSPs from three community-based HIV/AIDS service organizations. NCHSPs completed a 118-item self-administered, paper-and-pencil survey about HPV, cancer, and health communication. Data were analyzed using Stata/SE 14.1.Almost all (97%) NCHSPs were surrogate seekers and had looked for HIV/AIDS (97%), STD (97%), and cancer (93%) information. Most (60%) cancer information seekers had looked for information about HPV. The Internet (97%) and healthcare providers (97%) were health information sources almost all NCHSPs trusted. Nearly all NCHSPs (93%) were completely or very confident about their ability to find health information. The mean health information mavenism score (17.4 ± 2.1) was significantly higher than the scale's high-score cutoff (15.0) (p < 0 .001).NCHSPs look for and share health information with the vulnerable populations (e.g., PLWH, MSM) they serve. More research is needed to understand what NCHSPs' know and think about the health information they are sharing with vulnerable populations.

HIV Testing and Healthcare Utilization Among U.S. African-American Women.

A severe HIV/AIDS disparity exists for U.S. African-American women. Although HIV testing and healthcare engagement are paramount to HIV prevention and community health, many African-American women do not test for HIV or optimize healthcare services. To unpack the relationship between HIV testing and healthcare utilization among African-American women, latent class analysis (LCA) was used among a national, representative sample from the 2014 National Health Interview Survey to assess subgroup profiles of African-American women regarding HIV testing and healthcare utilization behaviors. This study also explored the covariates predicting latent class membership: age, income, cost of living worry, and healthcare service satisfaction. LCA identified three subgroups of U.S. African-American women: (a) Moderate HIV testing/Low healthcare utilization, (b) Moderate HIV testing/High healthcare utilization, and (c) No HIV testing/High healthcare utilization. Future HIV prevention interventions should be tailored to specific subgroups of African- American women based on HIV testing behaviors and healthcare use and experiences.

Substance Use Among Transgender Students in California Public Middle and High Schools.

BACKGROUND: Transgender adolescents face tremendous social stress in families and schools, which often leads to behavioral health disparities. This study assessed whether rates of substance use were higher among transgender adolescents when compared to nontransgender adolescents. METHODS: This study is a secondary data analysis of the 2013-2015 California Healthy Kids Survey (CHKS) that examines whether rates of substance use are higher among transgender youth when compared to nontransgender youth. Participants included 4778 transgender and 630,200 nontransgender students in middle and high schools in nearly all school districts in California. The study outcomes were lifetime, recent, and in-school use of cigarettes, tobacco, alcohol, marijuana, cocaine, and ecstasy as well as nonmedical use of prescription painkillers, diet pills, Ritalin or Adderall, and cold medicine. RESULTS: Transgender students were about 2-1/2 times more likely as nontransgender students to use cocaine/methamphetamine in their lifetime (odds ratio [OR] = 2.53; 95% confidence interval [CI] = 2.18-2.95) and about 2.8 times as likely to report past 30-day inhalant use (OR = 2.80; 95% CI = 2.41-3.26). Transgender students were more than twice as likely to report past 30-day prescription pain medication use (OR = 2.19; 95% CI = 1.90-2.53) and more than 3 times as likely to use cigarettes in school (OR = 3.37; 95% CI = 2.84-3.99). CONCLUSIONS: The study's findings indicate a need for community- and school-based interventions that reduce substance use among transgender youth.

HIV Testing and Health Care Utilization Behaviors Among Men in the United States: A Latent Class Analysis.

Emphasis has been placed on HIV testing and health care engagement, but little is known about how testing and engagement intersect, especially for men. We used latent class analysis to explore underlying profiles of U.S. men regarding HIV testing and health care utilization using data from the 2014 National Health Interview Survey. Multinomial regression was used to predict class membership in four classes: (a) Low HIV Testing/No Health Care Utilization, (b) Some HIV Testing/Low Health Care Utilization, (c) No HIV Testing/Some Health Care Utilization, and (d) High HIV Testing/High Health Care Utilization. Most men were in the No HIV Testing/Some Health Care Utilization class (46%), with a 0% chance of ever having had an HIV test but an 89% chance of seeing a general practitioner in the previous year. Research should include qualitative measures to capture information on facilitators and barriers to HIV testing for men who see general practitioners.

E-cigarettes, Cigarettes, and the Prevalence of Adolescent Tobacco Use.

