Historical Influences on Contemporary Tobacco Use by Northern Plains and Southwestern American Indians.

There are great differences in smoking- and tobacco-related mortality between American Indians on the Northern Plains and those in the Southwest that are best explained by (1) ecological differences between the two regions, including the relative inaccessibility and aridity of the Southwest and the lack of buffalo, and (2) differences between French and Spanish Indian relations policies. The consequence was the disruption of inter- and intratribal relations on the Northern Plains, where as a response to disruption the calumet (pipe) ceremony became widespread, whereas it did not in the Southwest. Tobacco was, thus, integrated into social relationships with religious sanctions on the Northern Plains, which increased the acceptability of commercial cigarettes in the 20th century. Smoking is, therefore, more deeply embedded in religious practices and social relationships on the Northern Plains than in the Southwest.

Historical trends and regional differences in all-cause and amenable mortality among American Indians and Alaska Natives since 1950.

American Indian and Alaska Native (AI/AN) death rates declined over most of the 20th century, even before the Public Health Service became responsible for health care in 1956. Since then, rates have declined further, although they have stagnated since the 1980s. These overall patterns obscure substantial regional differences. Most significant, rates in the Northern and Southern Plains have declined far less since 1949 to 1953 than those in the East, Southwest, or Pacific Coast. Data for Alaska are not available for the earlier period, so its trajectory of mortality cannot be ascertained. Socioeconomic measures do not adequately explain the differences and rates of change, but migration, changes in self-identification as an AI/AN person, interracial marriage, and variations in health care effectiveness all appear to be implicated.

Political parties and mortality: The role of social status and personal responsibility.

Previous research findings across a variety of nations show that affiliation with the conservative party is associated with greater longevity; however, it is thus far unclear what characteristics contribute to this relationship. We examine the political party/mortality relationship in the United States context. The goal of this paper is two-fold: first, we seek to replicate the mortality difference between Republicans and Democrats in two samples, controlling for demographic confounders. Second, we attempt to isolate and test two potential contributors to the relationship between political party affiliation and mortality: (1) socioeconomic status and (2) dispositional traits reflecting a personal responsibility ethos, as described by the Republican party. Graduate and sibling cohorts from the Wisconsin Longitudinal Study were used to estimate mortality risk from 2004 to 2014. In separate Cox proportional hazards models controlling for age and sex, we adjusted first for markers of socioeconomic status (such as wealth and education), then for dispositional traits (such as conscientiousness and active coping), and finally for both socioeconomic status and dispositional traits together. Clogg's method was used to test the statistical significance of attenuation in hazard ratios for each model. In both cohorts, Republicans exhibited lower mortality risk compared to Democrats (Hazard Ratios = 0.79 and 0.73 in graduate and sibling cohorts, respectively [p < 0.05]). This relationship was explained, in part, by socioeconomic status and traits reflecting personal responsibility. Together, socioeconomic factors and dispositional traits account for about 52% (graduates) and 44% (siblings) of Republicans' survival advantage. This study suggests that mortality differences between political parties in the US may be linked to structural and individual determinants of health. These findings highlight the need for better understanding of political party divides in mortality rates.

Ethics in public health research: changing patterns of mortality among American Indians.

Mortality rates for American Indians (including Alaska Natives) declined for much of the 20th century, but data published by the Indian Health Service indicate that since the mid-1980s, age-adjusted deaths for this population have increased both in absolute terms and compared with rates for the White American population. This increase appears to be primarily because of the direct and indirect effects of type 2 diabetes. Despite increasing appropriations for the Special Diabetes Program for Indians, per capita expenditures for Indian health, including third-party reimbursements, remain substantially lower than those for other Americans and, when adjusted for inflation, have been essentially unchanged since the early 1990s. I argue that inadequate funding for health services has contributed significantly to the increased death rate.

Differential impacts of health care in Australia: trend analysis of socioeconomic inequalities in avoidable mortality.

