Prevalence and location of tobacco smoke exposure outside the home in adults and children in the United States.

OBJECTIVES: Tobacco smoke exposure (TSE) is associated with many adverse health outcomes. The goal of this study was to provide insight into the prevalence and location of self-reported TSE outside the home for US adults and children. STUDY DESIGN: Cross-sectional survey. METHODS: Data from a nationally representative sample of US adults from 2014 were included. Participants who responded that they smelled smoke during the past seven days in various settings were considered to have been exposed to TSE. Parents were asked about TSE exposure of their children. RESULTS: Sixty-nine percent of all adults reported TSE outside their home in the past seven days. The most common exposure location among adults was on a public sidewalk and outside the doorway of a building (both 33%). Thirty-three percent of parents reported outside the home TSE for their children in the past seven days. Most commonly, the reported exposure was 'In some other place(s)' (16%), followed by at a relative's house (10%). CONCLUSIONS: This study reports on TSE outside the home in a wide variety of settings and a broad range of ages in a nationally representative US sample. A high proportion of US adults and children are exposed to TSE outside the home in indoor, outdoor, public, and private settings. Smoke-free laws, clinical interventions, education, and a change in social norms are required to stop TSE.

Protecting children and families from tobacco and tobacco-related NCDs in the Western Pacific: good practice examples from Malaysia, Philippines and Singapore.

BACKGROUND: Non-communicable diseases (NCDs) are generally considered diseases of adulthood, but NCD risk factors like tobacco use often are taken up during childhood and adolescence, and second-hand smoke exposure affects child survival and development. METHODS: At a regional meeting of the Asia Pacific Child and Family Health Alliance for Tobacco Control, members reviewed existing good practices of child-focused tobacco control approaches using health promotion strategies. These interventions were implemented nationally in Malaysia, the Philippines and Singapore. RESULTS: Three good practice national examples were identified that focused on creating supportive tobacco-free environments and upgrading cessation skills among paediatricians. These country examples highlight strategic areas to protect children and families from the harms of tobacco, as part of NCD prevention and control. Training paediatricians in brief cessation advice has enabled them to address tobacco-using parents. Fully enforcing smoke-free public areas has led to an increase in smoke-free homes. The Tobacco Free Generation is a tobacco control 'endgame' strategy that taps into a social movement to deglamorize tobacco use and empower youth born in and after year 2000 to reject tobacco and nicotine addiction. CONCLUSION: Tobacco control is pivotal in the fight against NCDs; health promotion strategies to protect children and youth from tobacco have a critical role to play in NCD prevention and control. Frontline health workers, including primary care paediatricians, need to step up and actively advocate for full implementation of the WHO Framework Convention on Tobacco Control, including tobacco tax increases and smoke-free areas, while monitoring patients and their parents for tobacco use and second-hand smoke exposure, preventing adolescent smoking uptake, and offering cessation support. A life-course approach incorporating child-focused efforts to prevent initiation of smoking and second-hand smoke exposure with measures promoting cessation among parents will offer the greatest chance of overcoming future tobacco-related NCD burden.

Characterization of the complete mitochondrial genomes of two Critically Endangered wedgefishes: Rhynchobatus djiddensis and Rhynchobatus australiae.

We present the complete mitochondrial genomes of the Critically Endangered whitespotted wedgefish, Rhynchobatus djiddensis (Forsskål, 1775), and bottlenose wedgefish, Rhynchobatus australiae (Whitley, 1939), with the R. djiddensis mitogenome documented for the first time. The genomes for R. djiddensis and R. australiae are 16,799 and 16,805 bp in length, respectively. Both comprise 13 protein-coding regions, 22 tRNA genes, two rRNA genes, and a non-coding control region. All protein-coding regions consistently start with the ATG start codon; however, the alternative start codon GTG is observed at the start of the COX1 gene. NADH2, COX2, and NADH4 have incomplete stop codons: T or TA, and tRNALeu and tRNASer , have atypical codons: UAA, UGA, GCU, and UAG. The phylogenetic analysis places R. djiddensis and R. australiae within the Rhynchobatus genus, separate from other families in the order Rhinopristiformes. We also highlight the most variable gene regions to expedite future primer design, of which NADH2 was the most variable (4.5%) when taking gene length into account. These molecular resources could promote the taxonomic resolution of the whitespotted wedgefish species complex and aid in the genetic characterization of populations of these and related species.

The effect of willow fodder feeding on immune cell populations in the blood and milk of late-lactating dairy goats.