BACKGROUND: Adolescent e-cigarette use has increased rapidly in recent years, but it is unclear whether e-cigarettes are merely substituting for cigarettes or whether e-cigarettes are being used by those who would not otherwise have smoked. To understand the role of e-cigarettes in overall tobacco product use, we examine prevalence rates from Southern California adolescents over 2 decades. METHODS: The Children's Health Study is a longitudinal study of cohorts reaching 12th grade in 1995, 1998, 2001, 2004, and 2014. Cohorts were enrolled from entire classrooms in schools in selected communities and followed prospectively through completion of secondary school. Analyses used data from grades 11 and 12 of each cohort (N = 5490). RESULTS: Among 12th-grade students, the combined adjusted prevalence of current cigarette or e-cigarette use in 2014 was 13.7%. This was substantially greater than the 9.0% adjusted prevalence of current cigarette use in 2004, before e-cigarettes were available (P = .003) and only slightly less than the 14.7% adjusted prevalence of smoking in 2001 (P = .54). Similar patterns were observed for prevalence rates in 11th grade, for rates of ever use, and among both male and female adolescents and both Hispanic and Non-Hispanic White adolescents. CONCLUSIONS: Smoking prevalence among Southern California adolescents has declined over 2 decades, but the high prevalence of combined e-cigarette or cigarette use in 2014, compared with historical Southern California smoking prevalence, suggests that e-cigarettes are not merely substituting for cigarettes and indicates that e-cigarette use is occurring in adolescents who would not otherwise have used tobacco products.

The E-cigarette Social Environment, E-cigarette Use, and Susceptibility to Cigarette Smoking.

PURPOSE: One concern regarding the recent increase in adolescent e-cigarette use is the possibility that electronic (e-) cigarettes may be used by those who might not otherwise have used cigarettes, and that dual use, or transition to cigarette use alone, may follow. METHODS: Questionnaire data were obtained in 2014 from 11th/12th grade students attending schools in 12 communities included in the Southern California Children's Health Study. We evaluated the cross-sectional association between e-cigarette use, the social environment (family and friends' use and approval of e-cigarettes and cigarettes), and susceptibility to future cigarette use among never cigarette smokers (N = 1,694), using previously validated measures based on reported absence of a definitive commitment not to smoke. RESULTS: Among adolescents who had never used cigarettes, 31.8% of past e-cigarette users and 34.6% of current (past 30-day) e-cigarette users indicated susceptibility to cigarette use, compared with 21.0% of never e-cigarette users. The odds of indicating susceptibility to cigarette use were two times higher for current e-cigarette users compared with never users (odds ratio = 1.97; 95% confidence interval: 1.21-3.22). A social environment favorable to e-cigarettes (friends' use of and positive attitudes toward the use of e-cigarettes) was also associated with greater likelihood of susceptibility to cigarette use, independent of an individual's e-cigarette use. CONCLUSIONS: E-cigarette use in adolescence, and a pro-e-cigarette social environment, may put adolescents at risk for future use of cigarettes. E-cigarettes may contribute to subsequent cigarette use via nicotine addiction or social normalization of smoking behaviors.

Patterns of Alternative Tobacco Product Use: Emergence of Hookah and E-cigarettes as Preferred Products Amongst Youth.

PURPOSE: There is a growing public health concern related to the rapid increase in the use of multiple tobacco products among adolescents. This study examined patterns of adolescent use of cigarettes, e-cigarettes, cigars/cigarillo, hookah/waterpipe, and smokeless/dip/chewing tobacco in a population of southern California adolescents. METHODS: Data from 2,097 11th- and 12th-grade participants in the Southern California Children's Health Study were collected via self-report in 2014. Study participants were asked about lifetime and current (past 30 days) use of cigarettes, cigars/cigarillos/little cigars, e-cigarettes, hookah/waterpipe, and smokeless/dip/chewing tobacco. Latent class analysis (LCA) was used to identify patterns of tobacco use. RESULTS: Hookah/waterpipe tobacco use had the highest current prevalence (10.7%) followed by e-cigarettes (9.6%). The prevalence of use of smokeless/dip/chewing tobacco was lowest, with 2.2% of adolescents reporting current use. The LCA suggested four distinct classes, comprising nonusers (72.3% of the sample), polytobacco experimenters (13.9%), e-cigarette/hookah users (8.2%), and polytobacco users (5.6%). Multinomial logistic regression based on these four classes found that males had double the odds to be polytobacco users relative to nonusers compared to females (odds ratio, 2.3; 95% confidence interval, 1.26-4.25). CONCLUSIONS: By identifying naturally occurring configurations of tobacco product use in teens, these findings may be useful to practitioners and policymakers to identify the need for tobacco control interventions that address specific tobacco products and particular combinations of polytobacco use. LCA can be used to identify segments of the population overrepresented among certain tobacco use classes (e.g., boys) that may benefit most from targeted polyproduct intervention approaches.

