Work in Progress: Immigrant Health Care from the Vantage of Cancer Testing and Screening.

This letter offers a perspective from cancer testing and screening on the improvements in immigrant insurance coverage and care charted in Bustamante et al.'s April 2019 article in JOIH on "Health Care Access and Utilization Among U.S. Immigrants Before and After the Affordable Care Act." Supportive evidence for their data may be found in complementary literature drawing from both the National Health Interview Survey the authors use and the Medical Expenditure Panel Survey, while post-ACA surveys and state level information suggest disparities remain for lawfully present and undocumented immigrants ineligible for Medicaid and unable to secure insurance to pay medical costs. Existent options for cancer services are discussed. Further relevant reform depends on voter awareness and collaborative efforts between consumer advocates and legislators.

Posttraumatic stress disorder, smoking, and cortisol in a community sample of pregnant women.

BACKGROUND: The prevalence of posttraumatic stress disorder (PTSD) in the United States is higher among pregnant women than women generally. PTSD is related to adverse birth outcomes via physiological and behavioral alterations, such as smoking. METHODS: We utilize salivary cortisol measures to examine how traumatic stress, smoking and the hypothalamic-pituitary-adrenal axis interact. Pregnant women (n=395) gave cortisol specimens as part of a cohort study of PTSD and pregnancy at three health systems in the Midwestern United States. Women were divided into three groups: nonsmokers, quitters (who stopped smoking during pregnancy), and pregnancy smokers. Mean cortisol values at three points, sociodemographics, trauma history, and PTSD were compared across groups. We assessed the association of smoking group and PTSD with late afternoon cortisol levels. RESULTS: Smokers, quitters, and nonsmokers differed on demographic risk factors and PTSD symptom load. Late afternoon and bedtime cortisol measures were significantly positively correlated with smoking in pregnancy, with smokers with PTSD presenting the highest cortisol levels. Regression analysis showed that smoking in pregnancy was associated with higher late afternoon cortisol in an additive manner with PTSD symptoms. CONCLUSIONS: Smoking appears to have a different relationship with cortisol level for those with and without PTSD. This is the first study to show additive effects of smoking and PTSD on cortisol levels in pregnant women. Since high cortisol, smoking, and PTSD have been shown to adversely affect perinatal outcomes, and since those continuing to smoke in pregnancy had the highest PTSD symptom load, PTSD-specific smoking cessation programs in maternity settings are warranted.

Abuse-related post-traumatic stress, coping, and tobacco use in pregnancy.

OBJECTIVE: To examine the relationship between trauma history, posttraumatic stress disorder (PTSD), coping, and smoking in a diverse sample of pregnant women, some of whom are active smokers. DESIGN: Secondary analysis from a prospective study on PTSD and pregnancy outcomes. SETTING: Maternity clinics at three health systems in the midwestern United States. PARTICIPANTS: Women age 18 or older (1,547) interviewed at gestational age fewer than 28 weeks. METHODS: Participants were classified at nonsmokers, quitters (stopped smoking during pregnancy), and pregnancy smokers. Demographic, trauma, and pregnancy factors, substance use, and use of tobacco to cope were compared across groups. Logistic regression assessed the influence of these factors on being a smoker versus a nonsmoker and a quitter versus a pregnancy smoker. RESULTS: Smokers differed from nonsmokers on all demographic risk factors (being African American, being pregnant as a teen, having lower income and less education, and living in high-crime areas), had higher rates of current and lifetime PTSD, and were more likely to report abuse as their worst trauma. Pregnancy smokers had lower levels of education, were more likely to classify their worst trauma as "extremely troubling," and were more likely to exhibit PTSD hyperarousal symptoms. In regression models, smoking "to cope with emotions and problems" doubled the odds of continuing to smoke while pregnant even after accounting for several relevant risk factors. CONCLUSION: Smoking behavior in pregnancy may be influenced by the need to cope with abuse-related PTSD symptoms. Clinicians should consider using trauma-informed interventions when working with tobacco-using pregnant women.