In a previous study, we showed that access to willow fodder decreased somatic cell counts (SCC) in the milk of local Mamber goats grazing in brushland at the end of lactation. To test whether the consumption of willow affects the cells of the immune system, Alpine crossbred dairy goats grazing in the same environment were either offered free access to freshly cut willow fodder (W, n = 24) or not (C, n = 24) for 2 weeks. The willow fodder contained 7.5 g/kg DM of salicin. The other major secondary compounds were catechin, myricitrin, hyperin and chlorogenic acid (2.2, 2.6, 1.0 and 0.75 g/kg DM, respectively). Udder health status was determined before the experiment, and each of the two groups included five (W) or six (C) goats defined as infected, as established by microbial cfu in milk, and 19 (W) or 18 (C) non-infected goats. Goats ingested, on average, 600 g of DM from willow (25% of food intake), resulting in minor changes in dietary quality compared to the controls, as established by faecal near-IR spectrometry. Throughout the 2 weeks of experiment, differences between groups in dietary CP contents were minor and affected neither by infection nor by access to willow; the dietary percentage of neutral detergent fibre (NDF) decreased in C and increased in W; dietary acid detergent fibre (ADF) increased; and the dietary tannin contents decreased for both treatments. However, milking performance and milk quality attributes in both W and C goats were similar. Initial SCC and milk neutrophil (cluster of differentiation (CD)18+ and porcine granulocyte (PG)68) cell counts were higher in infected than in non-infected goats; counts decreased significantly in W but not in C uninfected goats. The percentage of CD8+ T-cells increased in all C goats, while in the W group, a significant increase was found only for infected goats. The consumption of willow mitigated an increase in CD8+ in blood and triggered an increase in CD8+ in milk, suggesting an immune-regulatory effect independent of udder status. To our knowledge, this is the first report of a direct nutraceutical effect of fodder ingestion on the immune status of goats.

Changes in aquaporin-2 protein contribute to the urine concentrating defect in rats fed a low-protein diet.

Low-protein diets cause a urinary concentrating defect in rats and humans. Previously, we showed that feeding rats a low (8%) protein diet induces a change in urea transport in initial inner medullary collecting ducts (IMCDs) which could contribute to the concentrating defect. Now, we test whether decreased osmotic water permeability (Pf) contributes to the concentrating defect by measuring Pf in perfused initial and terminal IMCDs from rats fed 18 or 8% protein for 2 wk. In terminal IMCDs, arginine vasopressin (AVP)-stimulated osmotic water permeability was significantly reduced in rats fed 8% protein compared to rats fed 18% protein. In initial IMCDs, AVP-stimulated osmotic water permeability was unaffected by dietary protein. Thus, AVP-stimulated osmotic water permeability is significantly reduced in terminal IMCDs but not in initial IMCDs. Next, we determined if the amount of immunoreactive aquaporin-2 (AQP2, the AVP-regulated water channel) or AQP3 protein was altered. Protein was isolated from base or tip regions of rat inner medulla and Western analysis performed using polyclonal antibodies to rat AQP2 or AQP3 (courtesy of Dr. M.A. Knepper, National Institutes of Health, Bethesda, MD). In rats fed 8% protein (compared to rats fed 18% protein): (a) AQP2 decreases significantly in both membrane and vesicle fractions from the tip; (b) AQP2 is unchanged in the base; and (c) AQP3 is unchanged. Together, the results suggest that the decrease in AVP-stimulated osmotic water permeability results, at least in part, in the decrease in AQP2 protein. We conclude that water reabsorption, like urea reabsorption, responds to dietary protein restriction in a manner that would limit urine concentrating capacity.

UT-A urea transporter protein in heart: increased abundance during uremia, hypertension, and heart failure.

Urea transporters have been cloned from kidney medulla (UT-A) and erythrocytes (UT-B). We determined whether UT-A proteins could be detected in heart and whether their abundance was altered by uremia or hypertension or in human heart failure. In normal rat heart, bands were detected at 56, 51, and 39 kDa. In uremic rats, the abundance of the 56-kDa protein increased 1.9-fold compared with pair-fed, sham-operated rats, whereas the 51- and 39-kDa proteins were unchanged. We also detected UT-A2 mRNA in hearts from control and uremic rats. Because uremia is accompanied by hypertension, the effects of hypertension per se were studied in uninephrectomized deoxycorticosterone acetate salt-treated rats, where the abundance of the 56-kDa protein increased 2-fold versus controls, and in angiotensin II-infused rats, where the abundance of the 56 kDa protein increased 1.8-fold versus controls. The 51- and 39-kDa proteins were unchanged in both hypertensive models. In human left ventricle myocardium, UT-A proteins were detected at 97, 56, and 51 kDa. In failing left ventricle (taken at transplant, New York Heart Association class IV), the abundance of the 56-kDa protein increased 1.4-fold, and the 51-kDa protein increased 4.3-fold versus nonfailing left ventricle (donor hearts). We conclude that (1) multiple UT-A proteins are detected in rat and human heart; (2) the 56-kDa protein is upregulated in rat heart in uremia or models of hypertension; and (3) the rat results can be extended to human heart, where 56- and 51-kDa proteins are increased during heart failure.