Substance Abuse and Other Adverse Outcomes for Military-Connected Youth in California: Results From a Large-Scale Normative Population Survey.

IMPORTANCE: Military families and military-connected youth exhibit significant strengths; however, a sizeable proportion of these families appear to be struggling in the face of war-related stressors. Understanding the consequences of war is critical as a public health concern and because additional resources may be needed to support military families. OBJECTIVE: To determine whether rates of adverse outcomes are higher for military-connected adolescents during war compared with nonmilitary peers. DESIGN, SETTING, AND PARTICIPANTS: This study is a secondary data analysis of a large, normative, and geographically comprehensive administrative data set (2013 California Healthy Kids Survey) to determine whether military-connected youth are at risk for adverse outcomes, including substance use, experiencing violence and harassment, and weapon carrying, during wartime. These outcomes are of particular concern because they affect socioemotional adjustment and academic success. Data were collected in March and April 2013 and participants included 54,679 military-connected and 634,034 nonmilitary-connected secondary school students from public civilian schools in every county and almost all school districts in California. MAIN OUTCOMES AND MEASURES: Outcomes included lifetime and recent use of alcohol, tobacco, marijuana, prescription medications, and other drugs, as well as experiences of physical and nonphysical violence and harassment and weapon carrying during the last year. RESULTS: Multivariable logistic regression models indicated that military-connected youth had greater odds of substance use, experience of physical violence and nonphysical harassment, and weapon carrying. For example, military-connected youth had 73% greater odds of recent other drug use (eg, cocaine and lysergic acid diethylamide; odds ratio [OR], 1.73; 95% CI, 1.66-1.80) and twice the odds of bringing a gun to school (OR, 2.20; 95% CI, 2.10-2.30) compared with nonmilitary-connected peers. Their odds of being threatened with a weapon or being in a fight were also significantly higher than their civilian counterparts (OR, 1.87; 95% CI, 1.80-1.95 and OR, 1.67; 95% CI, 1.62-1.71, respectively). CONCLUSIONS AND RELEVANCE: Most military-connected youth demonstrate resilience. However, results suggest that during wartime, military-connected youth are at increased risk for adverse outcomes. Further, when compared with data from 2011, the rates of these negative outcomes appear to be increasing. These findings suggest a need to identify and intervene with military-connected adolescents and reflect a larger concern regarding the well-being of military families during wartime.

Psychosocial Factors Associated With Adolescent Electronic Cigarette and Cigarette Use.

BACKGROUND: Use of electronic cigarettes (e-cigarettes) among adolescents has increased since their introduction into the US market in 2007. Little is known about the role of e-cigarette psychosocial factors on risk of e-cigarette or cigarette use in adolescence. METHODS: Information on e-cigarette and cigarette psychosocial factors (use and attitudes about use in the home and among friends) was collected from 11th- and 12th-grade participants in the Southern California Children's Health Study during the spring of 2014. RESULTS: Of 2084 participants, 499 (24.0%) had used an e-cigarette, including 200 (9.6%) current users (past 30 days); 390 participants (18.7%) had smoked a combustible cigarette, and 119 (5.7%) were current cigarette smokers. Cigarette and e-cigarette use were correlated. Nevertheless, 40.5% (n = 81) of current e-cigarette users had never smoked a cigarette. Psychosocial factors (home use of each product, friends' use of and positive attitudes toward e-cigarettes and cigarettes) and participant perception of the harm of e-cigarettes were strongly positively associated both with e-cigarette and cigarette use. Most youth who reported e-cigarette use had friends who used e-cigarettes, and almost half of current users reported that they did not believe there were health risks associated with e-cigarette use. CONCLUSIONS: Longitudinal studies of adolescents are needed to determine whether the strong association of e-cigarette psychosocial factors with both e-cigarette and cigarette use will lead to increased cigarette use or dual use of cigarettes and e-cigarettes, or whether e-cigarettes will serve as a gateway to cigarette use.

School victimization and substance use among adolescents in California.