BACKGROUND: Recent avoidable mortality trends in Australia suggest that health care has made a substantial contribution to reducing mortality. This study investigates if the benefits of health care have been distributed equally by comparing declines in avoidable with non-avoidable mortality over time by socioeconomic status (SES). METHODS: We calculated avoidable and non-avoidable mortality rates in Australia by small areas for 1986, 1991, 1997 and 2002. We performed pooled cross-sectional trend analysis of indirectly standardized mortality rates by SES and year, modelling using Poisson regression with over-dispersion. Socioeconomic inequalities were quantified using the relative (RII) and slope (SII) index of inequality. RESULTS: The annual percentage decline in avoidable mortality at the higher end of the socioeconomic continuum (5.0%; 95% CI: 4.7-5.4%) was larger than at the lower end (3.5%; 3.2-3.8%), with increasing relative inequality between 1986 (RII = 1.54; 1.46-1.63) and 2002 (RII = 2.00; 1.95-2.06), greater than that in non-avoidable mortality (P = 0.036). In absolute terms, avoidable deaths fell annually by 7.4 (6.9-7.8) and 8.4 (7.9-8.9) deaths per 100 000 at the higher and lower end of the spectrum, respectively, with absolute inequality decreasing between 1986 (SII = 97.8; 87.6-107.9) and 2002 (SII = 81.5; 74.6-88.5). CONCLUSIONS: Health care has contributed to decreasing the absolute SES mortality gap. However, advantaged people have obtained a disproportionate benefit of health care, contributing to widening relative health inequalities. A universal heath care system does not guarantee equality in health-care-related outcomes.

Small-area variations in conviction rates for DWI: the significance of contextual variables in a Southwestern state.

Average annual conviction rates (1990-2000) of people arrested for driving under the influence of alcohol in each of New Mexico's 33 counties are described. Conviction rates vary from 58 to 95%. Rates are correlated with political conservatism, being higher where a higher proportion of voters voted for the republican presidential candidates, and with measures of crowding in the courts. Conviction rates are higher in rural than urban areas and are correlated with a low prevalence of alcohol-related problems in the population. The variance in conviction rates is higher in rural than urban areas, and higher where measures of court crowding are low. The results suggest that political culture and the efficiency of court functioning are each independently associated with conviction rates for DWI and may also be associated in a reciprocal fashion with both low DWI arrest rates and alcohol-involved crash rates.

Predictors of conviction and sentencing of DWI offenders in a New Mexico County.

OBJECTIVE: To analyze predictors of conviction and dismissal of individuals charged with DWI, and predictors of the sentences of those who are convicted. METHODS: Data come from the Citation Tracking System of the State of New Mexico's Motor Vehicle Division and includes information on all individuals who were arrested for DWI in San Juan County between August 1994 and December 2000. Independent variables were: age, gender, race/ethnicity, waiver of right to an attorney, court of arraignment, year of arrest, BAC, and number of prior DWI arrests. Dependent variables were: (1) conviction or dismissal, (2) jail or no jail, (3) incarceration/treatment or not, (4) fine or no fine, (5) length of jail sentence, (6) waived right of attorney, and (7) magnitude of fine. Multiple linear and logistic regression was used in the analyses. RESULTS: Use of an attorney is associated with reduced likelihood of conviction and, if convicted, in reduced likelihood of jail sentence and reduced jail time, but greater likelihood and magnitude of a fine. Native Americans were more likely than Hispanics and non-Hispanic whites to waive their right to an attorney. Native Americans were most likely to be sentenced to the detention/treatment program. BAC and number of prior arrests were each positively associated with increased likelihood of conviction and more severe sentences. There is also substantial variability in severity of sentencing among courts. CONCLUSION: Likelihood of conviction and severity of sentences are both determined by extra-legal factors, resulting in inconsistent application of the law. This may in turn contribute to a lack of compliance with laws related to DWI.

Life-course observations of alcohol use among Navajo Indians: natural history or careers?

