Annual Review of Public Health - Volume 31, 2010

Tobacco use exerts a huge toll on persons with mental illnesses and substance abuse disorders, accounting for 200,000 of the annual 443,000 annual tobacco-related deaths in the United States. Persons with chronic mental illness die 25 years earlier than the general population does, and smoking is the major contributor to that premature mortality. This population consumes 44% of all cigarettes, reflecting very high prevalence rates plus heavy smoking by users. The pattern reflects a combination of biological, psychosocial, cultural, and tobacco industry–related factors. Although provider and patient perspectives are changing, smoking has been a historically accepted part of behavioral health settings. Additional harm results from the economic burden imposed by purchasing cigarettes and enduring the stigma attached to smoking. Tailored treatment for this population involves standard cessation treatments including counseling, medications, and telephone quitlines. Further progress depends on clinician and patient education, expanded access to treatment, and the resolution of existing knowledge gaps.

Many historical developments, such as the Alma Ata Declaration or the Ottawa Charter, have drawn attention to the need for intersectoral work and for considering the health aspects of different policy proposals. In the 1970s, Finland started broad actions to change national diets to reduce the high mortality associated with cardiovascular diseases (CVDs). This and other work in Finland have involved many sectors and policies, resulted in significant public health improvements, and paved the way for the Health in All Policies (HiAP) initiative started during the Finnish European Union (EU) presidency in 2006. The initiative and the principles have encouraged further developments in Finland and have been linked with related developments within the EU and the World Health Organization (WHO).

Social environments and experiences get under the skin early in life in ways that affect the course of human development. Because most factors associated with early child development are a function of socio-economic status, differences in early child development form a socio-economic gradient. We are now learning how, when, and by what means early experiences influence key biological systems over the long term to produce gradients: a process known as biological embedding. Opportunities for biological embedding are tethered closely to sensitive periods in the development of neural circuitry. Epigenetic regulation is the best example of operating principles relevant to biological embedding. We are now in a position to ask how early childhood environments work together with genetic variation and epigenetic regulation to generate socially partitioned developmental trajectories with impact on health across the life course.

Targeted marketing techniques, which identify consumers who share common needs or characteristics and position products or services to appeal to and reach these consumers, are now the core of all marketing and facilitate its effectiveness. However, targeted marketing, particularly of products with proven or potential adverse effects (e.g., tobacco, alcohol, entertainment violence, or unhealthful foods) to consumer segments defined as vulnerable raises complex concerns for public health. It is critical that practitioners, academics, and policy makers in marketing, public health, and other fields recognize and understand targeted marketing as a specific contextual influence on the health of children and adolescents and, for different reasons, ethnic minority populations and other populations who may benefit from public health protections. For beneficial products, such understanding can foster more socially productive targeting. For potentially harmful products, understanding the nature and scope of targeted marketing influences will support identification and implementation of corrective policies.

After considerable declines in teen birth and pregnancy rates between 1991 and 2005, teen birth rates rose unexpectedly in 2006 and 2007. To understand these recent trends, we examined historical changes in fertility, trends in sexual behaviors, social forces, and public policies that may influence teen fertility. Although social forces such as poverty are critical in shaping adolescent reproductive choices, these do not explain rapid change in teen pregnancy risk since 1991. These recent changes, including increases in teen births since 2005, follow closely changes in teen contraceptive use. Likewise, contraceptive use is critical in explaining differences between U.S. and European fertility patterns. Public policies related to HIV prevention and sexuality education may have played a critical role in influencing teen pregnancy risk.

Significant public health problems associated with methamphetamine (MA) production and use in the United States have emerged over the past 25 years; however, there has been considerable controversy about the size of the problem. Epidemiological indicators have provided a mixed picture. National surveys of the adult U.S. population and school-based populations have consistently been used to support the position that MA use is a relatively minor concern. However, many other data sources, including law-enforcement groups, welfare agencies, substance abuse treatment program admissions, criminal justice agencies, and state/county executives indicate that MA is a very significant public health problem for many communities throughout much of the country. In this article, we describe (a) the historical underpinnings of the MA problem, (b) epidemiological trends in MA use, (c) key subgroups at risk for MA problems, (d) the health and social factors associated with MA use, (e) interventions available for addressing the MA problem, and (f) lessons learned from past efforts addressing the MA problem.

Increasing evidence suggests that public health and health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base. This article provides an overview of the state of the science of theory use for designing and conducting health-promotion interventions. Influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behavior. We describe key types of theory and selected often-used theories and their key concepts, including the health belief model, the transtheoretical model, social cognitive theory, and the ecological model. This summary is followed by a review of the evidence about patterns and effects of theory use in health behavior intervention research. Examples of applied theories in three large public health programs illustrate the feasibility, utility, and challenges of using theory-based interventions. This review concludes by identifying cross-cutting themes and important future directions for bridging the divides between theory, practice, and research.

Following the drug-approval process, concerns remain regarding the safety of new drugs that are introduced into the marketplace. In the case of rare adverse events, the number of subjects that are treated in randomized controlled trials is invariably inadequate to determine the safety of the new pharmaceutical. Identifying safety signals for new and/or existing drugs is a major priority in the protection of public health. Unfortunately, design, analysis, and available data are often quite limited for detecting in a timely fashion any potentially harmful effects of drugs. In this review, we examine a variety of approaches for determining the possibility of adverse drug reactions. Our review includes spontaneous reports, meta-analysis of randomized controlled clinical trials, ecological studies, and analysis of medical claims data. We consider both experimental design and analytic problems as well as potential solutions. Many of these methodologies are then illustrated through application to data on the possible relationship between taking antidepressants and increased risk of suicidality.

Simulation modeling of health reform is a standard part of policy development and, in the United States, a required element in enacting health reform legislation. Modelers use three types of basic structures to build models of the health system: microsimulation, individual choice, and cell-based. These frameworks are filled in with data on baseline characteristics of the system and parameters describing individual behavior. Available data on baseline characteristics are imprecise, and estimates of key empirical parameters vary widely. A comparison of estimated and realized consequences of several health reform proposals suggests that models provided reasonably accurate estimates, with confidence bounds of ∼30%.

Adolescents face a variety of challenges in their transition to adulthood; lesbian, gay, and bisexual adolescents face these typical challenges as well as additional challenges that are related to the social stigma of their sexual orientation. For some lesbian, gay, and bisexual adolescents, this stigma may induce psychosocial stress, leading to increased health risk behaviors and poorer health outcomes. In this article, we review data on the health and health care of LGB adolescents. We examine health indicators and health risks for LGB youth, including substance use, eating disorders, suicidality, risky sexual behaviors, violence exposure and victimization, and homelessness. We also examine health care provision and utilization for LGB youth. Lastly, we discuss ways in which researchers and clinicians can improve LGB adolescent health and health care.

Medical errors and adverse events are now recognized as major threats to both individual and public health worldwide. This review provides a broad perspective on major effective, established, or promising strategies to reduce medical errors and harm. Initiatives to improve safety can be conceptualized as a “safety onion” with layers of protection, depending on their degree of remove from the patient. Interventions discussed include those applied at the levels of the patient (patient engagement and disclosure), the caregiver (education, teamwork, and checklists), the local workplace (culture and workplace changes), and the system (information technology and incident reporting systems). Promising interventions include forcing functions, computerized prescriber order entry with decision support, checklists, standardized handoffs and simulation training. Many of the interventions described still lack strong evidence of benefit, but this should not hold back implementation. Rather, it should spur innovation accompanied by evaluation and publication to share the results.