From data to policy ... to politics. The Minnesotans health care plan for universal access to care.

Calls for major reform of the health care delivery system have been sounded at both the state and federal level. However, given the lack of consensus on health care reform at a federal level, more than half of the states are developing initiatives for universal access to care. In 1989, the Minnesota legislature created the Health Care Access Commission to develop a blueprint for universal access in Minnesota. To assist this effort, we studied the extent and nature of uninsurance and underinsurance within the state. In this article we report the findings of that study and discuss how the findings were first used to develop recommendations for universal access legislation. We then describe the fate of the legislation. Finally, we describe the veto and the creation of HealthRight, the recently enacted plan for health care reform bill in Minnesota. This plan simultaneously expands access to care and aims to contain health care costs.

An influenza B epidemic among children in day-care.

An outbreak of influenza virus type B infections occurred in the Frank Porter Graham Day Care Center from February to April, 1974. During the epidemic there were 27 isolations of influenza B virus from 20 children. One half of these were obtained from children who were well at the time of culturing. Attack rates as determined by virus isolation and seroconversion for most age groups approximated the 40% rate for the entire population. Clinical and microbiological data from this study were compared to those obtained in the center during the same three months in 1973. Increases in the incidence of otitis media and temperatures over 38 C were seen during the 1974 study. Intensive continuous microbiological surveillance for bacteria, viruses, and mycoplasmas failed to reveal predominance of any other potential pathogen to account for these clinical findings. The analysis permitted by the nature of this study design in a day-care setting revealed several unexpected findings: high attack rates unrelated to age; common inapparent infections; and frequent association with otitis media.

Training pediatric residents to prevent tobacco use.

OBJECTIVE: To assess the effectiveness and acceptability of incorporating the National Cancer Institute (NCI) Guide to Preventing Tobacco Use During Childhood and Adolescence into pediatric training. DESIGN: Preintervention and postintervention self-reported surveys for residents receiving training and postintervention baseline surveys for those residents not receiving training. Measures include: (1) a self-reported knowledge, attitude, and behavior survey of residents; and (2) physician behavior reports from parent exit interviews. SETTING: A hospital-based pediatric residency program and continuity clinic. SUBJECTS: Pediatric residents and parents of pediatric patients seen for well child examinations. INTERVENTIONS: Structured NCI smoking cessation curriculum modified for delivery during scheduled teaching activities. RESULTS: The NCI training was acceptable and perceived as important by residents. Many did not recall receiving the materials or training. Trained residents who remembered the intervention improved their smoking cessation counseling effectiveness. Most patients' parents think it appropriate for physicians to ask; however, most reported not having been asked about smoking or environmental smoke exposure. CONCLUSIONS: For residents to learn effective prevention counseling strategies, systematic, reinforced preventive educational curricula must become an institutionalized part of residency training.

Adolescents' risky behavior and mass media use.

OBJECTIVE: To understand better the relationship between adolescents' use of the mass media (including television, radio, and magazines) and their risky or unhealthy behaviors. DESIGN: Secondary data analysis of a 1987 in-home survey of 2760 randomly selected 14- to 16-year-old adolescents in 10 urban areas in the southeastern United States. MEASUREMENT: The extent of participation in eight potentially risky behaviors (sexual intercourse, drinking, smoking cigarettes, smoking marijuana, cheating, stealing, cutting class, and driving a car without permission) and the use of a variety of mass media. RESULTS: Adolescents who had engaged in more risky behaviors listened to radio and watched music videos and movies on television more frequently than those who had engaged in fewer risky behaviors, regardless of race, gender, or parents' education. White male adolescents who reported engaging in five or more risky behaviors were most likely to name a heavy metal music group as their favorite. Adolescents reported reading a wide diversity of magazines, and most reported reading at least one of a few selected magazines. Sports and music magazines were most likely to be read by adolescents who had engaged in many risky behaviors. CONCLUSIONS: Mass media health promotion efforts could more specifically target adolescents who are engaging in multiple risky behaviors.