Substance use and violence co-occur among adolescents. However, the extant literature focuses on the substance use behaviors of perpetrators of violence and not on victims. This study identifies patterns of school victimization and substance use and how they co-occur. The California Healthy Kids Survey was used to identify latent classes/clusters of school victimization patterns and lifetime and frequency of recent (past month) alcohol, tobacco, and marijuana use (N = 419,698). Demographic characteristics (age, gender, and race/ethnicity) were included as predictors of latent class membership. Analyses revealed four latent classes of school victimization: low victimization (44.4 %), moderate victimization (22.3 %), verbal/relational victimization (20.8 %), and high victimization (with physical threats; 12.5 %). There were also four classes of substance use: non-users (58.5 %), alcohol experimenters (some recent alcohol use; 25.8 %), mild poly-substance users (lifetime use of all substances with few days of recent use; 9.1 %), and frequent poly-substance users (used all substances several times in the past month; 6.5 %). Those in the high victimization class were twice as likely to be frequent poly-substance users, and mild poly-substance use was most salient for those in the verbal victimization class. Few studies have explored latent patterns of substance use and violence victimization concurrently. The findings indicate substantial heterogeneity in victimization and substance use among youth in California schools with implications for targeted and tailored interventions. Understanding how certain types of victimization are associated with particular patterns of substance use will provide schools with opportunities to screen for concurrent behavioral health problems among youth.

Substance Use Among Adolescents in California: A Latent Class Analysis.

Data from the California Healthy Kids Survey of 7th, 9th, and 11th graders were used to identify latent classes/clusters of alcohol, tobacco, and marijuana use (N = 418,702). Analyses revealed four latent classes of substance use, which included nonusers (61.1%), alcohol experimenters (some recent alcohol use; 22.8%), mild polysubstance users (lifetime use of all substances with less than 3 days of recent use; 9.2%), and frequent polysubstance users (used all substances three or more times in the past month; 6.9%). The results revealed that alcohol and marijuana use are salient to California adolescents. This information can be used to target and tailor school-based prevention efforts.

Prevalence and correlates of victimization and weapon carrying among military- and nonmilitary-connected youth in Southern California.

OBJECTIVES: The present analysis sought to explore the normative rates and correlates of school victimization and weapon carrying among military-connected and nonmilitary-connected youth in public schools in Southern California. METHODS: Data are from a sub-sample of the 2011 California Healthy Kids Survey (N=14,512). Items to assess victimization and weapon carrying were separated into three categories: physical acts (e.g., being pushed or shoved), nonphysical acts (e.g., having rumors spread about them) and weapon carrying. RESULTS: The bivariate results indicate that youth with a military-connected parent had higher rates of physical victimization (56.8%), nonphysical victimization (68.1%), and weapon carrying (14.4%) compared to those with siblings serving (55.2%, 65.2%, and 11.4%, respectively) and nonmilitary-connected (50.3%, 61.6%, and 8.9%, respectively) youth. Having a parent in the military increased the odds of weapon carrying by 29% (Odds Ratio=1.29, 95% confidence interval=1.02-1.65). Changing schools and a larger number of family member deployments in the past 10years were associated with significant increases in the likelihood of victimization and weapon carrying. CONCLUSIONS: The results of this analysis warrant a focus on school supports for youth experiencing parental military service, multiple relocations and deployments of a family member.

Substance use among military-connected youth: the California Healthy Kids Survey.

BACKGROUND: Young people in military-connected families may be exposed to deleterious stressors, related to family member deployment, that have been associated with externalizing behaviors such as substance use. Substance use predisposes youth to myriad health and social problems across the life span. PURPOSE: This study examined the prevalence and correlates of lifetime and recent substance use in a normative sample of youth who were either connected or not connected to the military. METHODS: Data are from a subsample of the 2011 California Healthy Kids Survey (N=14,149). Items in the present analyses included present familial military affiliation (no one, parent, sibling); number of deployments (none, one, two or more); gender; grade; and race/ethnicity. Substance use items assessed whether the youth reported lifetime use of alcohol, tobacco, marijuana, other drugs, or prescription drugs; and recent (past 30 days) use of alcohol, tobacco, marijuana, and other drugs. RESULTS: Multivariate analysis conducted in 2012 revealed that an increase in the number of deployments was associated with a higher likelihood of lifetime and recent use, with the exception of lifetime smoking. CONCLUSIONS: These results indicate that experiences associated with deployment of a family member may increase the likelihood of substance use.

Multi-level influence of school norms on tobacco use in South Africa: an ecometric consideration of group differences.