In this article, I describe changes in patterns of alcohol use and abuse among Navajo Indians from the mid-1960s to the late 1990s. The prevalence of alcohol dependence continues to be higher than in the general U.S. population, but remission is also common, as it was in the 1960s and previously. Men have substantially higher rates of alcohol dependence than women. The former engage in heavy drinking largely in response to the heavy drinking of those around them. The latter drink excessively largely as a response to psychiatric disorders, depression, and abuse by a partner or husband. As increasing numbers of people have moved to reservation and border towns, a youth culture has developed in which alcohol use is initiated by teenagers with their peers rather than, as in the past, with older kinsmen. Alcohol use has thus been freed from the constraints imposed by both isolation and family obligations.

Paradox and privilege: A 55-year follow-up of the mortality of Yale College graduates.

OBJECTIVE: Two hypotheses were tested: 1. People from privileged backgrounds had better survival than those from less privileged backgrounds. 2. The advantages of privilege were vitiated by fraternity membership. METHODS: A 55-year retrospective cohort study of survival since 1960 of 945 graduates of Yale College followed to 2015. RESULTS: The survival of graduates of private secondary schools (the privileged group) did not differ from that of public school graduates. However, graduates of private secondary schools who had not joined a fraternity in college had significantly better survival than private school graduates who had joined fraternities and than public school graduates, whether fraternity members or not. CONCLUSIONS: The benefits of a privileged background in respect of survival were undermined by fraternity membership. It is suggested that both self-selection and substance mis-use may have contributed to the survival difference.

Variations in jail sentences and the probability of re-arrest for driving while intoxicated.

OBJECTIVE: The probability of re-arrest for driving while intoxicated (DWI) is compared for four different groups of individuals classified by whether the individual was convicted and, if so, the type of sentence received. METHOD: Subsequent re-arrests for DWI were examined for all individuals whose index arrest for DWI had occurred between 1994 and 2001 in a county in New Mexico. The groups included (1) those convicted as a result of the index arrest and sentenced to a 28-day jail/treatment program (N (#)=(#) 2,703); (2) all those not convicted as a result of the index arrest (N = 709); (3) those who were convicted but not sentenced to jail (N = 1,047); and (4) those convicted and sentenced to jail (N = 1,290). RESULTS: Adjusting for covariates of BAC, number of prior arrests, ethnicity, age, and sex, the probability of not being re-arrested was greatest among those sentenced to the jail/treatment program (Group 1), next highest in the two groups convicted but not sentenced to jail/treatment (Groups 3 and 4), and lowest in the group that was not convicted (Group 2). Length of jail sentence among people convicted but not sentenced to the jail/treatment program was unrelated to the probability of re-arrest. CONCLUSION: Conviction for DWI, regardless of the sentence, appears to reduce the probability of re-arrest, and being sentenced to a multi-modal treatment/incarceration program further reduces the probability of re-arrest. However, the other types of sentences do not appear to differ in their impact on probability of re-arrest.

The prevention paradox, traffic safety, and driving-while-intoxicated treatment.

BACKGROUND: In San Juan County, New Mexico, a 28-day jail/treatment program for first-time driving-while-intoxicated (DWI) offenders was established in 1994 to reduce both DWI recidivism and alcohol-related crashes. This paper assesses the impact of the program on both outcomes. METHODS: The data are composed of driving records of all people arrested for DWI in San Juan County from August 1994 through December 2001. Subsequent re-arrests and crashes were analyzed to compare people who had been sentenced to the jail/treatment program and those who had not. Kaplan-Meier survival curves and Cox proportional hazards regression analyses were used. Covariates included age, gender, blood alcohol content (BAC), number of prior arrests, and ethnicity (Native American, non-Hispanic white, and Hispanic). RESULTS: Re-arrest rates were significantly lower for the treatment than the nontreatment group. Each of the three major ethnic groups showed similar effects. This was not observed for subsequent alcohol-related crashes, possibly as a result of insufficient numbers. BAC and number of previous arrests were, however, significant risk factors for subsequent crashes. Finally, although BAC and previous arrests were important risk factors for subsequent crashes, the vast majority of subsequent alcohol-related crashes occurred among people in the intermediate risk ranges. CONCLUSIONS: The jail/treatment program is effective in reducing the probability of DWI re-arrests. The evidence with respect to crashes is equivocal. That most crashes occur to people in the intermediate risk range exemplifies the prevention paradox, and means that the courts, which deal most severely with high-risk individuals, cannot be expected to have a major impact on alcohol-related crashes.