Physical and psychological follow-up on offspring of renal allograft recipients.

In light of concern regarding the effect of pregnancy on renal allograft recipients and the lack of information about their offspring, we studied ten infants born to eight allograft recipients (five female and three male). In all five female recipients, allograft function remained normal throughout pregnancy and the puerperium. Complications of pregnancy were minimal. Four patients were delivered by cesarean section, three for obstetrical reasons and one electively. Three of ten infants were premature births. There were no significant neonatal complications. At time of follow-up study, the offspring were 4 months to 6 8/12 years of age; physical examination was normal on all offspring. Developmental test results ranged from 82 to 131. Parents tended to be overly cautious and sought medical attention at the first sign of illness. Our data indicated no adverse effect on renal allograft function of the female recipients and no physical or developmental abnormalities in the offspring.

Characterization of Lyme meningitis and comparison with viral meningitis in children.

OBJECTIVES: The objectives of this study were to characterize Lyme meningitis (LM) in the pediatric population; to compare LM with viral meningitis (VM) with respect to epidemiology, history and physical examination, and laboratory data; and to provide means of early distinction of Lyme neuroborreliosis from other forms of aseptic meningitis. METHODS: This retrospective analysis involved children admitted to Alfred I. duPont Hospital for Children between 1990 and 1996 whose discharge diagnoses indicated viral or aseptic meningitis or Lyme disease. LM was defined as the presence of cerebrospinal fluid (CSF) pleocytosis with positive Lyme serology and/or erythema migrans. Patients were considered to have VM if they exhibited CSF pleocytosis and had a positive viral culture. Demographic, clinical, and laboratory data were collected for each patient, and patients with LM were compared with age-matched patients with VM. RESULTS: Of 179 patient records, 12 patients with LM and 10 patients with VM (all, >2 years old) were identified by using the above criteria. In comparing LM patients with VM patients, we noted no differences among demographic variables. Children with LM had significantly lower temperatures at the time of presentation. The presence of headache, neck pain, and malaise was similar for the two groups, but the duration of these symptoms was significantly longer among LM patients. Five children with LM had cranial neuropathies. All but 1 LM patient exhibited either papilledema, erythema migrans, or cranial neuropathy. These three findings were absent in the VM group. On CSF analysis, LM patients had fewer white blood cells (mean, 80/mm3 versus 301/mm3) and a significantly greater percentage of mononuclear cells than the VM patients. CONCLUSIONS: In this study, in a Lyme-endemic area, LM was about as common as VM in older children who were hospitalized with aseptic meningitis. Attention to pertinent epidemiologic and historical data, along with physical and CSF findings, allows early differentiation of LM from VM.

Cognitive effects of Lyme disease in children.

OBJECTIVE: To measure possible cognitive sequelae of Lyme disease (LD) within a pediatric population. DESIGN: Prospective, blinded, controlled study of cognitive skills in children who had been treated for LD. SETTING: A children's hospital in an area endemic for LD. PATIENTS: Forty-one children with strictly defined LD were compared with 14 control children who had subacute rheumatological diseases, and with 23 healthy sibling controls. OUTCOME MEASURES: Neuropsychologic measures were administered to each child to assess the following cognitive areas: IQ information processing speed, fine-motor dexterity, novel-problem solving and executive functioning, short-term and intermediate memory, and the ability to acquire new learning. Predisease and postdisease academic achievement test scores were also gathered. Impressions from parents concerning the disease's subsequent impact were also obtained. RESULTS: No differences between LD and control groups were found for any of the numerous neuropsychologic measures. Analyses also failed to show differences between LD patients grouped with respect to the presence or absence of known neurologic involvement, disease stage, duration of symptoms before therapy, or type of antibiotic treatment. No predisease versus post-disease difference in academic performance was found. No perceived long-term deterioration in cognitive, social, or personality areas was reported by parents. CONCLUSION: Children appropriately treated for LD have an excellent prognosis for unimpaired cognitive functioning.

Candy cigarettes: do they encourage children's smoking?