OBJECTIVES: Tobacco use has been found to be related to contextual-environmental characteristics. This study focuses on the influence of contextual norms on adolescent smoking behavior with consideration of racial differences. METHODS: Data for this study were derived from the South African Community Epidemiology Network on Drug Use survey. Students (n = 1,277) completed a self-administered questionnaire (available in Afrikaans, Xhosa, and English). School-level aggregate measures were developed from the items: whether they thought smoking was wrong, whether they thought they would be seen as "cool" if they smoked, how many of their closest friends smoked, and whether they had repeated a grade level in school. RESULTS: The results of this analysis revealed that after controlling for demographic characteristics, aggregate measures of importance for ever smoking were whether there were school norms of perceiving that smoking was not wrong, perceiving that smoking was cool, and high prevalence of having friends who smoke. Recent smoking was only predicted by attendance at schools with increased levels of academic failure. Black South Africans were less likely to ever smoke than Coloured or White. CONCLUSIONS: This study highlights the saliency of both compositional (academic failure) and ecological (collective perceptions about smoking) characteristics in predicting ever and recent smoking. Collective perceptions of smoking in a predominantly Black school were largely negative. These findings can be used to target school norms regarding tobacco use in Cape Town.

Tobacco use and suicidality: latent patterns of co-occurrence among black adolescents.

INTRODUCTION: Tobacco use is responsible for a considerable portion of the health disparities experienced by Blacks. In addition to its physiological effects, tobacco use has consistently been shown to be associated with suicidality among adolescents. The purpose of the present study is to describe the association between specific patterns of tobacco use behavior and those of suicidality among a nationally representative sample of Black high school students. METHODS: Responses from Black adolescents (N = 2,931) who completed the 2007 Youth Risk Behavior Surveillance Survey were included. Latent class analysis was utilized to identify typologies based on two domains: (a) lifetime and recent tobacco use and (b) suicidality. The association between tobacco use class membership and suicidality class membership as well as the direct effects of age and gender on class membership was also investigated. RESULTS: A significant proportion of Black youth reported smoking and suicidal behaviors. A 4-class model provided the best overall fit to the data for tobacco use behavior (nonsmokers, former smokers, light current smokers, and frequent current smokers); a 3-class model provided the best overall fit to the data for suicidality (not suicidal, mild suicidality, suicidal). Smoking status was associated with suicidality class membership, with more intense patterns of smoking related to increased probability of identification with both mild suicidality and being classified as suicidal compared with not suicidal. CONCLUSIONS: The results of this study indicate that any current smoking status increases the likelihood of suicidality at least 5-fold and provides incentive to target this specific portion of the population of Black adolescent smokers.

Social-ecological influences on patterns of substance use among non-metropolitan high school students.

Patterns of substance use are examined in a sample of over 1,200 youth in a non-metropolitan region of New England. Self-reported history and frequency of alcohol, tobacco, marijuana, inhalants, pain medications, and other hard drug use was assessed for 9th and 10th grade students. Latent class analyses identified four patterns of substance use: non-users (22%), alcohol experimenters (38%), occasional polysubstance users (29%), and frequent polysubstance users (10%). Contextual risk and protective factors in the individual, family, peer, and community domains predicted substance use patterns. Youth report of peer substance use had the largest effects on substance use class membership. Other individual characteristics (e.g., gender, antisocial behavior, academic performance, perceived harm from use), family characteristics (e.g., parental drinking, parental disapproval of youth use), and community characteristics (e.g., availability of substances) demonstrated consistent effects on substance use classes. Implications for prevention are discussed from a social-ecological perspective.

Associations between maternal closeness, suicidal ideation, and risk behaviors in Cape Town.

Health compromising behaviors, such as smoking and other risk behaviors tend to co-occur, and contribute to the leading causes of preventable death, disease, and disability among adolescents and young adults worldwide. The present study assesses a model of the direct and indirect effects of maternal closeness with suicidal ideation on smoking and risky behaviors. The sample consisted of 657 South African youth assessed over two time points with comparison of effects between males and females. Maternal closeness had a significant effect on suicidal ideation among females. Suicidal ideation had a significant effect on risky behaviors among males and lifetime smoking among females. A significant indirect effect was observed from maternal closeness to lifetime smoking among females. These results indicate that suicidal ideation is associated with lifetime smoking and risky behaviors separately among male and female adolescents and highlight the need to focus on the development of mental health preventive interventions for both genders.