State political cultures and the mortality of African Americans and American Indians.

PURPOSE: To test the hypothesis that mortality of African Americans is responsive to political cultures of particular states in which they reside whereas mortality of American Indians is unrelated to the political culture of the state but associated instead with cultural differences and with differences in the history of contact with Europeans. RESULTS: African American mortality rates are significantly correlated with the scale measure of political culture but there is no such association with American Indian mortality. CONCLUSIONS: The differing relationship of these two minority populations with the federal and state governments has shaped their mortality rates in significantly different ways.

Risk factors for polydrug use in a Native American population.

The Diagnostic Interview Schedule was used in 1993-1995 to collect information on the use of alcohol and other substances from 1,086 Navajo Indians living on or near their reservation in the southwestern United States. Bivariate and multivariate analyses are used to show that age of first alcohol use has declined over the past 50 years and is a significant risk factor for both alcohol dependence and polysubstance use. Limitations are noted.

A randomized trial of a DWI intervention program for first offenders: intervention outcomes and interactions with antisocial personality disorder among a primarily American-Indian sample.

BACKGROUND: Randomized trial evidence on the effectiveness of incarceration and treatment of first-time driving while intoxicated (DWI) offenders who are primarily American Indian has yet to be reported in the literature on DWI prevention. Further, research has confirmed the association of antisocial personality disorder (ASPD) with problems with alcohol including DWI. METHODS: A randomized clinical trial was conducted, in conjunction with 28 days of incarceration, of a treatment program incorporating motivational interviewing principles for first-time DWI offenders. The sample of 305 offenders including 52 diagnosed as ASPD by the Diagnostic Interview Schedule were assessed before assignment to conditions and at 6, 12, and 24 months after discharge. Self-reported frequency of drinking and driving as well as various measures of drinking over the preceding 90 days were available at all assessments for 244 participants. Further, DWI rearrest data for 274 participants were available for analysis. RESULTS: Participants randomized to receive the first offender incarceration and treatment program reported greater reductions in alcohol consumption from baseline levels when compared with participants who were only incarcerated. Antisocial personality disorder participants reported heavier and more frequent drinking but showed significantly greater declines in drinking from intake to posttreatment assessments. Further, the treatment resulted in larger effects relative to the control on ASPD than non-ASPD participants. CONCLUSIONS: Nonconfrontational treatment may significantly enhance outcomes for DWI offenders with ASPD when delivered in an incarcerated setting, and in the present study, such effects were found in a primarily American-Indian sample.

Program characteristics and enrollees' outcomes in the Program of All-Inclusive Care for the Elderly (PACE).

The Program of All-Inclusive Care for the Elderly (PACE) is a unique program providing a full spectrum of health care services, from primary to acute to long-term care for frail elderly individuals certified to require nursing home care. The objective of this article is to identify program characteristics associated with better risk-adjusted health outcomes: mortality, functional status, and self-assessed health. The article examines statistical analyses of information combining DataPACE (individual-level clinical data), a survey of direct care staff about team performance, and interviews with management in twenty-three PACE programs. Several program characteristics were associated with better functional outcomes. Fewer were associated with long-term self-assessed health, and only one with mortality. These findings offer strategies that may lead to better care.

Mortality of white Americans, African Americans, and Canadians: the causes and consequences for health of welfare state institutions and policies.

The life expectancy of African Americans has been substantially lower than that of white Americans for as long as records are available. The life expectancy of all Americans has been lower than that of all Canadians since the beginning of the 20th century. Until the 1970s this disparity was the result of the low life expectancy of African Americans. Since then, the life expectancy of white Americans has not improved as much as that of all Canadians. This article discusses two issues: racial disparities in the United States, and the difference in life expectancy between all Canadians and white Americans. Each country's political culture and institutions have shaped these differences, especially national health insurance in Canada and its absence in the United States. The American welfare state has contributed to and explains these differences.