Candy and bubble gum cigarettes are packaged to resemble cigarette brands, and so they may encourage young children to smoke. Two studies of the role of these products in the development of children's attitudes and behaviors toward smoking were conducted. In the first study, six focus group interviews were conducted with 25 children in three age groups (4 through 5, 6 through 8, and 9 through 11 years old). Children in each group were shown five candy and snack foods and asked about their opinions and experiences with each item. In the second study, 195 seventh-grade students in a southeastern city school system were surveyed about their cigarette smoking and candy cigarette use. In the focus groups, candy cigarettes were recognized by most children. Young children played with the candy cigarettes more than with other candy or snack items and made general references to smoking behaviors. Older children made favorable references to smoking behavior; most knew which stores sold candy cigarettes, and many had chosen to buy and use these items, despite parental disapproval. Candy cigarettes may play a role in the development of children's attitudes toward smoking as an acceptable, favorable, or normative behavior. Elimination of these products should be part of efforts to prevent initiation of smoking by children.

Cat-scratch disease presenting as multifocal osteomyelitis with thoracic abscess.

The case of a 4-year-old girl who presented with fever and back pain after being scratched by a kitten is presented. The diagnosis of cat scratch disease osteomyelitis was made by the detection of Bartonella henselae DNA by PCR analysis of a rib abscess aspirate.

Effect of age and testosterone on the vasopressin and aquaporin responses to dehydration in Fischer 344/Brown-Norway F1 rats.

To determine if the aging-associated decline in testosterone results in attenuated vasopressin (VP) responses to dehydration, testosterone implants were given to aged male Fischer 344Brown-Norway F1(F344BNF1) rats. Water deprivation caused comparable dehydration, increased plasma VP (pVP), and decreased posterior pituitary (PP) VP content in 4-, 15-, and 28-month-old rats. Dehydration increased VP mRNA content of supraoptic nuclei only at 4 months, whereas VP mRNA length was increased at both 4 and 15 months of age. The elevated pVP in the water-deprived aged rats indicates that even without an increase in VP mRNA content, PP VP storage was adequate to maintain elevated pVP. Dehydration increased aquaporin-2 content at 4, but not at 15 or 28 months of age, suggesting decreased renal responsiveness to VP. Testosterone replacement did not produce dehydration-induced increases in VP mRNA or aquaporin-2. Therefore, testosterone deficiency does not result in altered VP responses to dehydration in aged F344BNF1 rats.

Adolescents who use the emergency department as their usual source of care.

OBJECTIVE: To examine the factors associated with use of the emergency department (ED) as the only source of health care among adolescents. DESIGN: Analyses of the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls, a nationally representative sample of 6748 in-school male and female adolescents in 5th through 12th grade. The X2 statistics and logistic regression analyses were computed with the use of SUDAAN. RESULTS: Overall, 4.6% of the adolescents in the survey, or 1.5 million adolescents in the United States, reported that the ED was their usual source of health care. In multivariate models, factors associated with the use of the ED included male sex, African American ethnicity, fewer financial resources, and living in a rural area. Adolescents with higher levels of risky behaviors, a history of physical or sexual abuse, and higher depression scores were all more likely to use the ED as their usual source of care. Adolescents who reported using the ED as their usual care source were also less likely to have had regular well visits and were more likely to report having missed needed care than those with other sources of primary care. CONCLUSIONS: Adolescents who use the ED as their usual source of care are often from vulnerable populations. Many have special mental or physical needs that are unlikely to be met with ED visits only, and they are likely to have missed care they needed. Creating linkages between EDs and other services could help at-risk adolescents identify and use more appropriate sources of primary care.

Clinical preventive services efficacy and adolescents' risky behaviors.

OBJECTIVE/BACKGROUND: To analyze the value of studying or implementing office-based clinical preventive services for adolescents. Most adolescent mortality and morbidity is attributable to risky behaviors, yet clinical preventive services to reduce risky behaviors are often challenged because their efficacy has not been demonstrated. DESIGN: A cost-effectiveness model of adolescents' risky behaviors that compares standard practice with a program of screening visits for all adolescents and counseling visits for youth identified as high risk. We considered two risky behaviors, alcohol abuse and unsafe sexual activity, and five outcomes. MAIN OUTCOME MEASURES: Baseline cost-effectiveness of the program, minimum efficacy at which the program would be cost-effective, and sample sizes required for a trial of the program. RESULTS: Assuming that the program is 5% effective at preventing risky behaviors, it would cost $3035 to prevent any one adverse outcome and $471,000 to prevent a death from an automobile crash or from human immunodeficiency virus infection. Assuming society were willing to pay $600,000 to prevent a death (a generally accepted figure), the program would be cost-effective only if it were 5.6% effective at changing behavior. At this efficacy, the program would have a cost per year of life saved comparable to or better than many other accepted medical interventions. However, to demonstrate changes in outcomes at this efficacy would require a clinical trial with between 4000 and 95 million adolescents in each treatment group, depending on the outcome measured. CONCLUSIONS: Studying the ability of clinical preventive services to prevent outcomes of adolescents' risky behaviors would be impractical. The decision to implement these programs should be made based on current knowledge and beliefs; their efficacy can probably be studied only as part of widespread implementation.

Adolescents' access to care: teenagers' self-reported use of services and perceived access to confidential care.

BACKGROUND: Most surveys on adolescents' use of health services rely on parental report, and this may underestimate adolescents' use of confidential services. OBJECTIVE: To investigate adolescents' report of their own use of health services, access to care, and knowledge and use of confidential services. METHOD: A random digit-dialed survey of 14- to 19-year-old adolescents was conducted in Monroe County, New York. We screened 11 800 numbers and identified 4449 households (40%) of which 393 families (8.8%) had eligible adolescents. Of these, 259 (66%) consented and completed an interviewer-administered survey. RESULTS: Almost all adolescents (92%) rated their health as excellent or good and 90% had visited a health care provider within the year. Most (88%) identified a source of primary care. As many as 27% of adolescents had used more than one source of care. Many youth identify school personnel as important resources for health and counseling needs. Only 8.4% of respondents have used services confidentially, but nearly half of all youth did not know where they could obtain confidential care if they needed to. Adolescents were least likely to know where to obtain mental health or substance abuse and reproductive services. CONCLUSIONS: While most youth have used primary care, a substantial minority have not. Many teenagers depend on multiple sources of care, and they rely on school personnel as important sources of health information. Many do not know where they could go to review confidential services or for other services that they may need. Managed care insurance and public health policies should recognize adolescents' access needs to meet them appropriately.

Health-compromising behaviors: why do adolescents smoke or drink?: identifying underlying risk and protective factors.

OBJECTIVES: To better understand the motivation for adolescent smoking and drinking and to identify the underlying risk and protective factors associated with these behaviors among adolescents. DESIGN: Cross-sectional, school-based survey of students in grades 5 through 12. PARTICIPANTS: A nationally representative sample of 2574 boys and 2939 girls in grades 7 through 12 from 297 public, private, and parochial schools across the United States who participated in The Commonwealth Fund Survey of the Health of Adolescent Girls and Boys in 1997. MAIN OUTCOME MEASURES: Sex-specific adjusted relative risks (RRs) and 95% confidence intervals (CIs) comparing self-reported regular smokers and regular drinkers by risk and protective factors with adolescents reporting none of these behaviors. RESULTS: Adolescent boys and girls were equally likely to be regular smokers (11.2%). The prevalence rate of regular drinking was only slightly higher for boys (22.4%) than it was for girls (19.3%). The rates of both health-risk behaviors were significantly higher for those reporting risk factors, and the strengths of associations varied by sex. Sex differences also emerged in motivation for engaging in these behaviors. When we adjusted for demographic characteristics, exposure to childhood abuse (RR, 4.1; 95% CI, 2.4-7.0) and stressful life events (RR, 2.4; 95% CI, 1.1-5.4) were strongly associated with increased risk for boys' regular smoking. Similar associations were found for regular drinking. For girls, a history of abuse (RR, 1.8; 95% CI, 1.1-2.8), violence within the family (RR, 2.2; 95% CI, 1.6-3.2), depressive symptoms (RR, 1.6; 95% CI, 1.0-2.4), and stressful life events (RR, 3.1; 95% CI, 1.8-5.6) were significantly associated with increased risk for regular smoking. Similar associations were again found for regular drinking. Parental support was protective against both health-risk behaviors for both sexes. Participation in extracurricular activities was associated with lower risk for regular smoking for boys (RR, 0.4; 95% CI, 0.2-0.7) and for girls (RR, 0.3; 95% CI, 0.2-0.5); however, there was no significant association between drinking behavior and participation in activities. CONCLUSIONS: The increased risk for regular smoking and regular drinking among adolescents with a history of abuse, family violence, depressive symptoms, and stressful life events suggests that routine screening for abuse, violence, and other family experiences should be an essential component of adolescent health care visits. Effective prevention programs to reduce smoking and drinking among adolescents should recognize that health-risk behaviors may be associated with other negative life experiences and that the strength of these associations differs by sex.